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Advisory Council April 2019 Meeting Presentation: Care Planning and HIT

Monday, April 29, 2019

Printer Friendly Version in PDF Format (2 PDF pages)


Care Planning and Health Information Technology -- Exemplars

Arlene S. Bierman, M.D., M.S.
Director, Center for Evidence and Practice Improvement
Agency for Healthcare Research and Quality

AHRQ's Vision

  • Goal
    • A sustainable healthcare system that delivers high-value coordinated, integrated patient-centered care based in primary care optimizing individual and population health by preventing and effectively managing multiple chronic conditions (MCC).

The Care and Learn Model

Display shows that Situation and Aim is affected by (1) Community and Social Context, (2) Care (Healthcare, Assess, Use Evidence, Respond), (3) Learn (Adapt, Produce Evidence, Evaluate).
JGIM 2018

Data Capacity for Patient-centered Outcomes Research through Creation of an electronic Care Plan for People with Multiple Chronic Conditions

  • Partnership AHRQ and NIDDK with multiple federal partners
    • This project will build capacity for pragmatic, patient-centered outcomes research (PCOR) by developing an interoperable electronic (e)Care Plan to facilitate aggregation and sharing of critical patient-centered data across home, community, clinic and research settings.
    • Designed to improve interoperability of data for research and care and addressing the challenge of missing critical patient information that compromises patient health and safety and ability to conduct research on people with multiple chronic conditions (MCC).