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The Argument for Comprehensive Care Plans


Have you ever noticed that in healthcare, we place great emphasis on the transaction of the doctor-patient visit? How long it takes, what information we need, what things need to be done to or for the patient, how long the patient waits, how much we get paid for the visit, when the patient should come back. EHR systems, and even their antecedent paper charts, have been built around these encounters between the doctor and the patient. Arguably, these are very important events. Key decisions happen during these encounters – sometimes life-altering decisions. The role of the EHR during these encounters, originally serving as “electronic paper”, began with documentation of the encounter and billing. With evolution, EHRs brought more and more critical information into the user experience, surfacing key data points to improve clinical decision making. Today, we use the EHR to manage all of our work. Some modern EHRs even have features which help care teams address “care gaps” and offer practice management tools to better manage operating efficiency.

Indeed, EHRs have come a long way in serving doctors, care teams, revenue managers, and business administrators. It is important for the people involved in the delivery of healthcare services to have the best, right tools for the job. But where does “health” happen? Does health happen in the EHR? Does it happen in the daily avalanche of tasks and workflows inside a family medicine office? Does it happen during billing and reimbursement? Does it even happen in the encounter with the doctor? I don’t think it does.  I think health happens while our patients are out living their lives.  Health happens while people eat.  Health happens while people sleep.  Health happens when patients take the right medicines at the right times.  Health happens when patients know what to do, when to do it, how to do it, and why. 

Consider my patient, we’ll call her Marci.  Marci had a lot of health problems and was on an impressive medication list.  One of her chronic problems was osteoporosis (thinning of the bones), for which she was seeing an endocrinologist.  Another of her problems was kidney stones, for which she was seeing a urologist.  Her endocrinologist, in good faith, told her she needed to get more calcium in her diet to strengthen her bones.  Her urologist, also in good faith, told her she needed to minimize calcium in her diet to decrease her risk of more kidney stones.  Marci was caught in the middle between subspecialists who only saw part of her health.  Each subspecialist (partialist) did his best to advise Marci about how to manage one condition, yet Marci did not know what to go home and DO. Marci already had a lot to manage with her unwieldy medication list, managed by 5 different subspecialists and me.

With patients like Marci, it becomes easy to see why primary care physicians, in the role of comprehensivists, have a critical role to play in the coordination and integration of care.  My patients are not an elbow or an eyeball – they are whole, complex human beings.  They need mammograms and pap smears and colon cancer screening and immunizations.  They might be on a list of medications from various prescribers.  They often have multiple chronic conditions to be managed.  They have families and jobs and stress.  They have good and bad habits. They sometimes get sick. They may struggle with insomnia or dysphoria or anxiety, or all three. 

As a primary care physician, I collect and synthesize data. I talk to my patient, I talk to other providers involved in the patient’s care, I reconcile medication lists, and I apply knowledge and critical thinking to produce a plan of care, in parthernship with each patient, which is dynamic over time.  One of my favorite things about being a family doctor is the longitudinal relationship I have with my patients.  We are together through marriages, divorces, changes in employment, births, deaths, the best news, and the worst news. Along the way, the plan for their care evolves with them, as their lives unfold. In some cases, this plan is fairly simple and standard.  With increasing complexity, the plan becomes more detailed and individualized. In all cases, the plan needs to be comprehensive, reflecting the whole patient – because patients are not an elbow or an eyeball. The plan also needs to be dynamic, because life happens, and because every change affecting a patient’s health, for any reason, has the potential to impact the rest of the care plan, as we saw reflected in Marci’s case of conflicting recommendations about her calcium intake.  

EHRs typically provide (albeit with variable fidelity) a clinical profile of a patient, along wth a repository for results, documents, and communications, as well as encounter notes – lots and lots of encounter notes.  We’ve gotten better at making it easier to find pieces of information tucked away in the patient’s electronic record, and the next frontier is enabling the concept of a plan of care.  

Imagine a future where the EHR is built around a longitudinal, dynamic, comprehensive plan of care:

  • Each encounter note, with its associated diagnoses, orders, and patient recommendations would interact with and update the plan of care. 
  • The plan of care would generate tasks and reminders, flowing through smart workflows to the right team members.
  • Treating the plan of care like it is a reflection of the whole person, instead of an individual encounter, would improve patient safety by forcing care teams to reconcile every new recommendation against the rest of the plan.  
  • Care teams could more easily keep track of treatment goals and progress toward those goals. 
  • The plan would consolidate all of the most important details and information about each patient in one place, instead of fragmenting it, to be stored in various pockets of the EHR. 
  • At a glance, the care plan would give each clinician a clear representation of where every patient is in his or her healthcare journey.
  • The patient has a copy of the plan in language that the patient understands and can use to execute.

But we still haven’t addressed where “health” happens.  If I as a physician long for a comprehensive plan of care so that I can understand and track each patient through their healthcare journey, perhaps my patients need this, too.  I’m envisioning a world in which each patient completes every healthcare encounter with an updated, comprehensive plan of care that reflects everything they need to know about their health and how to manage it, regardless of the reason for that day’s visit.  It would contain, in lay terms, things like a reconciled medication list (including what to take, when to take it, and what they are taking it for), recommendations to cut down on caffeine, instructions for home blood pressure monitoring, signs and symptoms to watch out for and when to call the doctor, when the next clinical preventive service is due, upcoming appointments, treatment goals, and other valuable information – all targeted at empowering the patient to know what to do, when to do it, how to do it, and why. Humans are complex and healthcare is, too.  The single most important tool we can give our patients to promote health where health happens is knowledge, in the form of a plan.  A comprehensive plan of care.

Sara J. Pastoor, MD, MHA is Elation's Director of Primary Care Advancement and leader in primary care advocacy. Dr. Pastoor is a board certified and clinically active family medicine physician. Her experience as a primary care innovator spans a career in military medicine, academic medicine, private practice, and employer-sponsored delivery models. She received her MD from Rosalind Franklin University of Health Sciences and MHA from Trinity University.