Richard Antonelli, MD, a primary care pediatrician and medical director of integrated care at Boston Children's Hospital, has been thinking and working at making a difference in the field of care coordination for more than 20 years. He recalls that it was in 1983 when he started thinking about what he calls "the space between" - between a doctor's visit and the next one with the same doctor, or a specialist to whom the primary physician has referred the patient. The space between is when the patient is on his or her own to remember (or not) the doctor's instructions.

It's a time when care coordination could smooth the path to recovery, to better health. With funding and testing work from the Verizon Foundation, Antonelli is prepared to launch several care coordination projects aimed at doing just that.

Q: How do you envision care coordination making a difference for patients?
A: The first 18 years of my career were spent in full-time community practice. Early on I realized that the way practices were configured was not optimal for delivering high quality care. Oftentimes there were workarounds. There was often not a standard way of communication. About 12 years or so ago, I actually started to define many aspects of what care coordination is. I did work for the Commonwealth Fund, which really laid out a framework of what care coordination is. The work is actually in this space of what my strategic charge is, which is to meaningfully engage patients and families in their own care - patient self-management.

Q: Did care coordination become important to you because of what you observed in your own practice?
A: For both personal reasons and certainly professional reasons, it became clear to me very early that a typical patient encounter, 10-20 years ago, went something like this: "OK, Mr. Smith, you, the patient, or your child, should see the following specialist. Here are their numbers, and I'll see you back in a month." In particular, I found that was never very satisfying. We asked families - families who had children with behavioral or mental health needs, and we found that 86 percent of the time the families were completely on their own to coordinate care amongst their primary care providers, their specialty care providers and their behavioral health providers.

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Q. What is the thrust of care coordination?
A: In my care coordination work, I'm trying to find ways of how information gets tracked from the patient to the primary care provider, getting the right information to that specialist in the community or an academic center. So when the family goes from point to point they know that the information they have sanctioned to be able to share is following them across the care continuum. That is the ideal outcome for coordination of care. The literature is replete with vignettes of unnecessary testing, duplicate testing. Often the patient received one set from Dr. A, and they were all repeated by Dr. B because the information didn't flow. There's about 30 percent of the American healthcare dollar spent on either unnecessary or dangerous interventions.

Q: What are some of the care coordination projects you have in the pipeline?
A. One of the projects that I'm going to be doing is actually the continued development and refinement of care mapping as a process to engage patients and families in their own care, and to use that as a driver to support a care partnership between the patient, family and the healthcare system itself. That care map could live on a secure website. That care map could live with the patient's electronic medical record. That care map could be on somebody's smart phone. And the patient or family could give permission for whomever they would like to see that. One of the projects that I'm particularly excited about is care mapping because it will be pretty dramatic disruption of how care coordination activities are carried out.

Q: What is the timeline?
A: I'm in conversation now with the Verizon Foundation about those issues. My hope for care mapping is that it will be work that's going to be launched over the next few months in 2013. I already have international partners that are lining up to participate with care mapping - both in the U.S. and Canada and Europe as well.

Q. It sounds like Verizon will be engaged beyond money.
A. The Verizon Foundation, I think, is a pretty ideal partner for the kind of work that I'm trying to do, for a couple of reasons. One is much of the technology that will underlie these care coordination interventions really support optimal, structured, timely communications. There's also that critical focus on what I call patient- and family-centered and what a technology entity might call the consumer. Many of my interventions could be applied to hospitals and hospital systems, for example, but much of the value of care coordination is going to be realized because patients and families will be more engaged with their own care. In many cases they will be in control over what decisions need to be made when, with respect to sequencing, with respect to location of care and the like. So, I think there's a really nice synergy between care coordination as I view it, meaning very much anchored to the needs of the patient and the family and empowering them and with the resources that the Verizon Foundation is targeting with its priorities.

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Q. What kinds of technology will you employ besides the EHR?
A: Some of the work that I'm doing actually is in urban core, and some of the work that I'm doing is in some of the most remote areas of the United States, in very rural areas. And, so, the diversity of technologies to leverage this is something that we intend to build on as strength. It's not a single platform. It's not a single technology. But the good news is I don't need 20 years of developmental funding. I believe that extant technology can be appropriately adapted and focused to support care coordination.

Q. How are you envisioning the care-mapping project to play out>
A: We're presuming that patients and families want to empowered, want to be informed, and care mapping is a way to be meaningfully and measurably engage them. It's important to distinguish the difference between optimal care delivery and optimal care coordination delivery. Care coordination - the activities in the so-called space between is transmitting information in a timely, structured fashion, as opposed to care delivery, where we have standards: Here's what you need to do if somebody's having an asthma attack. These are the care standards for diabetes care. I could give you five correct prescriptions and three referrals to sub specialists, see you back in a month. And, as soon as you get into my waiting room, the literature shows that 50 percent of the time patients don't understand or recall what they were told in the exam room. You can imagine how that exponentially drops off as soon as you leave the building and get into your own kitchen. The right care was rendered, absolutely, and that's what we track in our electronic medical record and our chart but it's the space between that we need to pay attention to in care coordination.