title: Guiding Principles for Data Architecture to Support the Pathways Community HUB Model.
abstract: BACKGROUND
  The Pathways Community HUB Model provides a unique strategy to effectively supplement health care services with social services needed to overcome barriers for those most at risk of poor health outcomes. Pathways are standardized measurement tools used to define and track health and social issues from identification through to a measurable completion point. The HUB use Pathways to coordinate agencies and service providers in the community to eliminate the inefficiencies and duplication that exist among them.
  Experience with the Model has brought out the need for better information technology solutions to support implementation of the Pathways themselves through decision-support tools for care coordinators and other users to track activities and outcomes, and to facilitate reporting. Here we provide a basis for discussing recommendations for such a data infrastructure by developing a conceptual model that formalizes the Pathway concept underlying current implementations.
  The main contribution is a set of core recommendations as a framework for developing and implementing a data architecture to support implementation of the Pathways Community HUB Model. The objective is to present a tool for communities interested in adopting the Model to learn from and to adapt in their own development and implementation efforts.
  Experience with the Community Health Access Project (CHAP) data base system (the core implementation of the Model) has identified several issues and remedies that have been developed to address these issues. Based on analysis of issues and remedies, we present several key features for a data architecture meeting the just mentioned recommendations.
  Presentation of features is followed by a practical guide to their implementation allowing an organization to consider either tailoring off-the-shelf generic systems to meet the requirements or offerings that are specialized for community-based care coordination.
  
  
  CONCLUSIONS
  Looking to future extensions, we discuss the utility and prospects for an ontology to include care coordination in the Unified Medical Language System (UMLS) of the National Library of Medicine and other existing medical and nursing taxonomies.
  
  
  CONCLUSIONS
  Pathways structures are an important principle, not only for organizing the care coordination activities, but also for structuring the data stored in electronic form in the conduct of such care. We showed how the proposed architecture encourages design of effective decision support systems for coordinated care and suggested how interested organizations can set about acquiring such systems. Although the presentation focuses on the Pathways Community HUB Model, the principles for data architecture are stated in generic form and are applicable to any health information system for improving care coordination services and population health.
authors: Arizona Center for Integrative Modeling and Simulation and Rtsync Corp.
authors: Bernard P
authors: BP
authors: Zeigler
authors: Care Coordination Systems.
authors: Sarah
authors: S
authors: Redding
authors: Pathways Community HUB Certification Program.
authors: Brenda A
authors: BA
authors: Leath
authors: Prince Georges County Health Department.
authors: Ernest L
authors: EL
authors: Carter
authors: Arizona Center for Integrative Modeling and Simulation and Rtsync Corp.
authors: Cynthia
authors: C
authors: Russell
keywords: Care Coordination; Data Architecture; Pathways Model