CARE
PLANS
PART 2: THE CURRENT LANDSCAPE
This piece is a continuation of the Care Plan series. While Part 1 focused on what care plans are and how they came about, this article will explore how care plans are currently being used in the health space.
The Process of a Care Plan
There is not yet any clinically recognized universal standard for care plan creation and implementation. But using elements derived from CMS’s Meaningful Use Stage 2 requirements,1,2 the Coordinated Care Plan documentation from the Ontario Medical Association,3 the traditional nursing care plan structure,4 and the Care Plan Glossary from the ONC’s Standards and Interoperability Framework,5 we have created a generalized care plan journey map below.
The journey begins with a patient visiting his primary care doctor.
Understand Health History
The beginning of any care plan process, whether creation or review, requires an understanding of the patient’s health history. This should be summative in nature, and include basic information such as demographics, care team, vitals, problems, allergies, medications, therapies, notable encounters or procedures, and an indication of whether an advance care plan is in place. It is important to keep a patient summary up to date so that any care professional can reference it in an emergency.
Identify Health Concerns
The next step is to identify what the current problems or health concerns are. This can involve reviewing symptomology, eating habits, physical activity, sleep habits, psychological issues, management of medication, sexual health, cessation of bad habits, management of any other daily activity, or any social or environmental factors on health. Collection of vitals might also be involved in the identification of health concerns.
Set Goals
Goals are set to improve or resolve the identified health problems by the next review period. SMART goals (specific, measurable, achievable, realistic, time oriented) help break down goals into smaller specific steps. Goals should also be measured in a way that’s quantifiable so that changes can be seen over a pratice timeframe. These can include both patient defined goals such as longevity, function, comfort, etc., and clinician defined goals.
Instruct and Intervene
After the desired outcomes are specified, the interventions and instructions on how to acheive those goals can be delivered. Instructions are educational directions to the patient/other providers about how to care for the patient's condition, what to do at home, when to call for help, additional appointments, testing, medication changes/instructions, among others. Interventions are specified actions taken as steps toward achieving care plan goals. This can include adminstration of physical treatment, creation or adjustment to the medication plan, prescribed activities or community/social services, or removal of barriers to success.
Enlist Care Team
A team of individuals should be enlisted in the care of the patient. The care team includes both professional parties who manage and/or provide care, including medical practitioners, nurses, allied health practitioners (physiotherapist, speech therapist psychologist, pharmacist, etc.), social workers, and care managers; as well as non-professional members such as caregivers, family, friends, and the patient themselves. It should be determined by the patient which care team members are granted access to his or her health information.
Specify Outcomes to Review
It is important to set a specfic time for review of the care plan to determine whether patient needs are being met and if adjustments need to be made. Low level, relatively healthy individuals may only need an annual review of the care plan, whereas those with more severe chronic illnesses may need a much more frequent checkup. Specific metrics for followup should be determined based on the health concerns and goals set.
Live the Care Plan
The most important part of the care plan process is how the patient implements it. They must translate guidance from their brief interactions with clinicians into sustained lifestyle behaviors to improve their own health. Self care makes up over 99% of healthcare, and it is only successful with a good care plan.
The process is a cycle. Patients live the care plan until the next medical encounter.
Understand Health History
The beginning of any care plan process, whether creation or review, requires an understanding of the patient’s health history. This should be summative in nature, and include basic information such as demographics, care team, vitals, problems, allergies, medications, therapies, notable encounters or procedures, and an indication of whether an advance care plan is in place. It is important to keep a patient summary up to date so that any care professional can reference it in an emergency.
Identify Health Concerns
The next step is to identify what the current problems or health concerns are. This can involve reviewing symptomology, eating habits, physical activity, sleep habits, psychological issues, management of medication, sexual health, cessation of bad habits, management of any other daily activity, or any social or environmental factors on health. Collection of vitals might also be involved in the identification of health concerns.
