Virtually Priceless Thoughts

I came across an article today in the BMJ, Continuity of Care: a multidisciplinary review. This was a good summary of some of the Canadian work and use of the continuity of care term. Their redefinition of Continuity of Care in to three broad categories is a useful way to organize my thinking as it relates to Clinical Information Systems. Starting from the bottom of the figure:

1. Informational Continuity – links patient specific clinical information between providers and between events. This is related to past information. A provider can review previous blood work, etc.
2. Management Continuity – Describes sharing and modifying future goals and care plans for a specific patient.
3. Relational Continuity – Bridges past, present and future care through on going human relationships. This includes relationships to a group practice. Relational continuity can, I suppose, also include proxy relationships to extend a sense of continuity (which I use in my practice, e.g. “I’ve known Sandra for over 20 years, she’s excellent”).

I have mapped examples of tools to each level of continuity in the figure.

1. Informational Continuity – Includes paper charts and records stored electronically in EMRs, EHRs, etc. This is what we typically think of when we talk about interconnected records. Our standards are focused on information – labs, medications, DI reports, etc.
   Are there tools that can support the other two levels of continuity?
   
2. Management Continuity – Includes care plans as well as Clinical Decision Support in EMRs / EHRs and it also include paper-based clinical practice guidelines that can help direct care. Patient specific guidelines, care directives, etc can help to ensure that providers are not working at cross purposes to patient goals. Clinical Decision Support Systems can provide reminders and alerts at the point of decision making to ensure informational continuity can translate into management continuity. Patient specific care plans / goals are important to capture and share (e.g. advanced directives) to ensure patient goals are addressed. Here, we need standards and distribution mechanisms to synchronize patient specific care plans and goals between disparate clinical systems. There are several gaps in current pan-Canadian standards at this level.
   
3. Relational Continuity – How can clinical systems help with relational continuity? I think that this is a key question to ask.
   • Telehealth – the classic tools of telehealth / telemedicine can extend the reach of the face to face relationship through video conferencing. This helps span distances for rural / remote / specialty care especially. Group telehealth visits can extend relationships and trust by having a (kn)own provider in a visit to share knowledge and to lend credibility to the new provider(s).
   • Electronic Patient-Provider Communication – with your (kn)own providers, electronic communication (e.g. secure email) provides better access and thus continuity.
   • Electronic Provider-Provider Communication – between providers, quick, secure communication (or phone) can extend aspects of the relational continuity to a surrogate provider.

Thinking about how to achieve benefits in continuity at each of these three level, through technology, is a useful exercise for an organization during planning and design of programs and initiatives.

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