Continuity of Care Maturity Model (CCMM)
The HIMSS Continuity of Care Maturity Model (CCMM) helps healthcare leaders worldwide assess, implement and scale the seamless coordination of patient care across a continuum of care sites and providers.
Continuity of care is much more complex than implementing information and technology in a single care setting. Multiple stakeholders must act in concert to provide an environment that facilitates the best care and value. The CCMM assigns responsibility for critical aspects of coordinated care across administrators/governance leadership, clinical leadership, and IT/technology leadership. Organizations can leverage the CCMM to improve the interoperability, governance and workforce, and predictive analytics dimensions of digital health.
Implement Effective Health Information Exchange
Aggregate patient health data into a comprehensive presentation that includes information across the care continuum from acute settings, external providers, home care, social care, patient-created data and other sources.
Coordinate Patient Care
Fully integrate a shared care plan that is able to include multiple care pathways/protocols for multiple chronic conditions, and to share data items between the protocols (e.g., elderly patients with multiple complex health/social care needs based on the personal goals for the patient and their individual needs and abilities).
Advance Analytics Capabilities
Integrate internal and external de-identified longitudinal clinical, financial and other data, and non-patient-specific data. Analytics infrastructure enables automatic identification and reporting of gaps in data across all care providers.
Improve Patient Engagement
Put the patient in control of their health data and goals. Allow patients to electronically give consent on or deny care provider access to their medical record or parts thereof across the care continuum. Automate tracking of achievement for the patient and alerts/reminders to patients triggered from the organization's care team and other coordinated care providers.
- Comprehensive population health.
- Completely coordinated care across all care settings. Integrated personalized medicine.
- Near real-time care community-based health record and patient profile.
- National and local policies are aligned.
- Dynamic intelligent patient record tracks closed loop care delivery and multiple care pathways/protocols for each patient, along with patient compliance tracking.
- Organizational, pan-organizational and community-wide clinical decision support and population health tracking.
- Policies address non-compliance.
- Community-wide patient record with integrated care plans and biosurveillance.
- Patient data entry, personal targets and alerts are available.
- Patient data aggregated into a single cohesive record. Mobile tech engages patients.
- Community-wide identity management.
- Best clinical practices are derived from care community health data and operationalized across the community (continuous quality improvement and adaptation).
- Shared care plans track and update task coordination with alerts and reminders.
- E-prescribing. Pandemic tracking and analytics are in place.
- All care team members have access to all appropriate data.
- Semantic data drives actionable clinical decision support and analytics.
- Comprehensive audit trails.
- Policies are in place for collaboration, data security, mobile device use, and interconnectivity between healthcare providers and patients.
- Multiple entity clinical data integration.
- Regional/national PACS.
- Electronic referrals and consent are in place.
- Telemedicine is being used.
- Aggregated clinical and financial data.
- Medical classification and vocabulary tools are pervasive.
- Mobile tech supports point of care.
- Coordinated data governance across varied internal and external organizations.
- Patient record is available to multidisciplinary internal and tethered care teams.
- EMR exchange occurs on a limited basis. Immunization and disease registries for all patients.
- Patient-centered clinical data presentation exists.
- Pervasive electronic automated ID management for patients, providers and facilities.
- Policies drive clinical coordination and semantic interoperability.
- Change management process is documented and standardized.
- Limited shared care plans outside the organization.
- Leverage third-party reference resources.
- Basic alerts are in place.
- Some externally generated data is incorporated into the patient record.
- Policies for care continuity strategy, business continuity, disaster recovery, and security and privacy are in place.
- Data governance is active.
- Engaged in EMRAM maturation.
- Data is isolated.
- Governance is informal and undocumented.