Set Goals
Goals are set to improve or resolve the identified health problems by the next review period. SMART goals (specific, measurable, achievable, realistic, time oriented) help break down goals into smaller specific steps. Goals should also be measured in a way that’s quantifiable so that changes can be seen over a pratice timeframe. These can include both patient defined goals such as longevity, function, comfort, etc., and clinician defined goals.
Instruct and Intervene
After the desired outcomes are specified, the interventions and instructions on how to acheive those goals can be delivered. Instructions are educational directions to the patient/other providers about how to care for the patient's condition, what to do at home, when to call for help, additional appointments, testing, medication changes/instructions, among others. Interventions are specified actions taken as steps toward achieving care plan goals. This can include adminstration of physical treatment, creation or adjustment to the medication plan, prescribed activities or community/social services, or removal of barriers to success.
Enlist Care Team
A team of individuals should be enlisted in the care of the patient. The care team includes both professional parties who manage and/or provide care, including medical practitioners, nurses, allied health practitioners (physiotherapist, speech therapist psychologist, pharmacist, etc.), social workers, and care managers; as well as non-professional members such as caregivers, family, friends, and the patient themselves. It should be determined by the patient which care team members are granted access to his or her health information.
Specify Outcomes to Review
It is important to set a specfic time for review of the care plan to determine whether patient needs are being met and if adjustments need to be made. Low level, relatively healthy individuals may only need an annual review of the care plan, whereas those with more severe chronic illnesses may need a much more frequent checkup. Specific metrics for followup should be determined based on the health concerns and goals set.
Live the Care Plan
The most important part of the care plan process is how the patient implements it. They must translate guidance from their brief interactions with clinicians into sustained lifestyle behaviors to improve their own health. Self care makes up over 99% of healthcare, and it is only successful with a good care plan.
The process is a cycle. Patients live the care plan until the next medical encounter.
The Care Plan Product Landscape
As of January 2015, CMS transitioned Medicare to the more quality-based practice of reinbursing for care management of eligible patients with 2 or more chronic conditions. Now, physicians, certified nurse specialists, nurse practitioners, and physician assistants are incentivized to perform 20 minutes of non-face-to-face care coordination services for every Medicare-qualifying patient each month. This can include tasks such as recording and coordinating patient health information (even from outside their own practice), managing care transitions (such as discharge from a hospitalization), coordinating clinical home or community services, systematic assessments of patient needs, and finally, the creation and review of a perpetually accessible comprehensive care plan. Now that Medicare has begun this transition, other private insurance companies are beginning to follow suit to prioritize consistent, preventative care facilitated by patient-accessible care plans. As a result, many care planning services have emerged to address the software needs of care management.
This matrix aims to explore the effectiveness of current care plan services based on defined criteria. Each service was scored based on the percentage of criteria met in each of the eleven topic areas. A 0 means that none of the criteria points were fulfilled. Click on each criteria at the top of the matrix to break down what subcriteria were used for scoring. The final score, out of 100, is the average of the service’s scores in each criteria area.
