Background A critical need exists for effective electronic tools that facilitate multidisciplinary care for complex patients in patient-centered medical homes. Objective To identify the essential components of a primary care (PC) based electronic care plan (ECP) tool that facilitates coordination of care for complex patients. Methods Three focus groups and nine semi-structured interviews were conducted at an academic PC practice in order to identify the ideal components of an ECP. Results Critical components of an ECP identified included: 1) patient background information, including patient demographics, care team member designation and key patient contacts, 2) user-and patient-centric task management functionalities, 3) a summary of a patient's care needs linked to the responsible member of the care team and 4) integration with the electronic medical record. We then designed an ECP mockup incorporating these components. Conclusion Our investigation identified key principles that healthcare software developers can integrate into PC and patient-centered ECP tools.
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