A Clinical Information System (CIS) is any tool that helps organize patient data. Although the term brings to mind Electronic Medical Records (EMRs), the paper-based record can also play a central role in a Clinical Information System.
These CIS functions can directly assist self-management support:
1. Documentation of past, current and planned patient self-management activities in paper or electronic records.
2. Integration of patient data into a chronic illness registry to support proactive care of individual and evaluate care of a patient population. (see more on registries, below)
3. Electronic personal health record (ePHR). Patient- owned medical records are growing in popularity and can play a useful role in support of self-management. It may be totally independent of the poractice’s other medical record system or be a component of that system that has its own special rules of access.
Documentation
Outline: Self-management activities, goals and actions plans are at the heart of patient self-management. We should acknowledge and stress their importance by documenting them for patients and for ourselves.
CIS documentation of this kind supports provider follow up.
Reviewing patients’ plans pior to and during clinical encounters deepens provider relationships with patients and helps providers to capture patient successes, which promotes further change.
Tips and Tools for Documenting Self-Management Support
TIPS:
- For a paper-based system, include the goal-setting form (make sure to give a copy to the patient!)
- Decide who on the team is responsible for documenting self-management goals.
- Some people take goals more seriously if they are reviewed with their physician. Consider how to document patient/physician review.
- Plan how to review patient-set goals at every office visit.
- If a patient is not ready to set a goal, document this and create plans for raising the topic at future visits. [Special Opportunistic Care]
See examples of electronic charting of self-management goals and highlighted clinical data here.
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Registries
A patient registry is a list of all your patients with a particular diagnosis or problem. Data relevant to their illness are entered, and parameters for what needs attention can be established. Registries are used to monitor a patient population, to identify individuals with particular health care needs, and evaluate care for the whole population. They can also show targeted patient data useful for visit planning and panel management. For example, a registry could show you all patients with cystic fibrosis who are overdue for recommended care or could highlight a few key measures for the patients on today’s clinic schedule.
Read more and download a free Excel template for registries here.
Electronic Personal Health Records - ePHR
HiMSS defines an ePHR as:
A universally accessible, layperson comprehensible, lifelong tool for managing relevant health information, promoting health maintenance and assisting with chronic disease management via an interactive, common data set of electronic health information and e-health tools.
Patient-owned medical records are growing in popularity. In some cases, patients are given access to their medical records through secures web sites designed by their health care system. In other cases, commercial sites like Microsoft Health Vault and Google Health are offering consumers a platform to record health information on their own.
An ePHR is not an essential part of self-management but can be supportive of it. An ePHR can provide a patient with the data and tools they need to track and monitor their progress, with links to helpful information and support.
The two links below provide additional information on ePHRs.
- A study by Kaiser-Permanente of patient access to its electronic health record showed a significant decrease in office visits:
- See the “Tools and Resources” link at the HIMSS site including a checklist to identify features of an ePHR and information on Privacy issues