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Keywords

Care coordination, DIKW framework, Meaningful use, Telehealth

 

Authors

  1. LOOMAN, WENDY S. PhD, RN, CNP
  2. ERICKSON, MARY M. DNP, RN, CNP
  3. GARWICK, ANN W. PhD, RN
  4. CADY, RHONDA G. PhD, RN
  5. KELLY, ANNE MD
  6. PETTEY, CARRIE MD
  7. FINKELSTEIN, STANLEY M. PhD

Abstract

Meaningful use of electronic health records to coordinate care requires skillful synthesis and integration of subjective and objective data by practitioners to provide context for information. This is particularly relevant in the coordination of care for children with complex special healthcare needs. The purpose of this article is to present a conceptual framework and example of meaningful use within an innovative telenursing intervention to coordinate care for children with complex special healthcare needs. The TeleFamilies intervention engages an advanced practice nurse in a full-time care coordinator role within an existing hospital-based medical home for children with complex special healthcare needs. Care coordination is facilitated by the synthesis and integration of internal and external data using an enhanced electronic health record and telehealth encounters via telephone and videoconferencing between the advanced practice nurse and the family at home. The advanced practice nurse's ability to maintain an updated plan of care that is shared across providers and systems and build a relationship over time with the patient and family supports meaningful use of these data.