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Friday, March 22, 2013

On being Strategic rather than Comprehensive

In Meaningful Use, there are several components related to care planning that need to be communicated for transitions of care: The care team, the care plan (as described in CCDA), and patient instructions.  This was a good first start, but there's far more to do.  HL7, IHE, S&I Framework and many others have been working on developing a more comprehensive way to address care plans and care planning for quite some time.

This week, IHE PCC was reviewing content being developed for one of our work items related to care planning.  On the screen earlier this week was a proposal to add the following term to the IHE Glossary.

Care Plan   The synthesis and reconciliation of the multiple plans of care produced by each provider to address specific health concerns.

“You have defined care plan in terms of itself.” I comment.  Others immediately responded that they hadn’t.  “Sure you have: care plan and plans of care.” I chimed back.  I was then told that “Those are two different things.”, and thus began my education into what the current thinking is that's been developing across various groups.

This is what my daughter calls a face/palm (or in this case a head/desk) moment.  Those moments are usually accompanied by a loud noise as my palm (or my desk) comes quickly into contact with my face (or head).  I think the pain helps distract me from the former attack on my senses.

“OK,” I explained, “I’m never going to be able to explain this to anyone.  The way that the English language works, these two phrases mean the same thing.”  I did spend several years developing linguistic and natural language processing software, and managed to pick up a few things from my linguistic colleagues. 

A parse of “care plan” will result in in a noun phrase (a phrase acting as a noun) composed of “care” (noun adjunct = noun used as adjective) plan (noun).  Thus, plan is the main idea, and care is a qualifier that means the plan related to care.  I’m assuming I don’t need to define plan or care (yet).

A parse of plan of care results in a noun phrase, where “plan” and “care” are again nouns, “of” is a preposition, and care modifies/qualifies plan.  It is the plan about or related to care. 

My brain, and if you are reading this blog, likely yours, has been trained to treat “Care Plan” and “Plan of Care” as if they were the same thing.  We can all be indoctrinated to understand that they are different things, but recall what I said a few days ago about social interoperability, and what I said a few weeks before about not caring about what it is called, so long as I know what it is. 

These words fail the grandma test (and the developer test, and the provider test …). Something has to give here.  We need new words, because the ones we have only add to the confusion.  Definitions can be used to override instinct, but I'd much rather rely instincts, rather than circumvent them.  Let’s take a look at the words we have, and a picture to go along with them.

The image to your left shows that there is a first outer ring that encompasses the second inner ring, which has a third subcomponent containing a final inner component.  The image comes from material developed for the Longitudinal Coordination of Care project in the ONC S&I Framework from the Longitudinal Care Plan subworkgroup.  What follows are the words describing these rings that were suggested for the IHE PCC Glossary, and which are derived from the S&I Activities.

What it is called
What it is
Care Plan
The synthesis and reconciliation of the multiple plans of care produced by each provider to address specific health concerns.
Plan of Care
A concept some clinicians use to focus on discrete problems, the specific interventions to address the problem, and achieve a certain goal related to the problem.
Treatment Plan
A concept developed by a provider in collaboration with the individual to address an individual’s health concern under the purview of a single provider.
Information or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice. This is provided as a list of action steps given to a team member or patient to address health concerns.

The important part of what you see above is not the words on the left, but rather the words on the right.  The only notion of the “Care Plan” that I have ever seen is what my mother used to carry in her head for my step father, aided by her notes.  This concept exists rarely in the real world, but I have seen enough real world examples to know this isn’t a unicorn.  But it is rare enough to be a zebra (at least in my part of the world).

The second and third items are often confused, and in fact, IHE a few years back agreed that the code for the TREATMENT PLAN section in LOINC was the right place to put the CARE PLAN information (which has resulted in further discussions about change proposals to some existing profiles).  It’s confusing enough to experts, and healthcare providers certainly don’t agree on it either.  Instructions is perhaps a bit broader than I would expect, but seems to fit in with current notions.  And there seems to be agreement among healthcare providers that instructions are part of the care plan (at least those given to patients are).

The definition of the outermost object seems to be missing an important participant, the patient.  This is especially true when the phrase “Care Plan” is used with a definite article.  The only individual that has any chance of having access to “The Care Plan” is the patient or other care giver who has access to all the information available.  You can see why Care Plans are zebras.  You need an engaged patient or caregiver who wants to coordinate all this data, and they have to have access to it as well. 

My mother’s care plan  for my step father was flawed in that she did not have access to all the data, but that’s wasn’t for lack of trying. Using the definite article for a care plan ("The Care Plan") that is owned or developed by anyone other than the patient or their care giver is a mistake.  In the provider’s mouth, those words better be something like “this is the care plan that I’d suggest for you”, or “let’s go over your care plan”.  If “you” are not part of the care plan when your healthcare provider discusses it, then it’s probably his or her plan, and he or she shouldn’t be surprised when you change it to suit your needs.

