Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Integrated Care Coordination Information System: Primary Care Redesign

Slide presentation from the AHRQ 2011 conference.

On September 19, 2011, David Dorr made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (3 MB). Plugin Software Help.

Slide 1

Integrated Care Coordination Information System: Primary Care Redesign through Care Coordination and Population Management

David A Dorr, MD MS
Associate Professor
Department of Medical Informatics & Clinical Epidemiology
General Internal Medicine & Geriatrics OHSU

Funding for this research from The John A. Hartford Foundation, AHRQ, Intermountain HealthCare, and the National Library of Medicine.

More information at

Slide 2


  • Care Management Plus: International Conference on Cybernetics, Informatics and Systemics (ICCIS) need and trial.
  • Prioritized functions.
  • Unintended consequences.
  • Sustainability: Free take one vs. thoughtful partnership.

A.k.a—How to build a better system of care for your most at-risk primary care patients.

Slide 3

Image: A diagram shows the interaction between specialists, the primary care team, the caregiver, and the patient.

Slide 4

Image of a flowchart.

Needs assessment / Build system (1 year + )
Train clinics and care managers 

Randomly assigned goals for IT use.

Arm 1: Coordination of Care:

  • Complete assessment/care plan.
  • Education.
  • Goal setting and follow up.
  • Communication.
  • Motivation/coaching.
  • Completing CM services.

Arm 2: Quality:

  • Choose 5 of 20 quality measures: prevention, diabetes, vulnerable elderly, asthma, congestive hearth failure.

Data from ICCIS, Payers

Evaluation (Aim 4):

  • Outcomes (health/satisfaction) and their relationship to implementation and use of information technology (IT).

Slide 5

Needs assessment

Additional Care Management elements requested from 7 teams with EHRs:

  • Referral
  • Care Planning
  • Education
  • Follow Up
  • System
  • Reminders
  • Communication
  • Population

Slide 6

ICCIS Care Coordination Workflow

A centralized reminder list of tasks and communications that were proactively planned but incomplete allows population-based tasks to be merged with individual encounter tasks.

Image: Screen shot of the Care Manager Encounter Tickler List.

Slide 7

Quality measure dashboard

Image: Screen shot of the Quality measure dashboard is shown.

Dashboard can be run by clinic, team, or individual PCP.

Slide 8

ICCIS Interactive Quality Reports

Image: Screen shot of  a ICCIS Interactive Quality Report is shown.

The abilities to document exclusions at multiple levels and generate targeted population-based review cycles avoid the problems caused by static quality reports and allow providers to efficiently focus outreach efforts on high risk populations.

Slide 9

Patient Worksheet

Image: Screen shot of a Patient Worksheet is shown.

When working with persons with multiple illnesses or complex illness, a clinical summary that captures a core set of information improves patient outcomes (1). Care coordination and behavioral modification (goal setting) elements often require special effort and the quality summary requires more advanced monitoring and implementation than most standard EHRs provide.

Slide 10

It worked! (see our poster)

Table 1. Care coordination activities

 Arm 1Arm 2
Completed encounters81424463
Motivational interviewing1680428

Figure 3: Absolute adherence change for Arms and Clinics Arms reimbursed Table 1. Care coordination activities

Slide 11

Unintended consequences: Errors / fixes

  • 278 fixes of systemic errors in first 6 months of study.
  • Sources:
    • Data (multiple EHRs, minimal standards).
    • Workflow/usability.
    • Understanding/naming to reduce confusion.

Slide 12

Sustainability—'Free, take one'—dissemination to 208 teams

Image: A map of the United States shows the locations of the teams.

Slide 13

Sustainability: Thoughtful partnership

  • Readiness assessment: define benefit up front:
    • E.g., Medical Home care coordination; ACO reduction in hospitalizations and shared savings.
  • Partner on achievement of goals.
  • Share savings or benefit together:
    • Example: intensive care management demonstrations; SNP plans

Slide 14

CM+: care management plus

  • Oregon Health & Science University:
    • David Dorr, PI.
    • Kelli Radican.
    • Susan Butterworth.
    • Nima Behkami.
    • Marsha Pierre-Jacques Williams.
    • Gwenivere Olsen.
    • Molly King.
    • Kristin Dahlgren.
  • Columbia University:
    • Adam Wilcox.
  • Intermountain Healthcare:
    • Cherie Brunker, Co-PI (UU).
    • Liza Widmeir.
    • Mary Carpenter.
    • Bryan Gardner.
    • Ann Larson.
  • Advisory Board:
    • K. John McConnel.
    • Tom Bodenheimer.
    • Eric Coleman.
    • Cheryl Schraeder.
    • Heather young.
    • Steven Counsel.
    • Larry Caslino.

Slide 15

Thank you & Main lessons

WorkflowTickler as CDSS and single workflowNeeds assessment and requirements; usability
Patient-centered CarePatient  WorksheetAccuracy, usefulness from clinical staff
Unintended consequencesError tracking with clinical consequencesFixes needed
Sustainability"Free, take one" v.
Thoughtful partnership
Need has to be clearly assessed and targeted

Slide 16

Thank you!

Slide 17

Sticky problems

ProblemExplanationICCIS Result
Data in many different EHRsEHRs have different data structuresExtracted data from 4 different EHRs
Functions in HIT systems siloedMany functions are in separate EHR settingsCreate universal workflows in separate application
EHRs have variable standard implementationsAlthough a standard vocabulary is available, it isn’t usedNOT EASY—manual mappings, many errors until it is solved
Population management is an analytic, not transactional issueReports take a long time to run and are staticCreate interactive views of the reports (e.g., quality measure performance) with associated tables

Slide 18


Image: Flow chart shows the following steps:

Log metrics: click throughs (<5 seconds on page): 62% ; loops/ repeated actions
Interviews: Use / workflow / challenges / errors

Page last reviewed October 2014
Internet Citation: Integrated Care Coordination Information System: Primary Care Redesign. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care