The health care industry's focus has been, and is still, replacing the paper record with the electronic health record. HITECH accelerated the adoption of the electronic health record. The personal health record was introduced to enable patients to become more active participants in their care by providing them access to the records. Health information exchanges and interoperability have become more important.

These improvements are important. However, they are all centered on "the record."

Provider organizations will not thrive in an era of health reform simply because they have a superb and interoperable electronic health record. They will thrive because the care they deliver consistently follows a plan designed to ensure desired outcomes. The EHR must evolve so that it focuses on an individual patient's care plans — the steps required to maintain or create health.

Every patient's EHR should clearly display the master care plan — a long-term care plan to maintain health integrated with short-term plans for transient conditions. The EHR should be organized according to this master plan: It should highlight the steps needed to recover or maintain health, list the expectations of every caregiver with whom the patient interacts, and include tools such as decision support and a library of standard care plans. Interoperability is a necessity, as various providers must be able to use the plan-based EHR. 

Transformation of the Care Delivery Business Model

We are witnessing a truly transformational change in the business model of health care delivery. It is evolving from one of reactive care with fragmented accountability and a dependence on full beds to a model of health management, care that extends over time and place, and rewards for efficiency and quality.

Because changes in reimbursement reinforce this new model of health care, providers are taking new approaches in organization and practice. They are uniting multiple venues of care, holding clinicians accountable for the care delivered to a specific patient and creating patient-specific care plans that follow the evidence.

Business models not only are leading to significant changes in organization and practice, they also are leading to changes in the fundamental nature and design of the electronic health record. These EHR changes can be characterized as a transition from the electronic health record to the electronic health plan.

The Care Plan

The care health plan has attributes that need to be present to ensure health. The plan should be based on some fundamental ideas:

First, all people have a foundational plan. If the person is a healthy young man, the plan may be simple: establishing health behaviors such as exercise. If the person is a middle-aged man with high cholesterol and sleep apnea, the plan may be annual physicals, statins, a CPAP machine and a periodic colonoscopy. If a person is frail and elderly with multiple chronic diseases, the plan may be merging the care for each chronic condition, ensuring proper diet, and providing transportation for clinic visits.

Second, plans are a combination of medical care strategies with goals to maintain health (such as losing weight) along with public health campaigns such as immunizations.

Third, on top of foundational plans, there may be transient plans. For the patient who is undergoing a hip replacement, there is a time-bound plan beginning with presurgical testing and ending when rehabilitation has been completed. A patient undergoing a bad case of the flu has a time-bound plan.

Fourth, people who have a common plan are members of the same population. These populations may be all patients undergoing a coronary artery bypass graft in a hospital, all patients with a certain chronic disease, or all patients at high risk of coronary artery disease. Moreover, a particular person may be a member of multiple populations at the same time.

Fifth, risk is the likelihood that the plan will not be followed or will not result in desired outcomes. A patient motivated to manage his or her blood pressure has a lower risk than a patient who is not motivated. A frail person with multiple chronic diseases is at greater risk that the plans will not keep him or her out of the hospital than a person whose health is generally good despite having multiple chronic diseases.

Sixth, not all care will be amenable to a predefined patient plan. Life-threatening trauma, diseases of mysterious origin and sudden complications all require skilled caregivers to make the best decisions possible at the moment.

Seventh, plans should be based on the evidence of best care and health practices. And the effectiveness of a plan should be measurable, either in terms of plan steps being completed or desired outcomes being achieved.

The Plan-centric EHR

The electronic health record needs to evolve into plan-centric applications. These applications will have several characteristics:

A library of plans that covers a wide range of situations. This library will include, for instance, plans for managing hypertension, removing an appendix, losing weight and treating cervical cancer. There will be variations in plans that reflect variations in patient circumstances and preferences, e.g., plans that depend on whether the patient is a well-managed diabetic, or plans that reflect the slower surgical recovery time of an elderly person.

Algorithms to form a patient's master plan. A master plan will combine, for example, the patient's asthma, hysterectomy, depression and weight-reduction plans into a single plan. These algorithms will identify conflicts and redundancies among the plans and highlight the care steps that optimize a patient's health for all plans. For example, if each of the five plans has six care steps, the algorithms can determine which steps are the most important.

