Grant: CIHR Fellowship

Health professionals often work in silos. If any health information is communicated, the most common formats are paper or fax. This fragmentation has been shown to compromise patient safety by leading to inefficient, low-quality and low-value care. The ideal would be to use a longitudinal care plan, which is intended to be a single, reconciled source of health information shared between health professionals and patients to address a unified set of treatment and care goals. It should be patient-centered, dynamic and integrated with local electronic health records to facilitate real-time updates and bi-directional communication. The purpose of this research project is to inform the design and development of a collaborative Longitudinal Care Plan e-Tool (eLCP). Objectives: 1) To describe the current state of information exchange during care transitions for patients managed by multiple health professionals and services 2) To define key information needs, core components and desired presentation to inform the design of an eLCP prototype Methods: In-depth, unstructured interviews with patients and family members, workflow observations of health professionals, and medical document review will be used to develop comprehensive patient journey maps to understand the current state of care coordination and information exchange during care transitions to identify gaps for improvement. Focus groups will be conducted using semi-structured interview guides with patients, family members, and various health professionals to identify key information needs, core components and desired presentation of an eLCP. Separate Delphi processes will be conducted to refine the lists of information needs and components, and to prioritize by value added to the eLCP for 'patient and family' and 'health professional' views. Final rank-ordered lists will be created to inform the design and development of an eLCP prototype.