title: A patient-centered longitudinal care plan: vision versus reality.
abstract: OBJECTIVE
  As healthcare systems and providers move toward meaningful use of electronic health records, longitudinal care plans (LCPs) may provide a means to improve communication and coordination as patients transition across settings. The objective of this study was to determine the current state of communication of LCPs across settings and levels of care.
  
  
  METHODS
  We conducted surveys and interviews with professionals from emergency departments, acute care hospitals, skilled nursing facilities, and home health agency settings in six regions in the USA. We coded the transcripts according to the Agency for Healthcare Research and Quality (AHRQ) 'Broad Approaches' to care coordination to understand the degree to which current practice meets the definition of an LCP.
  
  
  RESULTS
  Participants (n=22) from all settings reported that LCPs do not exist in their current state. We found LCPs in practice, and none of these were shared or reconciled across settings. Moreover, we found wide variation in the types and formats of care plan information that was communicated as patients transitioned. The most common formats, even when care plan information was communicated within the same healthcare system, were paper and fax.
  
  
  CONCLUSIONS
  These findings have implications for data reuse, interoperability, and achieving widespread adoption of LCPs.
  
  
  CONCLUSIONS
  The use of LCPs to support care transitions is suboptimal. Strategies are needed to transform the LCP from vision to reality.
authors.affiliation: Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Patricia C
authors.initials: PC
authors.lastname: Dykes
authors.affiliation: Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Lipika
authors.initials: L
authors.lastname: Samal
authors.affiliation: Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Moreen
authors.initials: M
authors.lastname: Donahue
authors.affiliation: Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Jeffrey O
authors.initials: JO
authors.lastname: Greenberg
authors.affiliation: Western Connecticut Health Network, Danbury, Connecticut, USA.
authors.forename: Ann C
authors.initials: AC
authors.lastname: Hurley
authors.affiliation: American Medical Association, Chicago, Illinois, USA.
authors.forename: Omar
authors.initials: O
authors.lastname: Hasan
authors.affiliation: Harvard Medical School, Boston, Massachusetts, USA Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA.
authors.forename: Terrance A
authors.initials: TA
authors.lastname: O'Malley
authors.affiliation: Yale University School of Medicine, New Haven, Connecticut, USA.
authors.forename: Arjun K
authors.initials: AK
authors.lastname: Venkatesh
authors.affiliation: Partners HealthCare System, Boston, Massachusetts, USA.
authors.forename: Lynn A
authors.initials: LA
authors.lastname: Volk
authors.affiliation: Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Partners HealthCare System, Boston, Massachusetts, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D000328:Adult; D000368:Aged; D003266:Continuity of Patient Care; D057286:Electronic Health Records / Q000592:standards*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D062527:Meaningful Use; D008498:Medical Record Linkage; D008875:Middle Aged; D010347:Patient Care Planning; D018802:Patient-Centered Care / Q000458:organization & administration*; D018511:Systems Integration; D014481:United States; D057188:Workflow
keywords: Care Coordination; Electronic Health Record; Longitudinal Care Plan; Meaningful Use