|
50Interoperability | 50Patient Summary | 80Education | 60Goal Setting | 25Vitals Tracking | 50Dynamic Intervention | 75Data Ownership | 43Prof. Team Comm. | 0Non-prof. Team Comm. | 100Clinical Validity | 50Content Breadth | 53.00Average |
|
33 | 25 | 60 | 80 | 50 | 50 | 75 | 0 | 0 | 75 | 75 | 47.55 |
|
20 | 25 | 60 | 80 | 0 | 0 | 75 | 86 | 17 | 50 | 100 | 46.64 |
|
40 | 75 | 20 | 0 | 25 | 0 | 75 | 71 | 0 | 75 | 100 | 43.73 |
|
20 | 50 | 0 | 40 | 0 | 0 | 50 | 14 | 66 | 0 | 30 | 24.55 |
|
80 | 100 | 20 | 40 | 50 | 0 | 100 | 29 | 83 | 25 | 100 | 57.00 |
|
80 | 50 | 20 | 80 | 0 | 0 | 75 | 0 | 100 | 25 | 30 | 34.55 |
|
100 | 75 | 40 | 20 | 0 | 0 | 75 | 57 | 0 | 50 | 70 | 44.27 |
|
40 | 100 | 25 | 20 | 0 | 0 | 75 | 29 | 0 | 0 | 70 | 32.64 |
|
80 | 75 | 40 | 0 | 25 | 0 | 50 | 43 | 0 | 0 | 70 | 34.82 |
|
80 | 50 | 0 | 0 | 25 | 0 | 75 | 29 | 0 | 50 | 80 | 35.36 |
|
80 | 50 | 20 | 60 | 100 | 0 | 100 | 29 | 0 | 50 | 100 | 53.55 |
|
0 | 25 | 40 | 0 | 25 | 50 | 75 | 29 | 0 | 0 | 80 | 29.45 |
|
83 | 75 | 20 | 20 | 25 | 0 | 100 | 29 | 0 | 50 | 70 | 42.91 |
|
60 | 50 | 0 | 0 | 50 | 0 | 75 | 29 | 0 | 0 | 70 | 30.36 |
|
83 | 0 | 60 | 60 | 25 | 0 | 50 | 0 | 0 | 25 | 10 | 20.91 |
|
33 | 25 | 0 | 0 | 75 | 0 | 50 | 0 | 0 | 0 | 100 | 25.73 |
There is a clear distinction between patient portal services (Bridge, Patient Fusion, Intelichart) focused on data interoperability, health history, and professional care team communication; and the less clinical services (CareZone, Healthtap, Wellframe, Healarium) focused on patient engagement, goal setting, and non-professional care team communication. Wellframe, CareSync, and HealthVault are the few services that attempt to bridge the gap between those two focuses, putting them at the top of ranking as the more successful care plan services.
However, certain deficits seem to be shared by almost all of these services. While interoperability is a growing focus, there still seems to be trouble in adopting a universal data standard for content and holding services to consistent clinical quality metrics. Many services successfully incorporate data tracking and visualizations, though there is virtually no presence of actual insight from this data. Users are not receiving projected outcomes or recommendatons for behavior change based on collected data. Similarly, while users can access all of their health data, they rarely get to ‘own’ it. This means being presented the raw data for export, sharing, and personal documentation.
These limitations, and others collected through secondary literature research are explored further below.
The Care Plan Product Landscape
This matrix aims to explore the effectiveness of current care plan services based on defined criteria. Each service was scored based on the percentage of criteria met in each of the eleven topic areas. A 0 means that none of the criteria points were fulfilled. Click on each criteria at the top of the matrix to break down what subcriteria were used for scoring. The final score, out of 100, is the average of the service’s scores in each criteria area.
Interoperability
- Complies with meaningful use requirements.
- Meets CDA and/or FHIR data standards to integrate with EHRs.
- Meets CQRM standard compliance.
- HIPAA compliant.
- Integrates with clinical workflows.
- Compatible with many devices.
|
|
50
|
|||
|
|
33
|
|||
|
|
20
|
|||
|
|
40
|
|||
|
|
20
|
|||
|
|
80
|
|||
|
|
||||
|
|
100
|
|||
|
|
40
|
|||
|
|
80
|
|||
|
|
80
|
|||
|
|
80
|
|||
|
|
||||
|
|
83
|
|||
|
|
60
|
|||
|
|
||||
|
|
33
|
History
- Provides overview of general health condition.
- Service takes into account patients individual health concerns.
- Provides comprehensive medical history.
