TABLE 2.

Care coordination studies

Year	Author	Title	Objective	Study design	Population	HIT component	User	Outcome	Results
RCT
2018	Salisbury et al. 88 a	Management of multimorbidity using a patient‐centered care model: a pragmatic cluster‐randomized trial of the 3D approach	Was the patient‐centered, so‐called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health‐related quality of life, which is the ultimate aim of the 3D intervention	Pragmatic cluster‐RCT of 33 GP practices in England and Scotland assigned to intervention or usual care and followed for 15 months (n = 1546)	Age > 18 with at least three chronic conditions	Multicomponent intervention “the 3D approach.” Note template including prompts to ask patients about their most important concerns, their quality of life, and to perform depression screening. The template created a print out of collaborative management plan including names of a specific physician and nurse on the patient's care team	Nurse, pharmacist, provider	Health‐related QOL (EQ‐5D‐5L; illness burden, treatment burden, medication adherence score, and number of medications, and patient‐centered care	The intervention was associated with significant improvements in measures of patient centered care. Adjusted difference in means for patients reporting having a written care plan, health plan, or treatment plan (mean = 1.97 p < 0.001); Patients reporting they almost always discuss the problems most important to them in managing their own health (mean = 1.85 p < 0.001) In the intention‐to‐treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ‐5D‐5L 0·00, 95% CI –0·02 to 0·02; p = 0·93)
Non‐RCT
2019	Kersting & Welterman 89	Evaluating the feasibility of a software prototype supporting the management of multimorbid seniors: mixed methods study in general practices	To evaluate the prototypes (which is add‐on for German EHR systems to support longitudinal care management) feasibility from both a technical and users' perspective	Mixed method study of feasibility interviews and questionnaires assigned to general practitioners and practice assistants (n = 18)	Age > 65 years	CDS eCare Plan: information flags (reminders) on age‐ and sex‐specific preventive measures, diagnosis‐specific measures, and/or for predefined patient groups and identify quality deficits by providing dynamic action flags such as critical for uncontrolled BP	General practitioners and practice assistants (German health care system)	Usefulness/usability	The new EHR add on was well accepted and achieved a good usability rating. The users found it easy to install and worked without problems; (78%) were interested in using the software long‐term; The system usability scored SUS 73%–78%; Challenges encountered were mainly installation, and EHR missing interface to extract needed data
2019	Laleci Erturkmen et al. 90	A collaborative platform for management of chronic diseases via guideline‐driven individualized care plans	To present a method and corresponding implementation of a semi‐automatic care plan management tool and further report the results of usability studies carried out in four pilot sites by patients and clinicians of a care planning platform “Coordinated Care and Cure Delivery Platform” which helps with care planning for older adults with multimorbidity.	Usability study of product reaction cards and Nielsen walkthrough heuristic evaluation assigned to care team members, patients, and experts (n = 22, n = 26, n = 5, respectively)	Age > 65 years with special emphasis on CDS for type 2 diabetes, renal failure, heart failure, and depression	CDS eCare Plan: risk prediction and stratification; personalized treatment goals and interventions; reconciliation of conflicting treatment options and management of polypharmacy; Patient Empowerment Platform to incorporate patient needs, preferences, and psychosocial aspects of care	Patients and care team members (providers, specialists, nurses, pharmacists, physical therapist, nutritionists, social worker, homecare staff	Usability: QUIS7 questionnaire on learning factors and product reaction cards	This method was able to address the needs of care plan personalization and implementing clinical care guidelines Feedback on usability: (1) 23% Collaborative, (2) 17% Useful Empowering (3) 14% Complex (4) 20% Time‐consuming for the subgroup of care team members. QUIS7 Learning scores = 5.8–6.17 out of 9 (9 as “easy”)
2019	Mann et al. 91	Can Implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice: mixed‐methods process evaluation	To examine whether the measured lack of effect on the primary outcome in the 3D trial was due to implementation or intervention failure	Mixed methods process evaluation Mixed methods study for a process evaluation of the 3D multimorbidity trial assigned to the trial's overall dataset (n = 1546)	Age > 18 years with at least three chronic conditions	Multicomponent intervention “the 3D approach.” See description of HIT component in 2018 Mann et al.	Nurse, pharmacist, provider	Adoption of the 3D intervention; delivery of 3D reviews to patients; maintenance and reach	Adoption was incomplete, 49% of patients received both reviews, 30% partially reviewed; In completed reviews >90% of components were delivered
