The healthcare industry is transitioning from insular care of patients within the four walls of a single provider organization to a model of collaborative care across a community of independent providers. That represents a sea change within healthcare.
A patient’s care may span multiple organizations, disciplines and sites. As the care delivery paradigm changes, the old information paragons of medical records and claims are giving way to a more dynamic construct meant to convey the intended actions of all parties to a patient’s care – the care plan.
The care plan has gained popularity in population health circles as a tool to coordinate care, but does a care plan have a universal definition, and are the emergent collaborative care models well served by it? There are several steps that the care plan must go through in order to maximize its utility.
There is general agreement in the industry about what comprises the core of a care plan—it minimally must contain a list of issues or health concerns associated with a patient. Each issue has goals that frame the approach to resolving the issue (goals may have prioritizations from both patient and caregiver). Lastly, there are enumerated interventions (care actions) to address the issues, each having timelines and responsible parties.
This consensus on a relatively simple content definition belies the challenges that make this fundamentally different than arriving at a standard for other data structures like clinical summaries. The industry must normalize not just basic content, but non-standard content, analytic utility and workflow elements.
The audience for a care plan is multi-faceted. Patients must view some care-plan entries, such as discharge instructions from a hospital. Care plans supporting population health goals are used primarily by care teams of providers, both as contributors and consumers. Further complicating this is the expanded membership of care teams to include not just medical providers, but others such as ancillary services, care managers, social workers and psychiatrists to address psychosocial and logistical needs of the patient.
This variety of audiences gives rise to a corresponding variety of content generated by these parties, much of which is not as well defined as traditional medical vocabularies and terminologies are. Suddenly, issues such as appropriate content filtering by audience, and consistent representation of concepts become important for effective care delivery and analysis alike.
QuoteCare plans are not just documentation vehicles like other information containers, such as medical records and notes, which primarily hold facts and history. Care plans outline future courses of action.
Population health has a definite analytic component to assess care, allocate resources and measure outcomes. If the care plan is to be the primary information vehicle, then its content must support analytics well. Beyond the content normalization challenges already discussed, there are other factors that must be addressed.
For scorecard assessments, attribution to users of characteristics like inputs, activity and responsibility must be discernable. For activity reckoning, the documentation split between the care plan and other systems (for example, EHR charts) must be understood to accurately evaluate progress and outcomes. Care steps auto generated from best practices or evidence-based medicine protocols must be distinguished from organically determined care steps to evaluate plan appropriateness. These areas and others require metadata about the care plan to appropriately support the analytics that rely on it.
The biggest challenge facing the care plan may be the workflow accommodation. Care plans are not just documentation vehicles like other information containers, such as medical records and notes, which primarily hold facts and history. Care plans are indeed “plans” that outline future courses of action.
As with all complex planning, there is a lot involved in the development of the plan, such as tracking; handling changes; approval of proposed plan steps; synthesizing inputs; determining dependencies; escalation paths; and more. Therefore, the state of the care plan across these and other dimensions is a part of the content of the care plan, and must follow the care plan as it is exchanged, excerpted and used.
Despite these hurdles, the care plan is the current best option for an effective information conduit in the age of population health management and value-based care, largely because it has momentum. The industry has embraced the concept, it is in heavy use, and the refinement process is underway in earnest. Ultimately, the care plan will prove transformative to the way care is delivered and improved.
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