- Ease of obtaining medical record or medical history information.
|
|
50
|
|||
|
|
25
|
|||
|
|
25
|
|||
|
|
75
|
|||
|
|
50
|
|||
|
|
100
|
|||
|
|
50
|
|||
|
|
75
|
|||
|
|
100
|
|||
|
|
75
|
|||
|
|
50
|
|||
|
|
50
|
|||
|
|
25
|
|||
|
|
75
|
|||
|
|
50
|
|||
|
|
||||
|
|
25
|
Education
- Personalized, time-based instructions from care providers for both short and long term.
- Dynamic instructions based on assessment of understanding and new data.
- Education reinforcement through reminders, and context-sensitive notifications.
- Links to external relevant resources.
- Accounts for individual demographics (language, culture, age etc.)
|
|
80
|
|||
|
|
60
|
|||
|
|
60
|
|||
|
|
20
|
|||
|
|
||||
|
|
20
|
|||
|
|
20
|
|||
|
|
40
|
|||
|
|
25
|
|||
|
|
40
|
|||
|
|
||||
|
|
20
|
|||
|
|
40
|
|||
|
|
20
|
|||
|
|
||||
|
|
60
|
|||
|
|
Goal Setting
- Education-facilitated goal setting with or without clinician input.
- Editable and shareable plan of time-based goals.
- Patient encouragement and incentive.
- Feedback on progress toward goals.
- Projected outcomes based on current adherence trends.
|
|
60
|
|||
|
|
80
|
|||
|
|
80
|
|||
|
|
||||
|
|
40
|
|||
|
|
40
|
|||
|
|
80
|
|||
|
|
20
|
|||
|
|
20
|
|||
|
|
||||
|
|
||||
|
|
60
|
|||
|
|
||||
|
|
20
|
|||
|
|
||||
|
|
60
|
|||
|
|
Vitals Tracking
- Tracks progress towards specified care plan goals either manually through user input or through ambient sensors.
- Collects and stores biometric data such as heart rate, blood pressure, respiration patterns, posture, weight, physical activity, etc.
- Connects with other health applications and services (HealthKit, Fitbit, Jawbone, Withings, etc.) that track vitals.
- Ability to view trends in data.
|
|
25
|
|||
|
|
50
|
|||
|
|
||||
|
|
25
|
|||
|
|
||||
|
|
50
|
|||
|
|
||||
|
|
||||
|
|
||||
|
|
25
|
|||
|
|
25
|
|||
|
|
100
|
|||
|
|
25
|
|||
|
|
25
|
|||
|
|
50
|
|||
|
|
25
|
|||
|
|
75
|
Dynamic Intervention
- Provides summative insights about health status and actionable recommendations/education for improvement.
- Provides projected outcome of recommended intervention.
- Communicates summative trends in progress and health concerns to providers.
- Incorporates provider input into dynamic care plan.
|
|
50
|
|||
|
|
50
|
|||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
50
|
|||
|
|
||||
|
|
||||
|
|
||||
|
|
Access
- Provides secure access and proxy rights to view and edit health information
- Provides ability to export health information for personal records.
- Accessibility from many devices.
- Real time updating to the most recent health information.
|
|
75
|
|||
|
|
75
|
|||
|
|
75
|
|||
|
|
75
|
|||
|
|
50
|
|||
|
|
100
|
|||
|
|
75
|
|||
|
|
75
|
|||
|
|
75
|
|||
|
|
50
|
|||
|
|
75
|
|||
|
|
100
|
|||
|
|
75
|
|||
|
|
100
|
|||
|
|
75
|
|||
|
|
50
|
|||
|
|
50
|
Professional Care team communication
- Collects and stores contact information for all professional providers of care.
- Provides a search engine to locate and contact new care provider.
- Can schedule a physical or virtual appointment with a care provider.
- Can call or send an asynchronous message to care provider.
- Can synchronously chat or virtually consult with a care provider.
- Communication can be recorded and stored for later review.
