Table 2.

Alignment of the CCM to open source EHRs

CCM element	MedLynx	OpenMRSLA
Create a culture, organization and mechanisms that promote safe, high quality care	Upon implementation of MedLynx, care team were formed to provide chronic care with their responsibilities mapped to the EHR	The OpenMRSLA system was specifically redesigned for JWCH Institute Inc., to track and monitor the tuberculosis status of the homeless population they serve
Assure the delivery of effective, efficient clinical care and self-management support	MedLynx incorporated clinical reminders and alerts for the management and treatment of diabetes, hypertension and hyperlipidemia as well as supporting collaborative care between the provider and patient	JWCH coordinated housing and social services along with OpenMRSLA to track and identify those individuals who needed a current tuberculosis vaccination or who had previously received one
Promote clinical care that is consistent with scientific evidence and patient preferences	The clinical reminders and alerts used with MedLynx are aligned with current evidence-based practice in diabetes care	Tuberculosis is a treatable and manageable condition and inoculations were given to those who were found within OpenMRSLA to not be in compliance
Organize patient and population data to facilitate efficient and effective care	MedLynx would evaluate each patient's vital signs and medical history to determine the procedures and/or tests need for diabetes care	OpenMRSLA would coordinate housing, social service and medical data to determine the tuberculosis status of an individual, the medical program they were on, and their current housing situation
Empower and prepare patients to manage their health and healthcare	Educational modules with MedLynx provided information to patients about appropriate diabetes care	By tracking the tuberculosis and housing status of an individual, JWCH could provide more effective outreach
Mobilize community resources to meet needs of patients	Primary Care Systems used MedLynx to coordinate care within the community health network of West Virginia and provide information on a patient's chronic care status	JWCH worked within the larger SSRHI initiative to improve health services for the homeless by providing a patient's current condition and tuberculosis status through OpenMRSLA

CCM, chronic care model; EHR, electronic health record; SSRHI, Skid Row Homeless Healthcare Initiative.