In the battle for health and against disease, the commander-in-chief needs to be the patient.  They should be setting the objectives and goals, and approving the strategies used to reach them.  They may override some decisions where they feel necessary to in order to balance the priorities for each objective.  In the above definitions, I see the word “goals” used once, and the words “objective” and “priority” never appears.  The “plan” is what you do to meet goals.  The terms “goal” and “objective” are synonyms, and are often used interchangeably. 

I’ve been trained to specify objectives in a broad way, and to derive goals from objectives.  Goals allow you to measure whether the objective is being reached (in fact, if you work this way, the objective is often stated subjectively, and the goals are objective statements -- I never said social interoperability is easy).  If we talk about, and deliver goals and objectives together, I don’t think anyone will mind, and it’s still pretty easy to explain that goals need to be measurable.
"The key to strategy... is not to choose a path to victory, but to choose so that all paths lead to a victory." — Cavilo, The Vor Game
In a complex situation, there is never a single comprehensive plan which leads to success, but rather a collection of plans and alternatives in which enough plans succeed to result in the desired outcome.  Has your doctor ever told you: our plan is to try this (e.g., PT), and if that doesn’t work, then we will do that (Steroid injection), and finally, if necessary we will do the other thing (surgery)?  These represent the alternative paths (in a plan related to a knee problem).  I love this  doctorial we, but only when used collaboratively, that than in the royal fashion.

Planning is done at different levels, starting from principals, moving to strategies related to goals and objectives, and then on to tactics, which are executed via orders and instructions.  In developing a strategic plan for any purpose, you have high level principles and priorities, which lead to objectives and goals.  Each objective and goal can become the foundation of a tactical plan to achieve the objective.  In delegating the objectives from the strategic plan to others, the planner will often provide additional information and instructions about how to maneuver to reach the objective.

Strategic objectives and specific tactics are dynamic, responding to the changing system (thus, the need for alternatives).  I have never seen an overall comprehensive plan for patient care, such as would be describe in the “Care Plan”.  No organization I have ever worked with ever has an overall comprehensive plan in one place to reach its objectives.  Leaders can speak to the strategic objectives, and can often tell you what others are doing to achieve them at a high level.  The details of those tactics are delegated to experts in each objective.  If you want to know the detailed tactics, you have to speak to those experts.  The process is dynamic, as the tactics often change when alternatives are activated.

Rather than think about a comprehensive Care Plan as described above, I would prefer this view of the care planning process.

Strategic Care Plan:  This is an overview, containing the patient’s objectives and goals for overall care.  It identifies the patient’s principals and priorities that the care must meet.  It synthesizes and is used to reconcile differences between individual tactical care plans, but summarizes rather than contains all of them, although it should reference them in some way.  It most closely resembles the “Care Plan” described above.

Tactical Care Plan: This is a plan designed to achieve one (or more related) objectives.  It combines features of the Plan of Care and the Treatment plan above.  In the continuum between strategy and tactics, high level tactical plans will reference other, more detailed tactical plans.  My provider’s overall plan to control my blood pressure includes tactics that he is responsible for, and those he has delegate to others (e.g., a dietitian and me).  Those delegates may have tactical plans of their own.  Delegation is often represented through orders (e.g., medications, referrals and consultations) and instructions.

Orders and Instructions:  This component represents the orders and instructions in a tactical plan and most closely resembles the Instructions described above.  Orders and instructions in the tactical plan provide can provide links to those others who may have their own plans, and may provide alternatives to address changing conditions.  Advance Directives are nothing more than orders and instructions from the patient to the provider for care and treatment that are based on their principals and priorities.  They belong in the mix for care plans as well.

The "Care Planning" process should be less about comprehensive planning, and more about collaboration and objectives.  Yes, it is important to understand the steps to achieve an objective, but those plans need to be more agile and dynamic, coordinated through self-organizing care teams.

As I think about how my mother manages care, she is the commander-in-chief.  She doesn't have to know everything, but she does know where to go to get the details when she needs them.  In the mountains of data that healthcare can generate, it's not necessarily about what you know, but what you know about how to find out (Dr. Google is so powerful because of that).  Health IT can help, but we should not assume that all of the data will or must ever reside in one place.  It needs to be strongly linked together though, so that the generals can pull together the information they need, in order to carry out the hopes of the commander-in-chief.

-- Keith


  1. S&I LCC has always centered the Care Plan and the care planning process around the patient. I refer your readers to the following presentation for further clarification of the work you described:


  2. Ed Wagner's chronic care model is a good depiction of the intersect between an "informed and activated patient" and the multi-disciplinary care team. In another world, this would be called case management or CRM (dare I say it). This doesn't then resolve itself down to an architecture and data model. The two models we have been pointed to for "shared care" (similar to the conundrum re language you outline Keith is Flinders or Stanford model. Both of these are clinical rather than information models - but if anyone can point me to the latter to support the former, we'd love to see it. Great post thanks Keith.
    regards from "down under" here in NZ.