Posted by: Jenny Laurello
CDS, clinical decision support, continuity of care, EBM, evidence-based care, Evidence-based medicine, longitudinal care, longitudinal care plan
Guest post by: Patricia Button, EdD, RN, chief nursing officer and director of nursing content, Zynx Health
There are a myriad of challenges associated with actualizing (making real) the delivery of standardized evidence-based health care across the continuum of care. Continuity of care across the continuum refers to the degree to which a patient’s and family’s care is coherent and linked. And standardized evidence-based care refers to the degree to which care is provided consistently across the various venues of care and the degree to which that care is based on the most current research and best practices.
A key tool that has emerged as the means both for continuity and standardization is the so called “longitudinal care plan“. Such a plan can be thought of as “a single aligned plan of care, semantically available to all disciplines involved, containing information from disparate health and non-health sources, and fully available to the care / service recipient and capable of guiding care and interacting with health IT systems to maintain alignment.”[i] The motivation to deal with the challenges of implementing standardized, evidence-based cross continuum care is ever increasing as the quality and cost imperatives for such care are now mandated not only by professional commitment and integrity, but also by the various aspects of health care reform.
As organizations consider how to manage their investments in IT, it is critical to appreciate both the technical and software infrastructure required to implement and support care across the continuum and also the clinical decision support requirements to assure both the standardization and evidence base needed to assure continuity and impact quality and cost. Increasingly, there is both research based and empirical data that demonstrates the specifics of care that promote continuity and prevent unnecessary inefficiencies, redundancy, and errors in care. A first and key component of such CDS is the accumulation of critical data about a patient, family and their community that is vital to appreciating their health status and risks. This data needs to not only be collected, but routinely updated along the course of a patient’s health care journey. This data collected based on evidence related to both growth and development milestones, family history and environmental factors provides the basis for a well-informed health maintenance plan as well as systematic and thoughtful management of chronic illness.
Many of the challenges the health care industry is currently facing, unnecessary readmissions, ongoing high rates of medical error, gaps in patients’ and families’ experience of care, and high rates of those factors that increase the rate of chronic illness are related to systems of care that need enhanced technical infrastructure. That is well established. However, as the infrastructure is increasingly available, there must also be incorporation of clinical decision support in the infrastructure that supports both providers and patients to make sound decisions based on current research and best practices.
For more information, please visit Zynx Health.
[i] Standards & Interoperability Framework. Longitudinal Care Plan SWG Charter. Accessed at: http://wiki.siframework.org/Longitudinal+Care+Plan+SWG+Charter