Let’s clear the air right up front.  You do NOT have to use the infamous “.CHR…” dot-phrases if you don’t want to! No one is trying to turn you into a robot using the same cookie-cutter, boiler-plate lingo as everyone else.  Those dot-phrases were designed by your peers (docs, nurses, clinic staff) and were meant to be helpful (in fact many of your peers think they are).  You can customize them or ditch them as you see fit.  I don’t really care. As physicians we can use as much creativity as we like in our care plans.

But let’s think what our patients and their families want and need from us.  They want to know what medicines they are taking, in what doses, and for what reasons.  So we should all have the discipline to clean up our patients’ medication lists so that what gets printed in the After Visit Summary is accurate and makes sense to our patients.  Next, they want to know what some realistic goals and targets are for their main active problems.  They want to know what symptoms to look for, what to measure, and who to call if they have concerns.  They want to know their follow-up plan.  They want all this to be written in language that they can understand, and for it to be put in a standard place where they and their family to find the information.  And, by the way, they assume, quite reasonably, that if other doctors are seeing them for part of their care that we will all communicate well with each other so that everyone is working together to keep them healthy.  Now that’s a Collaborative Care Plan!

Let me tell you what I do as an endocrinologist seeing one of your patients who has diabetes among her various problems.  She might well have several other chronic problems she is dealing with.  Perhaps she sees Dr. Resnick for her mitral valve disease and Dr. Hsia for her ulcerative colitis.   Maybe you are already trying to help her make sense of those things as well as deal with her depression, asthma, and her alcoholic husband.  But right now for the patient and the daughter who has accompanied her to the clinic it is her diabetes that is troubling her the most.   She is waking up thirsty every morning with high blood glucose levels.   She feels like she has no energy during the day to cope with everything else.

My approach is to listen and get a sense of what a typical day is like for her.  When does she get up, put the cat out, walk the dog?  What matters most to her in her life?  What does she eat?   What else does she do in her day?  What are her priorities?  I then suggest options that should help her do everything she wants to do and feel better while doing it.  We come up with a Care Plan.  We set goals that matter to her.  We set short-term targets to help her get there.  I then type all this out in her progress notes while she and her daughter look on and correct me as needed.  My style is to be succinct but write it in plain language.  I prefer not to clutter up the Care Plan with generic advice like  ”Eat your fruits and vegetables, wash behind your ears, always wear clean underpants, don’t run while carrying scissors, etc.”  So I don’t use dot-phrases for this part of my charting, although I know many excellent physicians who do.

I then copy and paste this Medical Treatment Plan into the After Visit Summary.  If the patient is “Active” on MyGroupHealth I also send it to her by e-mail as she looks on.  I invite her to e-mail me or call me if she has concerns.  I also type out who else to contact (her primary care doctor or nurse or pharmacist).  I then go to the Problem List and create “CARE PLAN” by typing in GHC.13 (unless it already exists on the Problem List).  I mark the CARE PLAN High Priority so that it always shows up at the top of the Problem List.  I type in .txplanupdate and then type Diabetes in front of it.  This makes it clear that her Diabetes Medical Treatment Plan was changed by me on this date.  I may see that the patient’s primary care doctor changed her depression treatment plan a few days ago.  It would be great to see when Dr. Resnick last changed the plan for her mitral valve disease and what Dr. Hsia has in mind for her ulcerative colitis.

So that’s my new routine.  Our current approach to “Care Planning” may change over time.  EPIC may develop a slick new module with its own tabs and toolbars.  I don’t know.  What I do know is that by following a few simple conventions and “rules” as I have outlined above we can have a consistent, meaningful, and helpful way for our patients, their families, and our colleagues to know where to find their latest care plans.  What’s not to like about that.  To me it is a huge step towards providing patient-centered care that really works for everyone.