2018	Mann et al. 92 a	A computer template to enhance patient‐centeredness in multimorbidity reviews: a qualitative evaluation in primary care	To evaluate the effect on patient‐centeredness of a novel computer template used in multimorbidity reviews	Observations and interviews about a computerized note template as one component in a multicomponent RCT assigned to clinicians receiving intervention and usual care (n = 37)	Age > 18 years with at least three chronic conditions	Electronic disease template: 3D review template, structures chronic disease management, and data recording. The template prompts to ask patients about their important concerns, quality of life, and to perform depression screening. A report is printed out for collaborative management plan including names of the care team	Nurse, pharmacist, provider	Observations of different activities performed in intervention and control visits, perceptions of patient‐centeredness of visit	Patients' perceptions of the patient centeredness of reviews enhanced and patients appreciated the more complete comprehensive reviews; most clinicians admired identifying patients' agendas. Users stated that the template usage disrupted eye contact and dialog
2016	de Jong et al. 93	How professionals share an e‐care plan for the elderly in primary care: evaluating the use of an e‐communication tool by different combinations of professionals	To evaluate the use of a tool, Congredi, for electronic communication by professionals for the care of home‐dwelling elderly patients	Observational study of patient record analysis from the Congredi system assigned to patients and social workers and followed for 42 weeks (n = 448, n = 203, respectively)	Home‐dwelling elderly patients with MCCs in the Hague region of the Netherlands	e‐Communication and coordination tool; Named Congredi: an application for documenting care planning activities; emailing; linking other providers	Nurses, general practitioners, others professionals	Platform utility (number of contributors and number of activities documented)	A large group of professionals (n = 203, 21%) were active in 448 patient records. Where, three types of actions were registered: care activities (mean = 9.14), emailing (mean = 0.89), and process activities (mean = 0.29). Determined to be usable for improving multidisciplinary communication among professionals.
2014	Makai et al. 94	Evaluation of an eHealth intervention in chronic care for frail older people: why adherence is the first target	To investigate the effectiveness of an online health community (OHC) intervention for older people with frailty aimed at facilitating multidisciplinary communication	Observational controlled trial of 17 practices in university primary care network around the city of Nijmegen, the Netherlands, assigned to before and after implementation and followed for 12 months (n = 682)	Frail older patients identified through EASYcare Two‐step Older person Screening	Online health community (ZWIP) which contains a secure messaging system supplemented by a shared electronic health record. Access can be granted to clinicians by patients or their caregivers.	Frail older patients, their caregivers, general practitioners	Katz ADL, Katz 15, SF‐36 (mental health and social limitation), patient and GP rating of care coordination, patient experience	The use of this OHC did not significantly improve patient outcome. 26% of intervention patients used ZWIP at least once per month standardized difference between study groups for ADL 0.21; 95% CI −0.17 to 0.59; p = 0.27; for SF‐36 mental −8.34; 95% CI −17.02 to 0.34; SF‐36 social 0.84; 95% CI −0.78 to 2.45
2013	Martinez‐Garcia et al. 95	Sharing clinical decisions for multimorbidity case management using social network and open‐source tools	To develop a tool for collaborative work among health professionals for multimorbidity patient care	Pilot study of the use and acceptance of the SCP by health care professionals through questionnaire based on the theory of the technology acceptance model assigned to Internal Medicine dept. of a University Hospital in Seville, Spain and two primary care centers and followed for 6 months (n = 16)	Patients with >2 chronic conditions	Web application and social network technologies The Shared Care Platform (SCP) includes: a social network component (the Clinical Wall and enables communication/collaboration b/t health professionals, the future version of SCP will include CDS, patient assessment section, discussion section, conclusion section)	Nurses, primary care providers, internists	Usability	During the pilot 16 records created in Clinical Wall; A total of 10 professionals exchanged 33 messages; 12 of the 16 records (75%) were answered by the targeted health professionals; providers valued the clinical wall with mean scores of 7.87 for intention to use; 7.54 for perceived usefulness; 7.08 for perceived ease of use; 7.74 for subjective norm; 6.85 for facilitating condition;

Abbreviations: 3D, three‐dimensional; ADL, activities of daily living; health IT, health information technology, CDS, clinical decision support; eCare, electronic care; EHR, electronic health record; EQ‐5D‐5L, health‐related quality of life instrument; PLWMCC, people living with multiple chronic conditions; QOL, quality of life; QUIS7, questionnaire for user interaction satisfaction 7; RCT, randomized controlled trial; SUS, system usability score.

^aThe 3D study: improving whole person care in England and Scotland.