To ensure continuity of care and comprehensive disease management, an infrastructure needs to be in place that will allow several entities and professionals (e.g., hospitals, home care agencies,...

To ensure continuity of care and comprehensive disease management, an infrastructure needs to be in place that will allow several entities and professionals (e.g., hospitals, home care agencies, social workers, rehabilitation centers, family members, designated caregivers) to interact and exchange information. Such a data flow assumes that different patient record systems can talk to each other. What are the challenges in achieving continuity of care for patients with chronic conditions, and how can technology address some of those?