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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
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A patient-centered longitudinal care plan: vision versus reality.

Patricia C Dykes1, Lipika Samal1, Moreen Donahue2

  • 1Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA.

Journal of the American Medical Informatics Association : JAMIA
|July 6, 2014
PubMed
Summary

Longitudinal care plans (LCPs) are not effectively communicated across healthcare settings. Current LCPs are not shared or reconciled, hindering care coordination during patient transitions.

Keywords:
Care CoordinationElectronic Health RecordLongitudinal Care PlanMeaningful Use

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Area of Science:

  • Healthcare Informatics
  • Patient Care Coordination
  • Health Services Research

Background:

  • Longitudinal care plans (LCPs) are crucial for improving communication and coordination during patient transitions across healthcare settings.
  • Meaningful use of electronic health records (EHRs) necessitates effective LCP implementation.

Purpose of the Study:

  • To assess the current state of LCP communication across different healthcare settings and levels of care.
  • To determine how effectively LCPs are being utilized and shared among providers.

Main Methods:

  • Surveys and interviews were conducted with healthcare professionals from emergency departments, acute care hospitals, skilled nursing facilities, and home health agencies.
  • Transcripts were coded using the Agency for Healthcare Research and Quality (AHRQ) 'Broad Approaches' to care coordination framework.

Main Results:

  • Participants reported that true LCPs do not currently exist in their practice.
  • Existing care plans were not shared or reconciled across different care settings.
  • Communication of care plan information during transitions varied widely, with paper and fax being the most common formats.

Conclusions:

  • The current use of LCPs to support care transitions is suboptimal.
  • Significant challenges exist in data reuse, interoperability, and widespread adoption of LCPs.
  • Strategies are needed to transition LCPs from a concept to a practical reality in healthcare.