- Can provide access to all or specific health information to select care providers.
|
|
43
|
|||
|
|
||||
|
|
86
|
|||
|
|
71
|
|||
|
|
14
|
|||
|
|
29
|
|||
|
|
||||
|
|
57
|
|||
|
|
29
|
|||
|
|
43
|
|||
|
|
29
|
|||
|
|
29
|
|||
|
|
29
|
|||
|
|
29
|
|||
|
|
29
|
|||
|
|
||||
|
|
Non-Professional Care team communication
- Collects and stores contact information for all non-professional caregivers, friends, and family members involved in care.
- Can call or send an asynchronous message to caregiver.
- Can synchronously chat or virtually consult with a caregiver.
- Can synchronously chat or virtually consult with a caregiver.
- Can collaborate on health tasks with caregivers.
- Can provide access to all or specific health information to select caregivers.
|
|
||||
|
|
||||
|
|
17
|
|||
|
|
||||
|
|
66
|
|||
|
|
83
|
|||
|
|
100
|
|||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
||||
|
|
Clinical Validity
- Clinical trials or studies conducted to objectively view health efficacy.
- Involves vetted care professionals.
- Integration with clinical workflows.
- Reputable health or medical organizations or professionals behind product development.
|
|
100
|
|||
|
|
75
|
|||
|
|
50
|
|||
|
|
75
|
|||
|
|
||||
|
|
25
|
|||
|
|
25
|
|||
|
|
50
|
|||
|
|
||||
|
|
||||
|
|
50
|
|||
|
|
50
|
|||
|
|
||||
|
|
50
|
|||
|
|
||||
|
|
25
|
|||
|
|
Content Breadth
Covers the areas of:
- Nutrition
- Physical activity
- Sleep
- Mental resilience.
- Medication management.
- Bad habit cessation
- Sexual health.
- Managing activities of daily living.
|
|
50
|
|||
|
|
75
|
|||
|
|
100
|
|||
|
|
100
|
|||
|
|
30
|
|||
|
|
100
|
|||
|
|
30
|
|||
|
|
70
|
|||
|
|
70
|
|||
|
|
70
|
|||
|
|
80
|
|||
|
|
100
|
|||
|
|
80
|
|||
|
|
70
|
|||
|
|
70
|
|||
|
|
10
|
|||
|
|
100
|
Average
Criteria areas included: interoperability, patient summary, education, goal setting, vitals tracking, dynamic intervention, data ownership, profession and non-professional care team communication, clinical validity, and content breadth. The average score of all areas is show below. Scroll left or right to view individual criteria scores.
|
|
53.00
|
|||
|
|
47.55
|
|||
|
|
46.64
|
|||
|
|
43.73
|
|||
|
|
24.55
|
|||
|
|
57.00
|
|||
|
|
34.55
|
|||
|
|
44.27
|
|||
|
|
32.64
|
|||
|
|
34.82
|
|||
|
|
35.36
|
|||
|
|
53.55
|
|||
|
|
29.45
|
|||
|
|
42.91
|
|||
|
|
30.36
|
|||
|
|
20.91
|
|||
|
|
25.73
|
The Barriers to Care Planning
Episodic Review
Implementation of care plans are not always straightforward, and information must be updated in a fluid manner in order for it to be an effective plan. However, difficulties can arise when there is a lack of ability within a patient’s circle of care providers to access and update care plans. One factor can include difficulty in using the tool or application to update care plans.3
Inaccurate Information
The Change Foundation in Ontario found that up to a ⅓ of providers regularly relied on the caregiver and client to pass along information that was relevant to building the care plan.3 This can be an issue when human error, both on the client and care provider side, may cause inaccurate recording of an individual’s information. Patients at times may give inaccurate information regarding medications currently being taken. Care providers also oftentimes misjudge a patient’s capacity to manage themselves within a home environment.7
Creation in isolation
There is no current standardization of care plan content across health and social care organizations, as each functions under their own methods for care plan creation.9 This creates a lack of consistency across the medical community, and increases the potential for medical error when organizations must interface on behalf of a patient. Not to mention patients receiving different medical advice and instruction for the same illnesses across organizations will likely struggle with understanding and consequently, compliance.10
