Following is a scenario describes how multidisciplinary teams of healthcare professionals collaborating in a patient-centered medical home (PCMH), using an innovative cyberinfrastructure, can improve care outcomes and bring greater value to patients. This cyberinfrastructure has two software programs:
- A computerized health agent (CHA) that enables patients and clinicians to connect to the PCMH network via the Internet
- A next-generation electronic health record (EHR) designed for each clinician's specific role and special, as well as a next-generation personal health record (PHR), such as the PHPro™.
In this scenario John, a 40 year old high school teacher with type II diabetes, has been having trouble managing his blood glucose, blood pressure, and cholesterol levels, despite taking medication. He recently changed to a different primary care physician (PCP) who is involved in a PCMH network that uses the innovative cyberinfrastructure to help support and coordinate collaboration among a multidisciplinary team of clinicians.
Day 1: John calls his PCP to schedule the first office visit for the following week. After scheduling his appointment, the receptionist sends him instructions for accessing a comprehensive whole-person (mind-body) health assessment and joining the PCMH network. She also asks John to allow the results of the assessment to be sent automatically to the PCP; he agrees.
John then goes to his computer and opens his browser. He navigates to the PCMH web site and registers. After supplying the requested information and selecting a user name and password, he is automatically enrolled as a patient in the PCMH network. The CHA and PHR are then automatically downloaded and installed in his computer. The PHR then begins displaying a series of holistic health assessment questions on his screen.
After completing the detailed assessment, John's PHR automatically:
- Analyses the data using its mind-body health logic engine
- Stores the resulting biopsychosocial (biomedical and psychosocial) health information about securely in his computer in an encrypted data file
- Generates a personal profile report providing him an integrated "big picture" view of his physical and mental health—past, present, and probably future—as well as evidence-based guidelines that enables him to understand his problems, risks, prognosis, and the relative pros and cons of different preventive and treatment options.
John starts interacting with biopsychosocial profile report offline. The report, which is comprehensive and easy to understand, includes:
- A description his medical and emotional problems and risks based on the information he input into the PHR
- A warning that he was under a great deal of stress due to problems at work and in his personal life
- An alert that his high blood pressure may be exacerbated by a side-effect of a supplement he is taking
- An easy to understand visual depiction of his health status, treatments, and significant life events on a timeline spanning many year
- A prognosis that give him realistic expectations by predicting how his health will likely be in the future if things continue the way they are going, and how likely his health will improve if he takes effective steps to control his current problems and prevent his risks from becoming problems
- Information therapy containing explanations and evidence-based recommendations about his health and what to do, including how his mental stress may be raising blood glucose and blood pressure levels, as well as targeted actionable recommendations that anticipates his needs
- A list of questions to ask his doctor to assist in shared decision-making.
John's CHA also sends a predefined subset of data from John's data file to his PCP's CHA via an encrypted data file. The PCP's CHA stores the file in his computer in a folder (directory) containing the data files of other patients currently in treatment; the files of inactive patients are in another folder. Whenever the PCP accesses his EHR and selects to view John's health information, his data file is retrieved and the information it contains is presented in an interactive report.
Day 12: John meets his PCP for the first time and the two of them discuss the results of the initial biopsychosocial assessment. The doctor then gives John his annual physical and tells John that the results of the blood tests will be sent automatically to his PHR once the doctor receives them. In the mean time, the PCP refers him to see a cognitive-behavioral psychotherapist, who is also in the PCMC network, to help him to handle his stress. After the office visit, John calls the therapist and makes an appointment for later that week.
Day 15: During his initial session with the psychotherapist, John authorizes an automatic electronic transmission of specific whole-person information from his PHR database to the therapist's EHR.
After the session, John returns home and clicks a few buttons on his PHR, which automatically sends the authorized health information to the therapist's database. At the same time, certain data from the therapist's database are sent to the PCP's database to help the PCP track and coordinate John's care. In addition, the PCP is alerted that his database is updated.
