Healthc Inform Res.  2013 Mar;19(1):3-8. 10.4258/hir.2013.19.1.3.

Achieving Holistic Health for the Individual through Person-Centered Collaborative Care Supported by Informatics

  • 1Health Informatics Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.


This article seeks to describe the current state of informatics supported collaborative care and to point out areas of future research in this highly interdisciplinary field.
In this article, person-centered collaborative care is seen as a concept addressing both the provision of care over organizational borders between health and social care, and within care teams as well as the changed patient/client-care provider relationship characterized by increased patient/client involvement.
From a health systems perspective, there are several attempts to describe the conceptual and theoretical basis for collaborative care indicating that agreement on core concepts and terminology is difficult. From an informatics perspective, focus is on standardization of clinical content models and terminology to achieve interoperability of information technology systems and to support standardized care pathways. Few examples look into how ad-hoc collaborative care processes can be supported using information technology and informatics standards. Nevertheless, promising examples do exist showing that integrational Information Communication Technology services can be supportive for collaborative care developments. However, the current landscape consists of many fragmented, often technology-driven eHealth solutions targeting specific diagnostic groups in geographically and/or organizationally restricted settings.
A systematic approach incorporating organizational, clinical, informatics and social science knowledge is needed to perform further research in areas such as virtual team partnerships, new paradigms of care delivery, data and knowledge management as well as its secure sharing. Also organizational and legal aspects need to be further researched in order to facilitate the coordinated provision of health and social care to citizens including self-management, utilizing informatics support in a societal context.


Social Welfare; Health Information Management; Integrated Delivery of Health Care; Cooperative Behavior

MeSH Terms

Cooperative Behavior
Health Information Management
Holistic Health
Knowledge Management
Self Care
Social Sciences
Social Welfare

Cited by  1 articles

Big Data Analysis Framework for Healthcare and Social Sectors in Korea
Tae-Min Song, Seewon Ryu
Healthc Inform Res. 2015;21(1):3-9.    doi: 10.4258/hir.2015.21.1.3.


