{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T04:37:37Z","timestamp":1780547857984,"version":"3.54.1"},"reference-count":44,"publisher":"Oxford University Press (OUP)","issue":"6","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["J Am Med Inform Assoc"],"published-print":{"date-parts":[[2014,11]]},"DOI":"10.1136\/amiajnl-2013-002454","type":"journal-article","created":{"date-parts":[[2014,7,5]],"date-time":"2014-07-05T01:53:24Z","timestamp":1404525204000},"page":"1082-1090","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":48,"title":["A patient-centered longitudinal care plan: vision versus reality"],"prefix":"10.1093","volume":"21","author":[{"given":"Patricia C","family":"Dykes","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lipika","family":"Samal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Moreen","family":"Donahue","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey O","family":"Greenberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ann C","family":"Hurley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Omar","family":"Hasan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Terrance A","family":"O'Malley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arjun K","family":"Venkatesh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lynn A","family":"Volk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David W","family":"Bates","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2014,11,1]]},"reference":[{"key":"2015062501485801000_21.6.1082.1","doi-asserted-by":"publisher","DOI":"10.1007\/s11414-012-9288-9"},{"key":"2015062501485801000_21.6.1082.2","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-012-2169-3"},{"key":"2015062501485801000_21.6.1082.3","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.12328"},{"key":"2015062501485801000_21.6.1082.4","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzs066"},{"key":"2015062501485801000_21.6.1082.5","doi-asserted-by":"crossref","unstructured":"Jeffs L Kitto S Merkley J . Safety threats and opportunities to improve interfacility care transitions: insights from patients and family members. Patient Prefer Adherence 2012;6:711\u201318.","DOI":"10.2147\/PPA.S36797"},{"key":"2015062501485801000_21.6.1082.6","doi-asserted-by":"publisher","DOI":"10.1007\/s10916-012-9855-x"},{"key":"2015062501485801000_21.6.1082.7","doi-asserted-by":"publisher","DOI":"10.1016\/j.annemergmed.2012.08.032"},{"key":"2015062501485801000_21.6.1082.8","doi-asserted-by":"crossref","unstructured":"Moy NY Lee SJ Chan T . Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project. Jt Comm J Qual Patient Saf 2014;40:219\u201327.","DOI":"10.1016\/S1553-7250(14)40029-1"},{"key":"2015062501485801000_21.6.1082.9","doi-asserted-by":"publisher","DOI":"10.1097\/00000446-195902000-00042"},{"key":"2015062501485801000_21.6.1082.10","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1971.03190090048009"},{"key":"2015062501485801000_21.6.1082.11","unstructured":"Knox E Acheson R Anderson D . Epidemiology in health care planning: a guide to the uses of a scientific method. Oxford, UK: Oxford University Press, 1979."},{"key":"2015062501485801000_21.6.1082.12","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1991.03460190087026"},{"key":"2015062501485801000_21.6.1082.13","doi-asserted-by":"crossref","unstructured":"Wood MM . Guide to better care \u2026a nursing plan. Am J Nurs 1961;61:61\u20132.","DOI":"10.1097\/00000446-196161120-00024"},{"key":"2015062501485801000_21.6.1082.14","doi-asserted-by":"publisher","DOI":"10.1002\/cncr.27856"},{"key":"2015062501485801000_21.6.1082.15","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2012.48.4618"},{"key":"2015062501485801000_21.6.1082.16","unstructured":"Paterson JM Allega RL . Improving communication between hospital and community physicians. Feasibility study of a handwritten, faxed hospital discharge summary. Discharge Summary Study Group. Can Fam Physician 1999;45:2893\u20139."},{"key":"2015062501485801000_21.6.1082.17","doi-asserted-by":"publisher","DOI":"10.1177\/1062860609351236"},{"key":"2015062501485801000_21.6.1082.18","unstructured":"Sullivan F Wilson P . The completeness and accuracy of patient record transfer between practices. Health Bull 1997;55:16\u201319."},{"key":"2015062501485801000_21.6.1082.19","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamda.2010.09.007"},{"key":"2015062501485801000_21.6.1082.20","doi-asserted-by":"publisher","DOI":"10.1097\/NCQ.0b013e318237af71"},{"key":"2015062501485801000_21.6.1082.21","unstructured":"Lamson L Carver F . Nursing care plan not dead yet. Am J Nurs 1991;91:21."},{"key":"2015062501485801000_21.6.1082.22","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs.2009.034587"},{"key":"2015062501485801000_21.6.1082.23","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-008-0618-9"},{"key":"2015062501485801000_21.6.1082.24","doi-asserted-by":"publisher","DOI":"10.1111\/j.1532-5415.2010.02776.x"},{"key":"2015062501485801000_21.6.1082.25","unstructured":"CMS. Medicare and Medicaid programs; electronic health record incentive program\u2014stage 2 proposed rule. Washington, DC: Centers for Medicare & Medicaid Services, 2012."