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12:00 AM - Epic UGM 2025
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The 2025 DirectTrust Annual Conference
2025-08-04 - 2025-08-07    
12:00 am
Three of the most interesting healthcare topics are going to be featured at the DirectTrust Annual conference this year: Interoperability, Identity, and Cybersecurity. These are [...]
ALS Nexus Event Recap and Overview
2025-08-11 - 2025-08-14    
12:00 am
International Conference on Wearable Medical Devices and Sensors
2025-08-12    
12:00 am
Conference Details: International Conference on Wearable Medical Devices and Sensors , on 12th Aug 2025 at New York, New York, USA . The key intention [...]
Epic UGM 2025
2025-08-18 - 2025-08-21    
12:00 am
The largest gathering of Epic Users at the Epic user conference in Verona. Generally highlighted by Epic’s keynote where she often makes big announcements about [...]
Events on 2025-08-04
Events on 2025-08-11
Events on 2025-08-18
Epic UGM 2025
18 Aug 25
Verona

Events

Articles

Patient-Centered Medical Homes Need Better IT Tools, Study Says

patient-centered

Health IT tools must evolve beyond storing electronic health records and include additional functionalities, such as monitoring and notification capacities, to improve care coordination at patient-centered medical homes, according to a study published in the Journal of the American Medical Informatics Association, FierceHealthIT reports (Hall, FierceHealthIT, 3/23).

Study Details

For the study, researchers interviewed 28 individuals from three PCMHs. Participants included:

  • PCMH administrators and clinicians;
  • EHR and health information exchange representatives; and
  • Policymakers (Richardson et al., JAMIA, 3/21).

Study Findings

Study participants identified several ways current health IT tools hinder care coordination. Respondents said they had developed workarounds to compensate for the lack of certain IT system functionalities.

For example, some participants reported that they had used “homegrown” tools from Excel spreadsheets, Microsoft Access databases and paper forms to supplement data repositories that they had developed. However, using such homegrown tools can create barriers to notifying coordinators about a patient’s health status, according to FierceHealthIT (FierceHealthIT, 3/23).

Overall, the study identified five areas in which health IT could bolster care coordination among PCMHs, including:

  • Monitoring tools, including tools that track panels of patients and help identify patients most in need of care based on clinical and claims data;
  • Notification tools, including tools that alert clinicians and other PCMH staff when patients move across care settings and that visually present patient patterns to help PCMHs improve care;
  • Collaborating tools, including dynamic electronic care plans to help clinicians check a patient’s status and set care goals;
  • Reporting tools, including data extraction tools that help PCMHs generate aggregate data on processes, patient health and finances; and
  • Interoperability tools, including low-cost tools for health information exchange interfaces.

According to the study, “The major conclusions … suggest that existing health IT needs to evolve from digitized patient record repositories into interoperable electronic collaboration platforms that support both individual patients and patient populations to enable PCMH care coordination efforts.” The researchers concluded that “[f]ocusing technological solutions” on monitoring, notification, collaboration, reporting and interoperability capabilities “can offer transformative approaches to improving care coordination and quality” (JAMIA, 3/21).

Source