Article Figures & Data
Tables
Function Description Patient profile (core) Longitudinal patient profile and health history in the patient’s voice with health goals and levels of attainment (including barriers and facilitators) linked to each functional domain of the EHR to support shared decision-making. Health planning Longevity Patient and professional health assessment updated periodically to produce global health metrics (life and health expectancy, “body age,” wellness score, qualitative health strengths and challenges, total health benefit if all goals are achieved, and specific health benefits for individual care strategies). Health-related quality of life Assessment and tracking of health-related quality of life (meaningful life activities current level of functioning, eg, ICF,20 quality of life goals, readiness to address quality goals, and goal attainment scaling. Personal development Assessment and tracking of development connected with achieving life and health goals. These may include developmental milestones (Erikson), psychological needs (Deci and Ryan), adult learning (Zubialde, Mold, and Eubank), physiologic resilience, and spiritual development. Family and social context Review of the patient’s family and social environment related to health care support and the impact of sociocultural, economic, and personal value factors on the individual’s health care (eg, by using genograms). Advance care planning Completion and tracking of advance directives (care plans) and end-of-life care choices. Health care tracking Care narrative Description of the patient’s health status and encounters with the health care system that can be searched using natural language processing and linked to recommendations using advanced primary care terminology.21 Quantitative data Test results, imaging, reports, integrated person and population-level preventive services registry, and forecasting system linked to EHR 2.0 functionality to trend multiple, linked layers of data including life and health events. Health care collaboration and context Interdisciplinary communication Advanced interdisciplinary and interorganization communication, including transmission of core patient profile information using multiple layers (clinical and administrative information). Health data interoperability Connections to regional systems or information exchanges (community record sources) with the option of 1-click discrete data element transfer into the local record, if needed. Community and population health integration Continuous and automated data mining system and signal detection responsive to individual and population health goals, linked to point-of-care and prospective decision support. EHR = Electronic Health Record; ICF = International Classification of Functioning, Disability and Health.
Additional Files
The Article in Brief
Moving From Problem-Oriented to Goal-Directed Health Records
Zsolt J. Nagykaldi , and colleagues
Background When electronic health records were introduced, clinicians and patients were optimistic that computer technology would facilitate higher quality, more cost-effective and more patient-centered care. However, EHRs have not met many of these expectations. This report proposes applying the Goal-Directed Health Care model, focusing on patients' life and health goals, as an organizing framework for patient care and electronic health records.
What This Study Found Meaningful reform of primary care should not only address the provision, documentation and payment of care; it should be based on patients' goals for their lives and health, with corresponding redesign of electronic health records. This report from an international team of primary care researchers recommends that the current problem-oriented fee-for-documentation structure of EHRs be replaced by a framework built around life and health goals. This focus would not only better serve patients; it would also help refocus medical professionals on the full scope of human health. To begin the process of creating goal-directed electronic health records, the authors suggest incorporating core patient profile and health planner functions into existing EHRs and creating linkages between patient characteristics and other parts of the EHR. If patient attributes captured by EHRs are expanded to include actionable sociocultural and socioeconomic information, life and health goals, care preferences, and personal risk factors, they can be leveraged by other EHR components so that patients and clinicians can work together to develop personalized care. The authors point out that, although numerous systemic and administrative health care innovations have been tried, the problem-oriented approach to care and its conceptual image coded into the medical record remain the same across innovations. If patient life and health goals are to drive health care and medical record design, shifts will also need to occur in health care delivery, measurement, and payment.
Implications
- The authors call for research into how patients and health care teams can partner effectively using goal-directed health records.
