title: A practice-based information system for multi-disciplinary care of chronically ill patients: what information do we need? The Community Care Coordination Network Database Group.
abstract: Primary care physicians provide longitudinal care for chronically ill individuals in concert with many other community-based disciplines. The care management of these individuals requires data not traditionally collected during the care of well, or acutely ill individuals. These data not only concern the patient, in the form of patient functional status, mental status and affect, but also pertain to the caregiver, home environment, and the formal community health and social service system. The goal of the Community Care Coordination Network is to build a primary care-based information system to share patient data and communicate patient related information among the community-based multi-disciplinary teams. One objective of the Community Care Coordination Network is to create a Community Care Database for chronically ill individuals by identifying those data elements necessary for efficient multi-disciplinary care.
authors.affiliation: Department of Internal Medicine, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina.
authors.forename: W P
authors.initials: WP
authors.lastname: Moran
authors.forename: C
authors.initials: C
authors.lastname: Messick
authors.forename: P
authors.initials: P
authors.lastname: Guerette
authors.forename: R
authors.initials: R
authors.lastname: Anderson
authors.forename: D
authors.initials: D
authors.lastname: Bradham
authors.forename: J L
authors.initials: JL
authors.lastname: Wofford
authors.forename: R
authors.initials: R
authors.lastname: Velez
mesh_terms: D002908:Chronic Disease / Q000628:therapy*; D003153:Community Health Services; D003195:Computer Communication Networks; D016208:Databases, Factual; D006801:Humans; D016347:Medical Records Systems, Computerized; D010347:Patient Care Planning; D010348:Patient Care Team