Team-based. The master plan will cover the steps to be carried out by a patient's primary care provider, specialists, nurse practitioners, pharmacists, case managers and the patient. Each team member can see the master plan and his or her specific portion of the plan. Team members can assign tasks to each other.

Traversing care settings, geographies and different electronic health records. Health care systems will need interoperability approaches that enable individual providers to integrate their native systems with the shared plan.

Decision support and workflow logic. These tools will remind team members of upcoming and overdue activities, suggest changes in the plan should patient conditions and care needs change, and route messages to the appropriate team member regarding new test results or patient events.

A summary screen. This screen will present the status of the plan: on course or not, next steps per the plan, and key pieces of patient data that elaborate on plan status, such as active medications and recent lab values. This summary is different from a medical record–centric summary that highlights recent results, current problems and medications, but does not tell providers whether the plan is on course.

Analytics to assess the degree to which a patient's care and outcomes conform to the individual and master plans. These analyses determine whether and to what extent a population's care is on plan and whether the desired outcomes are being achieved. In addition to outcomes and process assessments, the analytics enable the assessment of the costs of carrying out a plan. As we become more proficient at analyzing large volumes of clinical data, the analytics will be able to suggest steps, based on the treatment patterns of other patients, that can be taken to improve plan efficiency, simplicity and outcomes.

The Evolution of the EHR

We will still need traditional electronic health record transaction capabilities: Providers need to review a radiology report and document a patient's history and the care delivered. Problems must be recorded and medications reconciled.

However, the evolution to a plan-centric record is underway. For example, evidence-based pathways and decision support logic have been embedded into electronic health records to guide provider decisions according to a plan based on patient condition.

Also, EHRs now include population health management technologies that enable the organization to understand its aggregate performance in undertaking disease-specific plans for multiple patients. Health information exchanges help providers coordinate care at multiple venues. Personal health records improve a patient's ability to become an active member of the care team. Providers are using CPOE-based decision support to help guide test orders and new prescriptions based on the evidence.

The evolution of the EHR also will blur the boundaries among population health, electronic health records, analytics and the personal health record applications. For example, logic that identifies next steps in the plan will need to be present in all of these applications.

Business Models in Other Industries

Financial services, retailers and music distributors, along with many other industries, have also experienced massive shifts in their business models.

Several decades ago, financial deregulation enabled banks to offer brokerage services. The business model of many banks shifted from banking (offering mortgages as well as checking and savings accounts) to wealth management. As banks shifted from transaction-oriented services to services that optimized a customer's financial assets, their core applications broadened to include an additional set of transactions (buying and selling stocks) and new services (financial advisory services).

Prior to the Web, most retailers' business models focused on establishing a brand, offering an appropriate set of well-priced products, and building attractive stores in convenient locations. The Web enabled retailers to gather significantly richer data about a customer's buying patterns and interests (and to use real-time logic to guide purchasing decisions). Retailers' core applications broadened to include well-designed e-commerce sites and analytics of customer behavior.

In both examples, even though there was a significant shift in the business model, applications necessary for the previous model continued to be necessary. Banks still had to handle savings account and mortgage payment transactions. Retailers still needed to manage inventory. And advances in these legacy applications — expanding inventory breadth and reducing inventory carrying costs — continue to be important.

In each case, a critical new set of applications was added to the legacy applications. Often, these new applications were more important than legacy applications.

The New Business Model

Major changes in an industry's business model invariably lead to major changes in the focus and form of the core applications used by that industry. The business model changes in health care will lead to a shift from applications focused on the patient's record to applications focused on the patient's plan for health.

The shift is underway. The electronic health record does not disappear as a result of this shift, but the strategic emphasis will move to technologies and applications that assist the care team (including the patient) in developing and managing the longitudinal, cross-venue health plan and assessing the outcomes of that plan.

John Glaser, Ph.D., is a senior vice president of Cerner Corp., headquartered in Kansas City, Mo. He is also a regular contributor to H&HN Daily.