Challenges to the Application of Integrated, Personalized Care for Patients with COPD-A Vision for the Role of Clinical Information

Abstract

Chronic Obstructive Pulmonary Disease (COPD) is a complex disease defined by airflow limitation and characterized by a spectrum of treatable and untreatable pulmonary and extra-pulmonary disease characteristics. Nonpharmacological management related to physical activity, physical capacity, body composition, breathing and energy-saving techniques, coping strategies, and self-management is as important as its pharmacological management. Most patients with COPD carry other chronic diagnoses and this poses a key challenge, as it lowers the quality of life, increases mortality, and impacts healthcare consumption. A personalized, multi-, and interprofessional approach is key. Today, healthcare is poorly organized to meet this complexity with the isolation between care levels, logic silos of the different healthcare professions, and lack of continuity of care along the patient's journey with the healthcare system. In order to meet the criteria for integrated, personalized care for COPD, the structural capabilities of healthcare to support a comprehensive approach and continuity of care needs improvement. COPD is preeminently a disease that requires a transition from a reactive single-specialty approach to a proactive interprofessional approach. In this study, we discuss the issues that need to be addressed when moving from current health care practice to a person-centered model where the care processes and information are aligned to the individual personal needs of the patient.

Keywords: COPD; care plan; chronic disease; clinical health informatics; multimorbidity; person-centered care.

Figure 1

The multi-professional team provides a highly specialized analysis and treatment recommendations for different domains of patient needs. The knowledge pertaining to the patient must not be lost when the patient transfers to primary care where, most often, the care process is confined to the GP and the nurse. Also, the multi-professional team should have tools for a rational sharing of knowledge to motivate the costly model for care organization.

Figure 2

The standard clinical pathway was constructed based on national guidelines and evidence from the literature. During the execution of the plan, data is registered to the EMR and the individual data dashboard that supports the care in the interprofessional group. Data can also be collected on the group level and be used to update the local standard clinical pathway. Patient reported data was included as important potential modifiers of the standard clinical pathway.

Figure 3

A schematic drawing that demonstrates the organization of the desired IT support system. The multi-professional team designs an optimal clinical pathway and key clinical indicators of disease severity and activity. The clinical pathway is translated to a care plan that provides continuity in the knowledge building along the care trajectory irrespective of provider. The clinical structured data are available in real-time and provide feedback to both healthcare and patients in real-time. Hence, the multi-professional group is supplied with tool for process optimization, patient service, and knowledge sharing.