Providers across the country are asking for a better way to do the job of care plan development and management. Recent incentives put in place, plus new models of care, require new methods and tools for care plan management. What healthcare needs is a Care Management System built to support team-based care and empower users to clearly understand and communicate the state of play of their healthcare. Given the complexity of care surrounding patients working with multiple providers, the challenge of logging, updating, and communicating the state of care activities is a constant problem for patient teams. One of our advisors, Dr. John Halamka, stated the issue at hand in a recent interview, “What we really need is a combination of Wikipedia and Facebook. The Wikipedia part is the narrative of your life, and it’s written by a team and updated frequently. Facebook-like [timelines] contain the events that are happening now.”
For a practical healthcare workflow, the future care plan must offer all members of the patient’s care team a multi-authorable platform that flexibly allows stakeholders to quickly understand the current state and future path of care. Designed appropriately, this solution would be available to the providers (and patients) documenting care. Additionally, it would have a simple method to facilitate updates and sharing across the patient team.
I found a recent experience with my son’s high school to be instructive on how to be able to view and manage a teaching plan for students. This past fall, at the beginning of his freshman year, we were introduced to a teaching plan tool that assists parents and students in understanding the educational plan for the school year. It’s not perfect, but it does a meaningful job. Within the platform we can see the teaching plan for the year, with information on the teachers, aides, and other administrators. If there is a change in the course schedule or teaching plan, the updates can be communicated and aggregated across the faculty, parents, and students. We receive updates on performance, can communicate questions, and even arrange off-line discussions with teachers. It’s structured in a parent- and student-friendly language, leveraging modern paradigms of technology and media. Certainly healthcare presents added complexities with comorbid conditions and privacy requirements, but this educational model is relevant.
Next time you go into your provider’s office, ask them to provide you a copy of your care plan. If you don’t get a hesitant, puzzled look (note: you will get a hesitant, puzzled look), they will print out or send you a disjointed, random data dump from the provider’s EMR. This will often be many pages in length, with little organization or structure, and will require you to decipher the 4W1H of your care. In some cases, you might get a cover letter from your physician describing the plan and some explanation of the report. You will also note that any care activities occurring outside the EHR of your specific provider will not be included or provided in the documentation. To be clear: this is not intended to criticize the great care provided by your clinical team. Rather, this is a reflection of the limited and archaic toolbox that clinicians have available to generate, track, and report your plan of care.
In our work, we focus on how to help providers, patients, and their caregivers – who often work with different healthcare organizations and care team members – develop, communicate, and manage care plans. Such plans include the patient’s history, where the patient is presently in their care plan, and where they’re going in the future. We call it the Living Plan of Care wherein all members of the team can update and understand the state-of-play with each patient’s care.
Imagine this scenario: A parent struggling to manage care for their medically-complex child can arrive at an ER with a legible, up-to-date care plan developed by a supportive and professional multi-disciplinary clinical team. The clinical team receiving the family at the ER can quickly understand the care plan for the child, which individuals are involved in care, and current or future activities underway. Such a solution would fundamentally change how providers communicate and coordinate the care of patients. It’s a Care Management System – the central component for enabling team-based care.
