Assessing Progress Toward the Vision of a Comprehensive, Shared Electronic Care Plan: Scoping Review

Abstract

Background: Care plans are central to effective care delivery for people with multiple chronic conditions. But existing care plans-which typically are difficult to share across care settings and care team members-poorly serve people with multiple chronic conditions, who often receive care from numerous clinicians in multiple care settings. Comprehensive, shared electronic care (e-care) plans are dynamic electronic tools that facilitate care coordination and address the totality of health and social needs across care contexts. They have emerged as a potential way to improve care for individuals with multiple chronic conditions.

Objective: To review the landscape of e-care plans and care plan-related initiatives that could allow the creation of a comprehensive, shared e-care plan and inform a joint initiative by the National Institutes of Health and the Agency for Healthcare Research and Quality to develop e-care planning tools for people with multiple chronic conditions.

Methods: We conducted a scoping review, searching literature from 2015 to June 2020 using Scopus, Clinical Key, and PubMed; we also searched the gray literature. To identify initiatives potentially missing from this search, we interviewed expert informants. Relevant data were then identified and extracted in a structured format for data synthesis and analysis using an expanded typology of care plans adapted to our study context. The extracted data included (1) the perspective of the initiatives; (2) their scope, (3) network, and (4) context; (5) their use of open syntax standards; and (6) their use of open semantic standards.

Results: We identified 7 projects for e-care plans and 3 projects for health care data standards. Each project provided critical infrastructure that could be leveraged to promote the vision of a comprehensive, shared e-care plan. All the e-care plan projects supported both broad goals and specific behaviors; 1 project supported a network of professionals across clinical, community, and home-based networks; 4 projects included social determinants of health. Most projects specified an open syntax standard, but only 3 specified open semantic standards.

Conclusions: A comprehensive, shared, interoperable e-care plan has the potential to greatly improve the coordination of care for individuals with multiple chronic conditions across multiple care settings. The need for such a plan is heightened in the wake of the ongoing COVID-19 pandemic. While none of the existing care plan projects meet all the criteria for an optimal e-care plan, they all provide critical infrastructure that can be leveraged as we advance toward the vision of a comprehensive, shared e-care plan. However, critical gaps must be addressed in order to achieve this vision.

Keywords: care coordination; care plan; care planning; chronic condition; chronic disease; digital health; e-care; eHealth; electronic care; electronic care plan; electronic tools; healthcare data; multiple chronic conditions; multiple conditions.

Figure 1

Multiple chronic conditions e-care plan data flow. FHIR: fast healthcare interoperability resources; SMART: substitutable medical applications, reusable technologies; EHR: electronic health records; API: Application Programming Interface.

Figure 2

Alignment of identified care plan projects with comprehensive, shared electronic care plan criteria. Red indicates suboptimal alignment with a criterion, yellow indicates partial alignment, and green indicates optimal alignment. DAM: domain analysis model; C-CDA: consolidated clinical document architecture; CKD: chronic kidney disease; eLTSS: electronic long-term services and supports; FHIR: fast healthcare interoperability resources; SDoH: social determinants of health; SMART: substitutable medical applications, reusable technologies; PeCP: pharmacist e-care plan; DCP: dynamic care planning; OCP: omnibus care plan; CSeCP: comprehensive, shared electronic care plan.