},{"key":"2015062501485801000_21.6.1082.26","unstructured":"S&I Framework. Longitudinal Coordination of Care Interoperable Care Plan Exchange Use Case v2.0. 2013. http:\/\/wiki.siframework.org\/file\/view\/LCC%20Care%20Plan%20Exchange%20Use%20Case%20Finalv2.pdf\/451850044\/LCC%20Care%20Plan%20Exchange%20Use%20Case%20Finalv2.pdf (accessed 19 Oct 2013)."},{"key":"2015062501485801000_21.6.1082.27","unstructured":"HHS.gov. Medicare and medicaid programs; electronic health record incentive program\u2014stage 2. Fed Regist 2012;77:53967\u20134162."},{"key":"2015062501485801000_21.6.1082.28","unstructured":"CMS. HITPC stage 3 request for comment. Washington, DC: Department of Health and Human Services, 2013."},{"key":"2015062501485801000_21.6.1082.29","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2702.2006.01475.x"},{"key":"2015062501485801000_21.6.1082.30","doi-asserted-by":"publisher","DOI":"10.1093\/geront\/46.1.128"},{"key":"2015062501485801000_21.6.1082.31","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijmedinf.2010.05.002"},{"key":"2015062501485801000_21.6.1082.32","unstructured":"Keenan G Yakel E Tschannen D . Documentation and the nurse care planning process. In: AHRQ, ed. Patient safety and quality an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality, 2008:1\u201340."},{"key":"2015062501485801000_21.6.1082.33","unstructured":"McDonald KM Schultz E Chapman T . Prospects for care coordination measurement using electronic data sources (Prepared by Stanford University under subcontract to Battelle on Contract No. 290-04-0020\u2014AHRQ SQI-II.). Rockville, MD: Agency for Healthcare Research and Quality, 2012."},{"key":"2015062501485801000_21.6.1082.34","unstructured":"TJC. The Joint Commission E-dition. Hospital 2010 2010. http:\/\/www.jointcommission.org\/assets\/1\/6\/hospital_pre-pubs_for_cop_changes_20110110.pdf (accessed 1 May 2012)."},{"key":"2015062501485801000_21.6.1082.35","unstructured":"McDonald KM Schultz E Albin L . Care Coordination Atlas Version 3 (Prepared by Stanford University under subcontract to Battelle on Contract No. 290-04-0020). AHRQ Publication No. 11-0023-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2010."},{"key":"2015062501485801000_21.6.1082.36","unstructured":"S&I Framework. Long Term Care Post Acute Care. 2013. http:\/\/wiki.siframework.org\/LCC+Long-Term+Post-Acute+Care+(LTPAC)+Transition+SWG (accessed 4 Mar 2013)."},{"key":"2015062501485801000_21.6.1082.37","unstructured":"HHS. Health information technology: standards, implementation specifications, and certification criteria for electronic health record technology, 2014 edition; revisions to the permanent certification program for health information technology; proposed rule. Fed Regist 2012;p 77. http:\/\/www.gpo.gov\/fdsys\/pkg\/FR-2012-09-04\/pdf\/2012-20982.pdf ."},{"key":"2015062501485801000_21.6.1082.38","unstructured":"NVivo qualitative data analysis software [computer program]. Version 10: QSR International Pty Ltd; 2012."},{"key":"2015062501485801000_21.6.1082.39","unstructured":"Miles M Huberman A . Qualitative data analysis: an expanded sourcebook. 2nd edn. Thousand Oaks: Sage, 1994."},{"key":"2015062501485801000_21.6.1082.40","doi-asserted-by":"publisher","DOI":"10.1002\/nur.1017"},{"key":"2015062501485801000_21.6.1082.41","unstructured":"Framework SI. Companion Guide to Consolidated CDA for MU2. 2013. http:\/\/wiki.siframework.org\/Companion+Guide+to+Consolidated+CDA+for+MU2 (accessed 30 Jul 2013)."},{"key":"2015062501485801000_21.6.1082.42","unstructured":"AHRQ. Patient Centered Medical Home Resource Center. 2011. http:\/\/pcmh.ahrq.gov\/portal\/server.pt\/community\/pcmh__home\/1483\/what_is_pcmh_ (accessed 14 Sep 2013)."},{"key":"2015062501485801000_21.6.1082.43","unstructured":"McDonald K Schultz E Albin L . Care coordination atlas version 3. Rockville, MD: Agency for Healthcare Research and Quality, 2010. AHRQ Publication No.11-0023-EF."},{"key":"2015062501485801000_21.6.1082.44","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.27.3.759"}],"container-title":["Journal of the American Medical Informatics Association"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/21\/6\/1082\/5891663\/21-6-1082.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2017,8,23]],"date-time":"2017-08-23T11:58:25Z","timestamp":1503489505000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jamia\/article-lookup\/doi\/10.1136\/amiajnl-2013-002454"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2014,11]]},"references-count":44,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2014,11,1]]},"published-print":{"date-parts":[[2014,11]]}},"alternative-id":["10.1136\/amiajnl-2013-002454"],"URL":"https:\/\/doi.org\/10.1136\/amiajnl-2013-002454","relation":{},"ISSN":["1067-5027","1527-974X"],"issn-type":[{"value":"1067-5027","type":"print"},{"value":"1527-974X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2014,11]]}}}