Communication issues
Patients and their medical providers suffer from poor information transfer, due to issues such as lack of time, lack of a standardized communication tool, the need to incorporate care planning and communication into the workflow, lack of compatible information technology across organizations, and privacy concerns of caregivers and patients. As healthcare IT systems are still in a relatively nascent stage and must adhere to a variety of patient confidentiality regulations, effective communication is still a crucial limitation.8
Privacy concerns
Many situations can arise where it’s difficult to know who to share the patient’s information with without causing privacy issues. An issue that causes problems in communication is that the caregivers themselves are sometimes reluctant to share information with care providers due to privacy concerns.6
Patient Noncompliance
Patient compliance is a difficult issue to address, and may be part of the reason that new roles such as grand-aides are beginning to appear in the healthcare landscape.11 Some patients are not motivated to set goals. Others have issues complying with their medication and diet requirements. Those with mental illnesses are even more prone to discontinue medications without consulting a care provider.3
The Next Steps for Care Plans
Care plans have come a long way since their conception. We have created a somewhat systematic approach to a patient health guide, yet have not standardized it for consistant communication and delivery of care. We have established appropriate intervention steps for a variety of diagnosed conditions, yet have not mastered the format and delivery of these steps so that they are effective and engaging to patients. We have figured out how to collect massive amounts of crucial patient health data, yet we have not offered that data to the patient to carry with them and seamlessly share throughout their diverse medical encounters. We are only on the cusp of the health technology wave, and care plans have a bright future ahead of them. Want a glimpse? Check out our next feature.
Authors
GoInvo
Beckett Rucker, MPD
@beckettrucker
Beckett is designer, product strategist, and researcher. She concentrates on designing beautiful and surprising health services and systems from the skintop to celltop to desktop. She holds bachelors of arts in psychology and studio art from Rice University and a master of product development from Carnegie Mellon University. She has worked on design and service strategy for companies such as Seniorlink, Johnson & Johnson, and Updox Patient Portals.
GoInvo
Edwin Choi, MA
Edwin is a biologist turned designer. Combining the sciences and art, he orchestrates healthcare software experiences to be beautiful and clinically refined. Edwin is a graduate of Washington University, and has a masters in biomedical design from Johns Hopkins University. He has worked on projects for companies including Partners Healthcare and Notovox.
Health Hats
Danny van Leeuwen, RN, MPH, CPHQ
@HealthHats
Danny is an action catalyst empowering people traveling together toward best health (patients, caregivers, clinicians). He wears many hats in healthcare: patient with MS, care partner for several family members’ end-of-life journeys, a nurse for 40+ years, an informaticist and a QI leader. Danny’s current work focuses on communication at transitions of care, person-centered health planning, informed decision-making, and technology supporting solutions created with and for people at the center. He has collaborated with PCORI, AHRQ, and MassHealth among others.
