An investigation of the information technology needs associated with delivering chronic disease care to large clinical populations.

Background: The growing number of individuals with complex medical and social needs has motivated the adoption of care management (CM) - programs wherein multidisciplinary teams coordinate and monitor the clinical and non-clinical aspects of care for patients with chronic disease. Despite claims that health information technology (IT) is essential to CM, there has been limited research focused on the IT needs of clinicians providing care management to large groups of patients with chronic disease.

Objective: To assess clinicians' needs pertaining to CM and to identify inefficiencies and bottlenecks associated with the delivery of CM to large groups of patients with chronic disease.

Methods: A qualitative study of two HIV care programs. Methods included observations of multidisciplinary care team meetings and semi-structured interviews with physicians, care managers, and social workers. Thematic analysis was conducted to analyze the data.

Results: CM was perceived by staff as requiring the development of novel strategies including patient prioritization and patient monitoring, which was supported by patient registries but also required the creation of additional homegrown tools. Common challenges included: limited ability to identify pertinent patient information, specifically in regards to social and behavioral determinants of health, limited assistance in matching patients to appropriate interventions, and limited support for communication within multidisciplinary care teams.

Conclusion: Clinicians delivering care management to chronic disease patients are not adequately supported by electronic health records and patient registries. Tools that better enable population monitoring, facilitate communication between providers, and help address psychosocial barriers to treatment could enable more effective care.