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.

中文翻译：

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对与向大量临床人群提供慢性病护理相关的信息技术需求的调查。

背景越来越多的具有复杂医疗和社会需求的个人促使采用护理管理（CM）——其中多学科团队协调和监测慢性病患者护理的临床和非临床方面的程序。尽管声称健康信息技术 (IT) 对 CM 至关重要，但关注为大量慢性病患者提供护理管理的临床医生的 IT 需求的研究仍然有限。目的 评估临床医生对 CM 的需求，并确定与向大量慢性病患者提供 CM 相关的低效率和瓶颈。方法 对两个 HIV 关怀项目的定性研究。方法包括观察多学科护理团队会议和与医生、护理经理和社会工作者的半结构化访谈。进行了专题分析以分析数据。结果 工作人员认为 CM 需要制定新的策略，包括患者优先排序和患者监测，这得到患者登记处的支持，但也需要创建额外的本土工具。常见的挑战包括：识别相关患者信息的能力有限，特别是关于健康的社会和行为决定因素的能力有限，在将患者与适当的干预措施相匹配方面的帮助有限，以及对多学科护理团队内沟通的支持有限。结论 为慢性病患者提供护理管理的临床医生没有得到电子健康记录和患者登记的充分支持。能够更好地进行人口监测、促进提供者之间的沟通并帮助解决治疗的心理社会障碍的工具可以实现更有效的护理。