Table 1

Functions to Incorporate into a Goal-Directed EHR

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
 LongevityPatient 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 lifeAssessment 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 developmentAssessment 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 contextReview 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 planningCompletion and tracking of advance directives (care plans) and end-of-life care choices.
Health care tracking
 Care narrativeDescription 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 dataTest 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 communicationAdvanced interdisciplinary and interorganization communication, including transmission of core patient profile information using multiple layers (clinical and administrative information).
 Health data interoperabilityConnections 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 integrationContinuous 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.