Abstract
For individuals with chronic and prolonged conditions such as cancer, care is complicated, fragmented, and poorly coordinated. Individuals with cancer experience transitions from home to physician office, clinic, outpatient service, emergency department, inpatient hospital, and community-based settings attended by different practitioners and numerous specialists at each. Because health care systems have not addressed community-wide care coordination, the burden of coordinating is often left to the individual and their family to manage.
Chronic disease care coordination frameworks help unpack the challenges and provide ways to understand how to intervene to improve care coordination for cancer. These frameworks elucidate the importance of the comprehensive person-centered, community-wide, and life span approach to coordination. Health information technology (HIT) is a critical enabler of solutions to these challenges. HIT-enabled care coordination is in a nascent stage in which most examples are within health care teams with limited interactions with patients. There are a number of examples of HIT solutions involving electronic health records, single-purpose mobile applications, or patient portals in chronic disease and fewer in cancer care coordination. There are few examples of platforms that support the comprehensive approaches needed. This offers great opportunity for collaboration among informatics, clinical, and patient participants to design, develop, implement, and evaluate HIT that effectively addresses the comprehensive nature of care coordination. This chapter offers an overview of care coordination frameworks, HIT functions needed for care coordination, examples of HIT-enabled care coordination, and opportunities to move the field forward.