Care plans in GP structured records

Peter Salmon, Glyn Hayes, Ian Herbert, Mike Bainbridge

Clinical Computing Special Interest Group (CLICSIG), PHCSG

31 Lickey Coppice, Rednal, Birmingham, B45 8PQ

salmp@meditel.co.uk

Abstract

There is widespread experience of the use of care plans (also known as treatment plans) in medical and nursing practice, and of their benefits for patient care. However there has been little success in translating this from a manual system into a computer (assisted) system. This paper explores some of the ways in which this could be achieved in the context of General Practice computer systems that provide structured medical records, and encounters along the way a number of allied issues that add further value. It also touches on the area of shared care planning with secondary and community care.

Introduction

The historical record of a patient's care is well understood and has been successfully implemented in many computer systems. Often these systems do not record the future, planned care of a patient so well, although routine immunisation and cervical screening are the exceptions that prove the rule. A formal structure for such a record is recognised - termed the "care plan", or "treatment plan". Formal care plans are used in many nursing contexts, and some medical ones. However they are not in widespread use in primary health care within the UK. We believe that such plans would improve the quality of care of patients with some problems, and hypothesise that their uptake and delivery would be more successful when done with the aid of a computer¹. The rationale for this hypothesis relates to the use of guidelines and reminders. In this paper we explore the use and value of formal care planning techniques, their relationship to guidelines and computerised reminders, and propose a mechanism for introducing them into the computerised problem oriented medical record (POMR).

A care plan consists of a summary statement of problem titles and supporting symptoms; treatment goals; actions planned; names of parties responsible for taking actions; and identification of individualised outcome assessment parameters².

There is a close relationship between care plans and guidelines that has often been recognised, but not fully defined, and the two can be confused.

Practice guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific circumstances"³

Care plans concentrate on the patient, and ultimately form part of a patient's record. They are individually tailored for that patient. Guidelines know nothing of individual patients, but describe the way in which a typical patient may be treated in a given situation.

The vision

Doctors are (correctly) very protective about their own ultimate authority with regard to the treatment of any patient in their care. Because patients are humans and not robots, they each have a uniqueness which their treatment needs to accommodate, and they can only be properly responded to by another human. Despite this, most medical conditions are treated in a common fashion, according to agreed standards that depend on the condition in question. Increasingly these are being formalised as "guidelines". These may be set by the Royal Colleges, or drawn up within a practice as an agreed standard between partners.

Much has been written which describes the fallibility of human decision-makers⁴, and it has been proposed that patient care may be improved when the doctor's decision-making is aided by some form of computerised guideline system^5,6,7,8. This can simply be available as a "quick reference cue card", which the doctor can call up on to the screen to refer to. However some systems have been extended in scope considerably, and work interactively with users to assist in the collection of data,; they actively support the decision-making process. It is this sort of computerised guideline which we believe can assist in the generation and use of care plans.

The vision which we have is of a clinical information system which the doctor uses to store information about patients. It is programmed to "recognise" the characteristics of the problem being managed, and to interact with the doctor, making the appropriate com-puterised guideline for that problem intuitively available. Part of this may be background analysis of the patient record to actively or passively highlight elements in it which deserve special attention.

As well as looking at the history of the patient's problem, a view of what is planned for the patient is made available. Items from this plan which are now due are highlighted, and probably brought to the user's attention on entry into the patient record. Overdue items which are significantly noteworthy are brought to the attention of the practice or the relevant clinician, even without the patient's record being accessed by the user.

The appropriate computerised guideline for the problem may be brought into play at the request of the clinician. It could lie alongside the patient record, it could incorporate the patient record, or it could be incorporated by the patient record - an "item" in the record in its own right. At the point of activation, the guideline configures itself to the current state of the patient record. It may then be used by the carer to assist in the patient's care. This will include dealing with things that have been planned at an earlier encounter and are now due, and is likely to result in planned (future) activities.

The care plan

A plan of care is a natural part of patient records. It is fully recognised that in primary health care many of the problems being dealt with are of a common and minor nature, and do not require any formal care planning. However, the GP may encounter any type of problem, many of which they will inevitably not be proficient in managing. Some problems, for example, asthma and diabetes, may be chronic, perhaps lifelong, with a prognosis that is highly dependent on the care provided. For these reasons (computerised) guidelines are becoming established, and care plans will be of value. Even straightforward consultations may benefit from the introduction of "watchdog" (background) guidelines, which examine the patient record as new data is entered, looking for potential problems which should be brought to the doctor's attention.

The essential elements of a care plan as described by Hammond² are:

The full "patient management plan" includes all the patient's problems, and clearly there may be interaction between the individual care plans - the care for one problem may exacerbate another (for example, beta-blockers for hypertension exacerbating the asthma, or drug-drug interactions). Often consultations are multi-tasking, dealing with many problems, whereas guidelines are generally single-tasking. For the purposes of this paper we will consider a care plan for a single, named problem. We will not try and address the problem of care plan interaction.

