CARE PLANS, GOALS, ACTIONS AND OUTCOMES: THE FUTURE HEALTH RECORD
It has been a while since I last wrote, having been busy with consulting work, keynote speaking and a family holiday in Europe.
As I have been reflecting on new topics to write about, I have realised that there are a number of exciting ideas that need some air time, as I have rarely seen them discussed in association with digital health. I’ve decided to pull these together into a series of blog posts entitled “The Future of Healthcare”. I trust that they will, as ever, stir some debate.
I also want to note that my plan is to write about ideas that are less commonly discussed, and not as obviously a part of digital health. For those of you that have been following my blog for a while, you’ll know that I’ve written extensively on topics such as:
What Exactly Is Digital Health?
Patients as Health Consumers
Why We Need a Partnership Model Between Patients and Doctors
The Rise of the Expert Patient
Patient Reported Outcomes vs Consumer Health Device Data
Activating the Caregiver – The Overlooked Lever in Healthcare
Separating The Signal From The Noise – Finding Clinical Relevance In Consumer Health Data
Whilst I’m passionate that these topics are crucial to the future of healthcare, I’m not planning to cover them extensively as part of this series.
The Future of Healthcare: Part 1 - Care Plans, Goals, Actions and Outcomes: The Future Health Record
I do a lot of work with clinical information systems. Systems for GPs (Primary Care Physicians), hospital doctors, allied health professionals, specialists, nurses and many others. The vast majority of them have one thing in common – they’re not very good. Issues with user experience, lack of clinical coding, poorly designed workflow, dated architecture and many other problems abound.
However, there is another major problem. Virtually all clinical information systems put problem / diagnosis lists, medications, allergies and summaries of recent episodes of care at the centre. This design has a number of inherent flaws…
It focuses on the problem, not on the solution
Medications are important, and save many lives. But they are rarely long-term root cause solutions to complex issues. The central focus on conditions and medications within medical records subtly reinforces the incorrect idea that we are addressing the root causes of a patient’s health issues. What is missing is a more holistic plan to not only address a problem with medication, but to move a patient beyond their immediate symptoms and into wellness. For example, what other actions (beyond medication) does the patient need to take to bring about better health? How do exercise, sleep and nutrition play a vital role in achieving that goal? And what is the goal? What will determine when improvement has been achieved?
It focuses on the past, not on the future
Records focused around problems and medications also cement a medical paradigm that looks backward in time. What conditions does the patient have and how are we medicating them? What was done and when?
Sadly, there is rarely much evaluation of the efficacy of particular interventions. As a patient I have rarely been asked how well a prescribed medication is working for me. Clinical information systems rarely force the capture of structured outcome information (either from health provider or patient) that can then be used to refine a treatment plan.
It focuses on sickness, not on wellness
Beyond sickness lies wellness. The goal of treating sickness should surely be to become well, not just to stop being sick. And yet our medical records largely focus on the tactical, medication related steps that address the symptoms of illness.
What would a true health record look like?
Despite the arguments that I will hear in response to this article, that healthcare professions aren’t funded to, or don’t have time to worry about these things, we need a new conceptual model that creates genuine health records, not just medical records. We need a new paradigm around which we can build a new generation of health records…
As I have reflected on this problem over the last couple of years, I have come to the conclusion that at the heart of every health record should be a care plan. A care plan that allows quantifiable goals to be defined, measured and updated on an ongoing basis. Goals that can be assigned actions so that there is a clear picture of what can be done towards achieving them. Actions that can be given to patients so that they are clear what they need to do. And outcomes that can be reported against those goals on a regular basis, e.g. how am I going against this goal?
The following diagram shows a proposed structure for care plans, goals, actions and outcomes that should be at the heart of a modern health record:
The Care Plan stores information about the patient, the health provider(s) managing the plan and the health conditions / problems being treated.
A series of Goals can be defined as part of the Care Plan, e.g. bringing BMI below 30, or bringing blood glucose levels within a normal range.
A number of Actions can be defined that guide a patient with regard to what they need to do to achieve the Goals. An Action can relate to multiple Goals.
Consumer Health Observations are consumer recorded vital signs (e.g. weight, blood pressure, blood glucose, etc.) that can be recorded against a Goal, providing a history of achievement towards a particular Goal. Consumer Health Observations can also show that a patient is deteriorating or moving further away from a Goal.
Clinical Measurements are clinically record vital signs that can be recorded against a Goal, providing a history of achievement towards a particular Goal.
By taking a more structured approach to care plans, new models of care can be designed that support safe and efficient remote management of patients. By carefully defining best practice goals for a particular health condition / problem, patients can (remotely from the health provider) record consumer health observations, sharing their progress (or lack thereof) through digital channels with their health provider(s).
In the event that a patient is progressing well towards a goal, they may not require any intervention (particularly in the case of chronic condition) and can continue to be safely and efficiently monitored remotely.
However, if a patient is deteriorating, or not tracking within the safe boundaries as defined by the care plan, health provider(s) can be alerted digitally, allowing them to decide whether a patient needs an urgent or scheduled face-to-face intervention.
Health records with care plans, goals, actions and outcomes at the centre are a must have for our future health system. We need to start building clinical information systems that support this…
7. The Lack of a Proper Market Scan
Many health provider organisations I work with are trying to be innovative. Some even have innovation divisions. I think that’s a great thing.
However, what I find concerning is that I often see organisations undertaking pilots with the worst solution in a product category. Often over-excitement at the first solution they saw, or persistence on the part of the vendor, results in pushing ahead with something that is innovative relative to current practice, but ultimately not as good as many of the alternatives.
Now sure, it’s hard to keep up in a world that is changing so quickly. But please, let’s reach out and do a proper (international) market scan before committing time, energy and valuable dollars to a pilot.
