Development of IT-Enabled Chronic Care Management for the Medically Underserved: A Contextualist Framework

Abstract: While efforts to address the management of chronic diseases in the context of large, urban hospitals are underway, the literature is silent on how to facilitate such efforts in the community clinics that provide services to many chronic-care patients who are medically underserved. We offer a contextualist framework for developing IT-enabled chronic care management in community clinics. To understand and support the required collaboration between diverse stakeholders located across institutional boundaries, the framework adapts Pettigrew's Contextual Inquiry as the overarching analytical lens. The framework focuses on the context of community clinics, including patients, clinicians, administrators, technology providers, and institutional partnerships; it considers the content of developing IT-support based on the Chronic Care Model, and, as basis for the development process, it adapts Holtzblatt and Beyer's Contextual Design principles. We demonstrate the workings of the framework through a case study of how IT-enabled support for chronic care management was designed and implemented into a community clinic in the Southeast U.S. over a three-year period, and, finally, we discuss its theoretical and practical implications in relation to extant literature. Keywords: contextualist framework, IT development, chronic care management, electronic health record INTRODUCTION Healthcare in the U.S. represents a large and growing portion of the GDP, with 2007 per capita spending rising to $7,421, or 16.2 percent of GDP (Hartman et al. 2009), and chronic diseases are the leading cause of death, consuming roughly 75 percent of all health expenditures (www.cdc.gov/chronicdisease/resources/publications/ AAG/pdf/chronic.pdf). To improve management of chronic patients over long periods of time, clinicians have investigated more holistic treatment methodologies, such as the Chronic Care Model (CCM) (Wagner et al. 2001). The CCM is based on six critical elements: (1) community resources with linkages to other healthcare agencies, (2) self-management support to inform, educate, and engage patients, (3) leadership focus on quality of care within provider organizations, (4) delivery system design to ensure coordination between providers for a given patient, (5) evidence-based decision support, and (6) clinical information support for managing lifelong chronic conditions. Developed more than a decade ago, the CCM has become widely adopted in the U.S. and around the world (Coleman 2009). However, to date, research on the CCM has focused on the effectiveness of the CCM in larger healthcare system settings, with little emphasis on smaller primary care facilities that lack the formal infrastructure to support quality improvement efforts (Strickland et al. 2010). Based on the CCM, several types of Health Information Technology (HIT) are critical enablers of improving chronic care management. Electronic Health Records (EHR) can help institutions manage and share chronic care data. While the promise of the EHR has been espoused for over forty years, their adoption in North America has been limited (Goldschmidt 2005, Simon et al. 2007). More recently, clinical support systems incorporating evidence-based medicine have been integrated into some EHR systems. These systems aim to leverage patient information into recommendations, with the results provided to clinicians in a timely fashion, often in the form of alerts and reminders (Austin et al. 1994). Although these tools are supportive of chronic care management, the predominant share of provider organizations has not yet adopted them (Simon et al. 2007, Yu et al. 2009). Focusing on chronic care patients, personal health records (PHR) are also important. These systems interact with the providers' EHR systems, but there are challenging issues related to the security and confidentiality of records shared via the Internet (Grimson 2001, Pratt et al. 2006, Tang et al. …