Many problems involve a series of visits. A simple example would be that of a high blood pressure found during a well man screening clinic. A series of blood pressures will need to be taken, and if the blood pressure is found to be persistently high, then appropriate treatment will need to be started and monitored. The patient record for such a patient at the end of the first visit may look something like this:

To this we could add the details of what we're going to do about it:

Blood pressure next week with the practice nurse

Blood pressure and review two weeks with the doctor

If, at the third visit, no treatment was felt to be necessary, a review for three months could be planned. If treatment was started, the plan would be updated to record that the patient should be seen weekly by the nurse to check the blood pressure and ask about side effects, and should see the doctor in a month's time for review and to check the results of blood investigations taken after the third week.

There are two significant questions to ask about this latter part of the record, the care plan: why, and how - how in the "how can this be done" sense, rather than "how is it theoretically possible".

Why ?

In order to:

• remind yourself next time of what you decided to do during this patient encounter: "Where is the patient now?"
• provide a better, more structured methodology for treating problems
• co-ordinate care of the patient between practice team members, so that items of care are not duplicated or missed
• clarify the care plan for your colleagues in case they have to deal with the patient - for instance, when you're away: do they know what you intend?
• allow the computer to highlight missed items
• opportunistically catch those people who come in for another problem just before they are due for a review and save them a further visit
• give the patient a clear idea of what is to come, possibly to obtain his/her agreement/co-operation
• provide the data necessary to audit the quality of your care
• improve clinician compliance with the guideline⁹

How ?

By:

• developing the established models for structuring medical records to support care plans
• introducing mechanisms to associate computerised guidelines with specific types of record
• creating reminders

Reminders

We propose the reminder as the main type of item in a patient record which will contribute to a care plan. It is a useful entity in its own right, without any reference to care plans. Computer generated reminders have been shown to improve patient care¹⁰. We suggest that they may be used as the building blocks by which care plans can be formed, given the structure of a problem oriented medical record.

The key information a reminder should contain comprises:

• the problem it is linked to
• a link to the guideline that led to its creation (if any), including the guideline version, and guideline component
• the date on which, or a time window within which, the planned action is to take place
• a description of the planned action
• the person, or the kind of person (for example, 'practice nurse'), responsible for performing the action
• a priority level - this really measures how serious it would be to miss/delay the stated action; it may be that the system responds more "loudly", in other words with greater visibility, when a high-priority action becomes due
• a status: is this reminder live, dealt with ("answered"), or cancelled?; due and overdue can be inferred by comparing the date due with the current date

It may also be worth recording:

• the event that caused the reminder to be recorded
• the intention for performing the stated action
• that a reminder may expire as a consequence of an event elsewhere in the patient record; for instance, a cervical smear reminder may expire as a result of the patient having a hysterectomy; thus reminders should have expiry expressions associated with them, not just dates
• the default way in which it is expected that the reminder will be "answered"; this is a practical step which will facilitate their uptake and use; for example, reminders to collect patient data could be considered "answered" if that data is entered into the system at the time the reminder becomes due
• outcome metrics: a way of measuring how well what is planned is achieved; this may relate to the treatment outcome directly - for instance, for the problem of iron deficiency anaemia, the goal may be "get Haemoglobin level above 11 mg/dl by DD/MM/YY"; the outcome metric would then be the haemoglobin level; for other reminders the outcome metric may be "How close to the due date did I achieve the action being reminded for?"; in many cases this concept may not be appropriately used, so it is optional; however, the audit of the quality of care is one of the core reasons for introducing a care plan, and a concept like this is needed to do the audit.

When the action represented by a reminder is carried out, an entry will generally be made in the patient's notes "in answer to the reminder" to say this is so. The status of the reminder which starts off as "active" will be changed to "completed". It does not need to remind any more.

Reminders may be answered in a number of different ways.

• when the reminder is seen as active by the user, an "answer key" is actioned which allows the user to answer the reminder manually with a new item in the patient's notes
• the progress of the computerised guideline either makes the reminder obsolete, or contains the answer to the reminder enabling it to be answered automatically
• the introduction of a new reminder of identical type makes the old reminder obsolete; the problem here is to decide whether the timing of the two reminders which may 'belong to' (be derived from) different care plans is sufficiently close to enable the reminders to be considered duplicates
• the reminder is manually cancelled because the action concerned is unnecessary or cannot be done

In these ways, the reminder successfully implements all of the requirements of data collection for a care plan as outlined by Hammond². Additionally it builds on concepts which are already well established in primary health care systems - for instance, recall dates and markers. Because reminders are problem-linked, the set of active reminders (those which are currently due or are not yet due, and unanswered) stored under any one problem may constitute the care plan for that problem. (Of course, if they have not been entered as a care plan, they may not be sufficiently well-organised to meet that description.) What is required is a mechanism for entering, managing and viewing these reminders, and we would propose that a computerised guideline system is the appropriate tool.

