Medicine today is single encounter-oriented, with the patient medical record structured to support one encounter at a time, where an encounter is either a single outpatient visit or an inpatient stay. The problem with this single encounter orientation is that it often takes a number of encounters to get a correct diagnosis and that care for a medical condition could extend over many encounters before the medical situation can be resolved. Further, for chronic conditions, care for the condition is needed over an extended period of time, even over the patient’s lifetime.

If a physician does not take responsibility for this continuing care, then three things could happen as described under the following categories:

1. Coordination: There is no physician to coordinate care.
2. Continuity: Care for the medical condition is prematurely stopped.
3. Consistency: The care plans for the medical condition over time are inconsistent or even contradictory.

I call the three desirable aspects of care for a medical condition over time—coordination, continuity, and consistency—the “three C’s.”

In order to support a physician in continuing care and support of the three C’s, I propose two data structures: a “case” and an “episode of care.” The difference between the two is that a case would support a chronic condition lasting over a long period of time, even a lifetime, while an episode of care would be for a medical condition where care is given until the condition is resolved with an expected outcome.

Each data structure would include:

• Identity of the patient
• The medical condition
• The physician coordinating care, including contact information
• Current care plan for the medical condition
• Next encounter
• List of past encounters dealing with the medical condition.

The case or episode of care would be visible across medical organizations where the patient was seen for care.

Assignment of a managing physician would insure coordination of care.

Today there is a new care plan for each encounter. I propose that there also be a care plan in a case or episode of care that remains the same across encounters until it is changed. Every other physician seeing the patient would have the obligation of following this care plan except in emergent situations. This would ensure consistency of care.

Identification of a next encounter would ensure that care is continued.

A non-managing physician would be able to identify a second opinion that would be sent to the managing physician for consideration of inclusion in the care plan for the case or episode of care. The managing physician should also periodically encourage the patient to get a second opinion from another physician.

Physicians caring for the patient would identify when a current encounter is related to the medical condition so it could be listed in the list of encounters for the case or episode of care. Selection of an encounter on the list by a physician would retrieve medical record documents for the encounter.

An example of a medical condition for which an episode of care might be appropriate is a “prostate-related incontinence” that would be expected to be eventually resolved in a number of ways, including surgery.

A severe fracture of the knee could start off being handled by an episode of care ending after surgery and rehabilitation is successfully completed, but might morph into a case as complications could occur much later in life, such as arthritis or a knee replacement. At times when the knee problem is quiescent, the case may have no managing physician or next encounter; this can be safely done for the knee problem because further care is only needed when the patient experiences a clear problem.

Some medical conditions could advance in severity without the patient knowing it. These should retain their case information for managing physician and next encounter. Next encounters could represent periodic appointments to access the medical situation.

One medical organization’s approach to identifying a next encounter for a patient—especially an encounter that may occur a good deal later, such as a year—is to save appointment search parameters to be automatically used to book an appointment for the patient at the later date with the patient being informed when the booking occurs. This solves the problem that physician schedules for appointments may not be available yet to book an appointment so far in the future.

There should be provisions for changing the physician managing the case or episode of care, for example, at the patient’s request or upon the patient moving from one medical organization to another, with a method provided to enable communication between the two physicians. This approach to a changeover of physicians might resolve the non-continuance of care when a patient changes medical organizations.

Today, there are obstacles and considerations in implementing such a solution to the three C’s:

• There is currently no secure way for electronic medical record systems (EMRs) in different medical organizations to securely share medical information such as cases or episodes of care.
• Currently, there is no standard way for an EMR to retrieve encounter-based medical records from another medical organization.
• The patient should be aware of the existence of a case or episode of care with a managing physician so the patient can participate in care.
• Care is often given by a team of physicians rather than single physicians, which may require support beyond a single case or episode of care, which could include the possibility of care being given by physicians in different medical organizations.
• It may be appropriate to address the overall care for an individual via a case rather than for a single medical condition, for example, for a homeless individual who is costing a county a lot of money and has many different medical conditions.
• Identification of the next encounter may be difficult because the schedule for a physician may not yet be created or released for booking. (Storing search parameters to be used to book an appointment automatically at a future date solves this problem.)

Michael R. McGuire is the author of A Blueprint for Medicine.

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