; (3) has a network of affiliated personal physicians and patient treatment facilities; (4) maintains an online Web site for patient and provider communication and collaboration and patient access to the patient’s health information; (5) has a plan for use of health information technology in providing services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and remote patient monitoring management of care and patient adherence to recommendations made by their provider); (6) provides deidentified demographic data sets for clinical, statistical, and social science research to develop culturally competent best practices and clinical decision support mechanisms for the long-term illness or medical condition; (7) uses a health assessment tool for the individuals targeted, including a means for identifying those most likely to benefit from remote patient monitoring