Knowledge Management and Healthcare

Saturday, November 2, 2013, 1:30pm

The Use of Knowledge Management in the Health Care: The Implementation of Shared Care Plans in Electronic Medical Record Systems at One Primary Care Practice

Connie Pascal, Claire McInerney, John Orzano, Elizabeth Clark, Alfred Tallia and Lynn Clemow


The organization at the heart of this case study is Practice One a large suburban primary care practice in the Northeast currently in the process of transforming into a patient centered medical home (PCMH). Practice One is also a research site for a NIH-NIDDK funded pilot project to study the feasibility of combining knowledge management (KM) techniques at the organizational level with motivational interviewing (MI) behavioral counseling methods at the interpersonal level would improve the health outcomes of patient with type II diabetes. This paper traces how Practice One is going about building its organizational capacity to support care coordination for its high-risk patients as well as its patients with chronic conditions such as diabetes, asthma and hypertension As one of the pillars of the Patient Centered Medical Home (PCMH) model, care coordination has become a key component in the effort to improve patient outcomes while curbing the cost of treating largely preventable diseases. The paper tells the story of how the Lead Physician and the Population Care Coordinator (PCC - a new role in the primary care workforce) went about designing and developing a new knowledge object the shared care plan (SCP) as a tool to improve collaboration with its high risk diabetes patients. As defined by the feasibility study, the content of the SCP is co-constructed through the on-going social interaction between the patient and the providers and staff of the primary care practice. The SCP is a knowledge object that helps the providers can use to help patients with chronic diseases better self-manage their conditions by leading them through the process of becoming aware of their personal priorities and setting achievable goals for improving their health behaviors. This paper describes how the first step towards designing the SCP was to define it in their own organizational terms and the design it as paper document before implementing it into the EMR system. The paper outlines the components of their Shared Care Plan document as a knowledge object. The case study also surfaces a number of issues that the Lead Physician and the PCC are struggling with including how to get the staff and patients to adopt to using this new knowledge object to collaborate with each other as well. 

2013. All rights reserved.