There is global concern about healthcare cost, quality, and access as the prevalence of complex and chronic diseases, such as heart disease, continues to grow. Care for patients with complex chronic disease involves diverse practitioners and multiple transitions between medical centers, physician practices, clinics, community resources, and patient homes. There are few systems that provide the flexibility to manage these varied and complex interactions. Participatory and user-centered design methodology was applied to the first stage of building a mobile platform for care coordination for complex, chronic heart disease. Key informant interviews with patients, caregivers, clinicians, and care coordinators were conducted. Thematic analysis led to identification of priority user functions including shared care plan, medication management, symptom management, nutrition, physical activity, appointments, personal monitoring devices, and integration of data and workflow. Meaningful stakeholder engagement contributes to a person-centered system that enhances health and efficiency.

The Center for Medicare and Medical Services in the United States compares hospital's readmission performance to the facilities across the nation using a 30-day window from the hospital discharge. Heart Failure (HF) is one of the conditions included in the comparison, as it is the most frequent and the most expensive diagnosis for hospitalization. If risk stratification for readmission of HF patients could be carried out at the time of discharge from the index hospitalization, corresponding appropriate post-discharge interventions could be arranged. We, therefore, sought to compare two different risk prediction models using 48 clinical predictors from electronic health records data of 1037 HF patients from one hospital. We used logistic regression and random forest as methods of analyses and found that logistic regression with bagging approach produced better predictive results (C-Statistics: 0.65) when compared to random forest (C-Statistics: 0.61).

Cancer is a top concern globally. Cancer care suffers from lack of coordination, silos of information, and high cost. Interest is emerging in person-centered technology to assist with coordination to address these challenges. This study evaluates the usability of the "personal health network" (PHN), a novel solution leveraging social networking and mobile technologies, among individuals undergoing chemotherapy and receiving care coordination. Early results from interviews of 12 participants in a randomized pragmatic trial suggest that they feel more connected to the healthcare team using the PHN, find value in access to the patient education library, and are better equipped to organize the many activities that occur during chemotherapy. Improvements are needed in navigation, connectivity, and integration with electronic health records. Findings contribute to improvements in the PHN and informs a roadmap for potentially greater impact in technology-enabled cancer care coordination.