Views necessary to support care planning

Four views of the patient's notes are worth developing for the benefit of care planning:

1. A view of all currently due reminders. It must be obvious to the user if this view contains anything when a patient's notes are first opened so that opportunities to deal with due or imminently due reminders are not missed.
2. The view of current problems can be enhanced to bring out the various components - narrative, treatment and reminders. Of note, the justification for individual reminders could be demonstrated in this view, by revealing the links between reminders and the notes which led to their creation.
3. The guideline view. In current systems the guideline is not generally considered as another "view". However there is significant benefit in having a view which intelligently and flexibly collects together information which would otherwise be available through a number of different views, and presents it in a carefully formatted manner in the context of new data entry, and development of the care plan.
4. The patient's view of the care plan. It may be preferable to provide a paper view of the care plan for the patient to an on-screen view.

For some problems, where there is a dedicated guideline available, the guideline view may be usefully superimposed over, or integrated with, the problem view. This may result in information stored elsewhere being brought into the view of the named problem, because of its relevance in this context. So for instance, the fact entered in an earlier interview, under the heading of "Screening", that a patient has no family history of hypertension, could be made available under a "Hypertension" heading by combining the problem and guideline views.

Grouping reminders to form a care plan

Reminders, stored under a problem, together with the relevant historical narrative, may constitute a care plan. The user may choose to manage the whole through the means of a computerised guideline. If this were the case, the nature of the currently active reminder(s) may be used by the guideline to position itself.

For instance, to use the hypertension example that we started with earlier:

A 40-year-old gentleman is found to have high blood pressure on routine screening. The clinic where this occurred may well have been managed using a computerised guideline, which itself called the appropriate guideline to manage a single high blood pressure reading. A new problem heading of "O/E High blood pressure reading" is created under which the first blood pressure reading will be visible. The guideline will prompt the user to record the following:

After the first of these visits, the nurse "answers" the first reminder with the result of the blood pressure taken. Unless the blood pressure has risen dangerously, no more needs to be done. After the second visit, the second reminder is answered, and the care plan is updated to reflect the treatment necessary by the introduction of a new (group of) reminder(s).

Together, the "goal" note and the subsequent two reminders form the care plan for this problem for this patient. The goal note is perhaps superfluous in this situation, but provides a simple example of how it can be developed.

Perhaps a more realistic example of where the goal is more usefully stated is for a 12-year-old girl with asthma. The goal may be to keep her Peak Expiratory Flow Rate (PEFR) above 250 l/min, her asthma-disturbed nights to fewer than two a week, and her days off school due to asthma to one a month or fewer.

By recording a goal with a measurable aspect at the start of the care of a problem, it is possible to audit not just the care process, but the care outcome too.

Audit of care plans

Care planning has implications both for the quality and the cost of care. If the right treatment is given at the right time, treatment will be optimal for the patient, and not entail wastage. There is much use of the term "critical path" in literature concerning care plans. "A critical path attempts to achieve continuous quality improvement by aligning actions of the care team."¹¹ The implication is that optimal care will proceed along the critical path, and this requires planning effort¹².

The main question in regard to the audit of care plans is "Did I provide the level of care for this patient that I had said I would?" This may be answered from the process and/or outcome viewpoint. The ability to do the latter depends on the information provided by the user when the care plan is generated. In the longer term, rigorously recording care plans, their outcomes, and the relationship to any guideline from which they are derived, provides the best basis for producing the next generation of that guideline. It is one of the major routes to "evidence-based medicine". In a way, using a guideline can be considered "concurrent audit", where best practice is applied to the care process in "real time".

Sharing care using electronic links

The care plan is of particular importance where more than one person is responsible for the care of the patient. This is true within the practice where the practice nurse, district nurse, physiotherapist and others join the general practitioner in the patient's care. One very exciting area where care plans may become more prominent is where the care is shared with the hospital. If the care plan can move between the practice and hospital, being updated with what is due next by either party, so that everyone is clear, it may prove a very useful tool.

Conclusion

Care planning is practised to some extent by all clinicians as an inevitable part of their management of patients. However formal care planning along the lines laid down by practice guidelines is only slowly being taken up in the primary health care arena. Because of the increasing sophistication of modern medicine, the ongoing requirement for quality and audit, and in the light of advances in electronic links, improving the infrastructure for shared care, care planning is a valuable (and may become an essential) discipline. Computerised reminders may serve as one of the building blocks used to facilitate the uptake of care planning in primary health care.

Implementing guideline-based care planning in full will require a richer set of 'context of care' terms than are now available in Read 3.1. For care plans and guidelines to be interchangeable between care organisations implies an extended, standard medical record structure as well. The PRESTIGE project¹³, sponsored by the European Union, is devoted to providing generic information technology to support guideline use in clinical care, and will explore these issues in depth. It will build exemplar systems in primary, acute and shared care within the next three years. However we believe that the extended use of reminders advocated in this paper would be a valuable first step in what will inevitably be a substantial (and exciting) process.

Acknowledgments

Many thanks to Sheila Teasdale for her help with the literature searches, and the constructive criticism from CLICSIG.

References

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