The critical components of an electronic care plan tool for primary care: an exploratory qualitative study

Lisa Rotenstein, Suhavi Tucker, Rose Kakoza, Lori Tishler, Adrian Zai, Charlotte Wu


Background A critical need exists for effective electronic tools that facilitate multidisciplinary care for complex patients in patient-centered medical homes.

Objective To identify the essential components of a primary care (PC) based electronic care plan (ECP) tool that facilitates coordination of care for complex patients.

Methods Three focus groups and nine semi-structured interviews were conducted at an academic PC practice in order to identify the ideal components of an ECP.

Results Critical components of an ECP identified included: 1) patient background information, including patient demographics, care team member designation and key patient contacts, 2) user- and patient-centric task management functionalities, 3) a summary of a patient’s care needs linked to the responsible member of the care team and 4) integration with the electronic medical record. We then designed an ECP mockup incorporating these components.

Conclusion Our investigation identified key principles that healthcare software developers can integrate into PC and patient-centered ECP tools.


patient care planning; health information technology; interdisciplinary communication; health care team; primary care

Full Text:



Wagner EH, Coleman K, Reid RJ, Phillips K and Sugarman J. Guiding transformation: how medical practices can become patient-centered medical homes [Internet]. Commonwealth Fund, 2012. Available from: Accessed 9 August 2015.

Rich E, Lipson D, Libersky J and Parchman M. Coordinating care for adults with complex care needs in the patient-centered medical home: challenges and solutions [Internet]. Agency for Healthcare Research and Quality, 2012. Available from: Accessed 8 August 2015.

McDonald KM, Schutz E, Chapman T, Davies S, Pineda N and Lonhart J et al. Prospects for care coordination measurement using electronic data sources [Internet]. Agency for Healthcare Research and Quality, 2012. Available from: Accessed 8 August 2015.

Chunchu K, Mauksch L, Charles C, Ross V and Pauwels J. A patient centered care plan in the EHR: improving collaboration and engagement. Families, Systems, & Health 2012; 30(3): 199–209. PMid:22866953.

Dykes PC, Samal L, Donahue M, Greenberg JO, Hurley AC and Hasan O et al. A patient-centered longitudinal care plan: vision versus reality. Journal of the American Medical Informatics Association 2014;21(6):1082–90. PMid:24996874; PMCid:PMC4215040.

Wagner M. Population Health Management 2013: Scouting the PHM Roster. KLAS, 2013.



  • There are currently no refbacks.

This is an open access journal, which means that all content is freely available without charge to the user or their institution. Users are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles in this journal starting from Volume 21 without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open accessFor permission regarding papers published in previous volumes, please contact us.

Privacy statement: The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party.

Online ISSN 2058-4563 - Print ISSN 2058-4555. Published by BCS, The Chartered Institute for IT