Contributors
Web Designer & Developer
Yanyang Zhou
Web Designer & Developer
Jennifer Patel
@catamariface
GoInvo, MIT
Juhan Sonin
@jsonin
University of Missouri | toomanyclicks.com
Jeff Belden, MD
@jeffbelden
University of Michigan
Joyce Lee, MD, MPH
@joyclee
THINK-Health | Health Populi blog | Huffington Post
Jane Sarasohn-Kahn, MA, MHSA
@healthythinker
Healthcare Provocateur
Harry Sleeper
@harrysleeper
References
- 1. “Stage 2 Meaningful Use Core Measures”. (2015, August). Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_15_SummaryCare.pdf
- 2. United States, Department of Health and Human Services. “Chronic Care Management Services”. S(2015, May). Centers for Medicare and Medicaid Services. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf
- 3. “Key Elements to Include in a Coordinated Care Plan”. OMA. (2014, June). Retrieved November/December, 2015, from https://www.oma.org/Resources/Documents/CoordinatedCarePlan_June2014.pdf
- 4. “NHS Guide to long-term conditions and self care: What is a care plan?” (n.d.). Retrieved December 21, 2015, from http://www.nhs.uk/Planners/Yourhealth/Pages/Careplan.aspx
- 5. General Information. (n.d.). Retrieved December 25, 2015, from http://wiki.siframework.org/LCC Longitudinal Care Plan (LCP) SWG
- 6. Circle of Care. (2015, August). Retrieved December 25, 2015, from https://www.ipc.on.ca/images/Resources/circle-of-care.pdf
- 7. Palmieri, J. J., & Stern, T. A. (2009). Lies in the Doctor-Patient Relationship. Prim. Care Companion J. Clin. Psychiatry The Primary Care Companion to The Journal of Clinical Psychiatry,11(4), 163-168
- 8. Better communication between caregivers reduces medical errors, study finds. (n.d.). Retrieved December 20, 2015, from https://med.stanford.edu/news/all-news/2014/12/better-communication-between-caregivers-reduces-medical-errors.html
- 9. Resource Careplan. (n.d.). Retrieved December 20, 2015, from https://www.hl7.org/fhir/careplan.html
- 10. How to Deal with Conflicting Advice from Healthcare Professionals. (n.d.). Retrieved January 25, 2016, from http://www.brainline.org/content/2009/06/how-to-deal-with-conflicting-advice-from-healthcare-professionals.html
- 11. Garson, A., Green, D. M., Rodriguez, L., Beech, R., & Nye, C. (2012). A New Corps Of Trained Grand-Aides Has The Potential To Extend Reach Of Primary Care Workforce And Save Money. Health Affairs, 31(5), 1016-1021.
- 12. Wellframe. (n.d.). Retrieved December 19, 2015, from http://www.wellframe.com/
- 13. Healarium. (n.d.). Retrieved December 15, 2015, from http://www.healarium.com/
- 14. HealthTap. (n.d.). Retrieved December 17, 2015, from https://www.healthtap.com/
- 15. Amwell. (n.d.). Retrieved December 21, 2015, from https://amwell.com/
- 16. CareZone | Easily organize health information in one place. (n.d.). Retrieved December 22, 2015, from https://carezone.com/home
- 17. Caresync. (n.d.). Retrieved December 20, 2015, from http://www.caresync.com/
- 18. Caring in Place. (n.d.). Retrieved December 20, 2015, from http://caringinplace.com/website/index.html
- 19. Patient Portal Software for Hospitals and Physicians :: Bridge Patient Portal. (n.d.). Retrieved December 19, 2015, from http://www.bridgepatientportal.com/
- 20. Inxite Health Systems. (n.d.). Retrieved December 20, 2015, from https://www.inxitehealth.com/
- 21. My Care Plan. (n.d.). Retrieved December 17, 2015, from http://www.journeyforward.org/planning-tools/my-care-plan
- 22. Online Patient Portal Software - InteliChart. (n.d.). Retrieved December 22, 2015, from http://www.intelichart.com/
- 23. Microsoft HealthVault. (n.d.). Retrieved December 20, 2015, from https://www.healthvault.com/us/en
- 24. Patient Fusion. (n.d.). Retrieved December 18, 2015, from https://www.patientfusion.com/
- 25. Epic: Mobile Applications and Portals. (n.d.). Retrieved December 20, 2015, from https://www.epic.com/software-phr.php
- 26. AskMD. (n.d.). Retrieved December 28, 2015, from https://www.sharecare.com/askmd/get-started
- 27. Medfusion Plus - Medfusion. (n.d.). Retrieved December 21, 2015, from http://www.medfusion.com/solutions/medfusion-plus/