Lori Popejoy, PhD, APRN, GCNS-BC, FAAN
Mary L. Hook, PhD, RN-BC


Kyle Carson
Greg Craig (ANA)
Laura Hermann Langford (HL7)
Stephanie Hartleben (Elsevier)
Sharon Hewner
Stephanie Johnson (Epic)
Chelsea Biel (Epic)
Bonnie Wakefield
Matthew Keller
Jean Scholz
Pauline Sokolow
Christine Spisla
Brooke Trainum (ANA)
Nikki VandeGarde (Cerner)


Use a bottoms up approach with engaged EHR developers and clinical experts to identify essential care coordination data elements (user story) and processes (swim lanes) used to simple and complex transitions across settings

We worked to design a “swim lane” diagram to illustrate the care coordination and documentation workflow using examples from home care, primary care, and skilled nursing. For all examples, the beginning of the care coordination process starts with initiating the case and moves to how assessment information is obtained directly from patients using the medical record and other existing sources of information. The focus must turn from describing process to developing decision-making aides and interventions to improve outcomes. Participants stressed importance of data accuracy and working to create published standards for interoperability. Vendors reported progress on “better together” efforts, sending and receiving discreet data with longitudinal care plan development with health professional and patient facing features.