The therapist requires different health information than the PCP. Since the cyberinfrastructure is configured to distribute the appropriate data sets based on each clinician's specialty, the data received by the therapist includes detailed information about John's mental health that the PCP did not receive. This information includes analyses of the connections between John's thoughts, attitudes, emotions and behaviors; the nature of his current stressors and life problems; his coping skills and tendencies; certain observations of daily living (ODL) data; as well as his psychosocial history and significant past experiences. The therapist views this information through his EHR. He then adds his professional observations and psychological test results into EHR, as well as information that is sent from his EHR to the PCPs.
Day 19: After the PCP receives John's blood test results from the lab, those data are automatically sent to John's data file. An alert appears on John's as in icon on John's computer notifying him that new information is available for viewing via his PHR. Later that day John accesses his PHR and views his lab test results in language, graphs, and picture he can understand. As suspected, his A1c glucose levels are too high and his cholesterol levels are borderline. He clicks a link next to the abnormal levels and receives additional information therapy explaining the likely causes for his condition and suggesting steps for him to take. In addition, he receives an alert that sent to him automatically by his PCP's CHA; it instructs him to contact his PCP to schedule a follow-up visit ASAP, which he does online via the PHR.
Day 22: John goes to his PCP's office for the follow-up. He is prescribed new medications as recommended by the clinical guidelines displayed on the PCP's EHR. If his EHR implements the patient-centered cognitive support (PCCS) process, a virtual human model would be used to assist with guideline selection and generations of a holistic plan of care. A wellness coach working in the PCP's office, who uses a different version of the EHR, then sits with John, explains his self-management plan of care, and answers John's questions.
Day 23: John goes to his psychotherapist for his second session during which he and the therapist reviews his mental health report generated by the therapist's EHR. The report contains useful information that helps them determine treatment goals and methods for achieving those goals. This information also suggests a diagnosis and assists the therapist in establishing a treatment plan. The therapist then gives John a homework assignment. He is asked to use the self-help problem management guide on his PHR to assist him in managing stress, improving his coping skills, and developing more effective ways dealing with his personal problems. This assistance augments and supports the care rendered by his therapist.
Ongoing for the next 8 weeks: John continues meeting with his psychotherapist weekly and uses his PHR as a self-help tool. He also uses the PHR to collect observations of daily living (ODL) data on a regular basis. These data include his levels of stress, the situations in which the stress is high, his mood and thought processes when under stress, his behavioral reactions to the stress, medication use, physical activity levels, diet, as well as his blood glucose and blood pressure levels using home monitoring tools. The PHR analyzes these data automatically and displays a report explaining how John's mind and body are interacting, the changes taking place in his physical and mental health, trends, projections, and warnings. Similar data are sent automatically in encrypted data files by John's CHA to his therapist and PCP's CHA. Their CHAs then automatically update the versions of John's data file stored in their computers, thereby ensuring the most recent data available for viewing via their EHRs. In addition, the wellness coach receives a subset of the data, which updates John's data file stored in her computer. Each of these collaborating healthcare professionals are alerted whenever information on a patient is updated. When they view their EHR reports, the new data are automatically processed and warnings are displayed if newly discovered problems with John's health appear.
End of episode of care: Upon completion of his mental health treatment, John is alerted to use his PHR to do an outcome assessment in which a portion of the initial assessment is repeated. The results are calculated automatically revealing positive changes in his level of stress, mood, key cognitions (attitudes and beliefs), coping skills, as well as in his glucose and blood pressure levels; his cholesterol remains at a borderline level, however. The results are sent via his CHA to the PCP, psychotherapist, and wellness coach. In addition, the initial and outcomes data are de-identified and sent in a data file to a CHA connected to a research database, which imports the data. The data are then immediately available to collaborating networks of researchers and clinicians studying care outcomes and evolving the clinical guidelines for ever-better results.
Bottom line: This scenario exemplifies the benefit of delivering whole-person care in a coordinated and integrated manner supported by and innovative cyberinfrastructure consisting of (a) a CHA that connect clinicians and patients to a PCMH network via the Internet and (b) next-generation EHRs and PHR. The result is a happier and healthier person, who is a more productive employee, and who self-manages one's health more effectively. This benefits many by reducing utilization of healthcare services to lower employer overhead, insurer payouts, and the person's out of pocket expenses. In addition, healthcare professionals benefit from better outcomes, fewer errors, and more satisfied patients. And everyone benefits from greater peace of mind knowing that care is well-coordinated and delivered competently.
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