1. WHO. Constitution of the World Health Organization: basic documents. 1989. 45th ed. Geneva: WHO.
2. Alaszewski A, Billings J, Coxon K. Leichsenring K, Alaszewski A, editors. Integrated health and social care for older persons: theoretical and conceptual issues. Providing integrated health and social care for older persons: a European overview of issues at stake. 2004. Aldershot, UK: Ashgate;53–94.
3. Rigby M, Hill P, Koch S, Keeling D. Social care informatics as an essential part of holistic health care: a call for action. Int J Med Inform. 2011. 80(8):544–554.
4. Koch S, Vimarlund V. Critical advances in bridging personal health informatics and clinical informatics. Yearb Med Inform. 2012. 7(1):48–55.
5. European Committee for Standardization. Health informatics: system of concepts to support continuity of care. Part 1: Basic concepts. 2007. Brussels, Belgium: European Committee for Standardization;(EN13940-1).
6. Stewart M. Towards a global definition of patient centred care. BMJ. 2001. 322(7284):444–445.
7. Hagglund M. Sharing is caring: integrating health information systems to support patient-centred shared homecare [dissertation]. 2009. Uppsala, Sweden: Uppsala University.
8. Miller B, Kessler R, Peek C, Kallenberg G. A National Agenda for Research in Collaborative Care: papers from the Collaborative Care Research Network Research Development Conference. 2011. Rockville (MD): Agency for Healthcare Research and Quality.
9. D'Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu MD. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J Interprof Care. 2005. 19:Suppl 1. 116–131.
10. Mur-Veeman I, van Raak A, Paulus A. Comparing integrated care policy in Europe: does policy matter? Health Policy. 2008. 85(2):172–183.
11. Vedel I, Monette M, Beland F, Monette J, Bergman H. Ten years of integrated care: backwards and forwards. The case of the province of Québec, Canada. Int J Integr Care. 2011. 11 Spec Ed:e004.
12. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996. 74(4):511–544.
13. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001. 20(6):64–78.
14. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998. 1(1):2–4.
15. Chronic Care Model: Meet the Needs of Specific Populations [Internet]. c2013. cited at 2013 Mar 18. Cambridge (MA): Institute for Healthcare;Available from:
16. Marchibroda JM. The impact of health information technology on collaborative chronic care management. J Manag Care Pharm. 2008. 14:2 Suppl. S3–S11.
17. Rossi Mori A, Mazzeo M, Mercurio G, Verbicaro R. Holistic health: predicting our data future (from inter-operability among systems to co-operability among people). Int J Med Inform. 2013. 82(4):e14–e28.
18. Goossen W, Goossen-Baremans A, van der Zel M. Detailed clinical models: a review. Healthc Inform Res. 2010. 16(4):201–214.
19. Wac K. Smartphone as a personal, pervasive health informatics services platform: literature review. Yearb Med Inform. 2012. 7(1):83–93.
20. Eysenbach G. Consumer health informatics. BMJ. 2000. 320(7251):1713–1716.
21. Kalra D. Health informatics 3.0. Yearb Med Inform. 2011. 6(1):8–14.
22. Rigby M. Personal health, person-centred health and personalised medicine: concepts, consumers, confusion and challenges in the informatics world. Yearb Med Inform. 2012. 7(1):7–15.
23. National Board of the interaction at the admission and discharge of patients in hospital care (SOSFS 2005:27) [Internet]. 2005. cited at 2013 Mar 18. Stockholm, Sweden: Socialstyrelsen;Available from:
24. Chu S. Modelling collaborative care information: the nursing perspective. Stud Health Technol Inform. 2006. 122:535–539.
25. Hagglund M, Scandurra I, Koch S. Studying intersection points: an analysis of information needs in shared homecare of elderly. J Inf Technol Healthc. 2009. 7(1):1–20.
26. Hägglund M, Scandurra I, Koch S. Scenarios to capture work processes in shared homecare: from analysis to application. Int J Med Inform. 2010. 79(6):e126–e134.
27. Hägglund M, Scandurra I, Mostrom D, Koch S. Bridging the gap: a virtual health record for integrated home care. Int J Integr Care. 2007. 7:e26.
28. Hägglund M, Chen R, Koch S. Modeling shared care plans using CONTsys and openEHR to support shared homecare of the elderly. J Am Med Inform Assoc. 2011. 18(1):66–69.
29. Ling T, Brereton L, Conklin A, Newbould J, Roland M. Barriers and facilitators to integrating care: experiences from the English Integrated Care Pilots. Int J Integr Care [Internet]. 2012. Jul-Sep. 12. cited 2013 Mar 20. Available from:
30. Kaiser Permanente HealthConnect Electronic Health Record [Internet]. c2013. cited at 2013 Mar 18. Oakland (CA): Kaiser Permanente;Available from:
31. My HealtheVet [Internet]. c2013. cited at 2013 Mar 18. Washington (DC): U.S. Department of Veterans Affairs;Available from:
32. The information system as a tool for efficient organizational administration [Internet]. c2011. cited at 2013 Mar 18. Tel Aviv, Israel: Maccabi Institute for Health Services Research;Available from:
33. Hardy B, Mur-Veemanu I, Steenbergen M, Wistow G. Inter-agency services in England and the Netherlands: a comparative study of integrated care development and delivery. Health Policy. 1999. 48(2):87–105.
34. Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood). 2010. 29(4):614–621.
35. Wentzer H, Bygholm A. Attending unintended transformations of health care infrastructure. Int J Integr Care. 2007. 7:e41.
36. Rigby M, Koch S, Keeling D, Hill P, Alonso A, Maeckelberghe E. Developing a new understanding of enabling health and wellbeing in Europe: harmonising health and social care delivery and informatics support to ensure holistic care. 2013. Strasbourg, France: European Science Foundation.
Full Text Links
  • HIR
export Copy
  • Twitter
  • Facebook
Similar articles
Copyright © 2023 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: