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Using the EHR to Impact Episodic and Longitudinal Care Plans

Published on 11/6/2017

As health care systems and providers move toward meaningful use of electronic health records (EHRs), longitudinal care plans provide a means to improve communication and coordination as patients transition across settings. But what do we mean by a “longitudinal” plan, and how does that interact with the episodic care plan? 

We’re all familiar with the notion that when we go to see our physician, whether it be for something planned or something unplanned – a heart attack, a broken leg or something that occurs because of a chronic condition that we live with – that episode is time-based. Everything that happens in an acute or ambulatory encounter is captured. That includes lab results, hourly or twice-daily physiological monitoring of vitals and more – it’s all used to watch the patient’s progress. 

Generally, a care plan is put in place for that episode based on evidence and best practices, and there are measurable objectives. For example, if I’ve got an infection and I’m given an antibiotic, my response to the antibiotic and any other instructions from my physician is documented in my EHR. At the end of my care plan, whether it was three days or three weeks, the data is assessed and my outcome on that episode is documented. The record and the plan are right there, contained by the time of that visit. 

How the episodic and longitudinal care plans interact 

Just because my infection has passed and the care plan exacted for that episode has run its course doesn’t mean that I’m no longer concerned for my health, or that I can stop visiting the doctor entirely. This is where the longitudinal health record comes in: Longitudinally, I’m going to think about my health across the span of my life. 

Let’s consider another example. A diabetic’s patient record would likely contain daily blood glucose and insulin readings, and those things will be tracked longitudinally regardless of any episode of care, because diabetes is a chronic condition. The patient’s caregiver or care team will likely have a longitudinal plan that breaks down the treatment over the course of a year or five years or a person’s life, and that plan will include objectives for the patient to meet while managing their condition. A diabetic patient, for instance, will document their annual eye exam and podiatry exam, which are both indicators of how well the patient is managing their diabetes. 

In this way, we can think of the longitudinal care plan in  the same terms as we do the episodic care plan – just with a broader timeframe in mind. But here’s where it’s critical for these two plans to work with each other: Let’s say that diabetic patient is moving along and managing their diabetes, and something happens – a broken leg, for example – that requires a visit to the emergency department (ED). At that moment, the episodic record and plan will take over – but that patient will want the appropriate information from their longitudinal plan to be revealed to the ED care team. The care team working on the broken leg will also need to know about that patient’s diabetes, as well as any medications or allergies that are documented in the longitudinal record. The care team, in other words, should be positioned to know a set of things about the patient that are going to put them in the best position to effectively and efficiently manage the unexpected episode. 

After that patient with the broken leg is discharged, the relevant information from that episode of care plays into the longitudinal record. If, for example, there was a complication discovered that affected the patient’s diabetes, it would live in the longitudinal record as a known point. This way, the episodic record and plan and the longitudinal record and plan can learn from and contribute to one another. 

Incentivizing health care organizations to implement longitudinal records 

Ideally, electronic systems can pull together the various elements of the longitudinal care plan to create an appropriate view for the patient, clinician or caretaker and provide actionable information. But not all patients have established a longitudinal care plan, not all electronic systems speak to each other and communication gaps remain. One of the primary barriers to accomplishing this ideal state of interoperable care plan data is the lack of incentives for health care organizations. 

When we think about where the episodic and longitudinal care plans are housed and why they exist, it’s easy to understand why we have this barrier, based on how health care has been practiced and reimbursed in the past. Episodic electronic records exist in places where we go to receive care – the doctor’s office or a hospital or at a post-acute care facility. The model was: A patient required health services, they went to a location to receive care and an insurer or the patient paid for that care. Services were documented not only for purposes of continuity of care and consistency, but also so that the health care organization knew what to bill for. That was how the payment models worked – patients receive care, they pay for care, they move on. 

How alternative payment models are changing reimbursement 

Based on that model, there was little incentive for the health care system to track a patient’s health over time. Today, we’re beginning to see that change. That change starts in small ways, such as with the new alternative payment models that are coming out which have concepts around hospital readmittance avoidance. 

For example, if a patient goes in for a hip surgery covered by a bundled payment, the patient is then responsible for maintaining their treatment plan once discharged. If the patient doesn’t follow their treatment plan and a complication arises, resulting in further inpatient services or another surgery, the insurer may not be responsible for covering the cost of subsequent treatment. This way, we’re seeing health care institutions realize a fiduciary concern linked to whether their patients stay healthy or follow their rehabilitation regiment– which means there must be a way to track events and data that occur outside the four walls of a hospital. 

The consumer push for the longitudinal record 

Right now, the health care industry is seeing a new dawn of patient empowerment – thanks in part to legislation like the 21st Century Cures Act. It’s no surprise that patients want access to their health data and to certain direct elements of their care. Today, we’re no longer just talking about the health care provider and the payer – we’re talking about the provider, the payer and the consumer. 

Today’s consumers want to be active participants in their health care. They want to be involved in decisions about what they should be doing to live well and what they should be doing to contribute to a positive recovery. They want to know who is on their care team, and they want their caregivers to be active contributors to their longitudinal record. 

I know this not because it’s the result of a study (though we have plenty of information about the consumerization of health care). I know from personal experience. 

My oldest son Sam was born with aortic valve stenosis, a heart condition and one that, as a new parent, was very scary for two new parents. Sam received excellent care, but the nature of his condition meant that we had to monitor changes in his heart growth frequently as a baby and into his toddler years. We were seeing my son’s cardiologist every two months, then six months, then once a year and eventually every other year – and data from each visit and interaction was documented in Sam’s health record. 

Sam will turn 15 this year and is as healthy as an ox – but the data from his heart condition is still relevant. As an industry, it should be our goal for all to have easy, reliable access to their health data so they be an active participant in living the healthiest life they can.

Ultimately, the longitudinal record is about putting the patient at the center of health care – and that should be the primary concern for today’s health care organizations. 

We’re focused on connecting traditional venues, the health continuum and advanced information about a person’s lifestyle to empower individuals in their health and care. Learn more about our longitudinal health record here.