The Individual Care Plan as Electronic Health Record: A Tool for Management, Integration of Care, and Better Health Results

The Individual Care Plan as Electronic Health Record: A Tool for Management, Integration of Care, and Better Health Results

Manuel José Lopes, César Fonseca, Patrícia Barbosa
Copyright: © 2020 |Pages: 12
DOI: 10.4018/978-1-7998-1937-0.ch001
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The idea of the need for healthcare planning, whether in the individual or collective dimensions, is consensual among all health professionals. Despite this consensus, as well as a discourse that values teamwork, planning focused on health professionals has prevailed. Due to the current circumstances, particularly those resulting from changes in the epidemiological profile of the population, a new way of planning individual healthcare is required that must meet the following criteria: be of an individual nature, integrate the active participation of the citizen/family caregiver, be focused on care in the course of life, safeguard interdisciplinarity, assist in decision making about care, and be able to record decisions about care.
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Definition Of Icp

ICP is defined as

  • 1.

    A person-centered tool that

  • 2.

    Constitutes a space for dialogue among all caregivers1 that

  • 3.

    Supports and facilitates the management of pathways and

  • 4.

    The integration of care.

These four dimensions are assumed fundamental. The fact that ICP is defined as person-centered means that it will not be the plan of any profession or sector, but rather the plan of that person, who is primarily responsible for their life and health self-care and autonomous regarding the care process. These may be delegated to other caregivers when the person so wishes or when the requirement of care exceeds their abilities. Because of this centrality in the person, the ICP will always be a space for dialogue between caregivers with the sole objective of building a personalized intervention instrument.

This dialogue will have to be a permanent exercise to be congruent with the evolutionary nature of the health-disease process and the inherent care process. The person appointed by him/her must carry out the management of courses or the care coordinator or case manager, depending on the case; should understand the integration of care as the integration between multiple levels, sectors and / or care providers.

ICP as a care-planning tool is useful whether we equate care to the sick person, with or without dependence, or to the healthy person, with a promotion or prevention perspective.

In this context, the person, sick or healthy, will be the main protagonist and will bring to this space of dialogue and negotiation his narrative, which is based on his experiences and concerns. The centrality conferred on the person stems from the principle of self-determination as a basic dimension of human dignity (Baez & Reckziegel, 2013; Takayuki, 1999). It will also bring your expectations, or if you will, your goals (see Figure 1, right side). These will play a key role in that it will be based on them that care will be planned, e.g. through an approach that uses people's life and health goals to guide health professionals in creating personalized care plans that attends to priorities, needs, preferences and shared values (Nagykaldi, Tange, & De Maeseneer, 2018).

Figure 1.

Construction model of the individual care plan


In their narratives, people will use a common language, in contrast to professionals who will use classified languages. However, the former needs to be approximated to some sort of classified language; otherwise, it will not be possible to be treated systematically by information systems. For this purpose there are multiple possibilities, one of the most investigated being the Omaha System (Gao & Kerr, 2016; Topaz, Golfenshtein, & Bowles, 2014). This terminology has the advantage of being cross professional, having a conceptual and empirical basis and being interoperable with other classified languages.

In turn, the various professionals will bring a conceptual and empirical narrative based on the scientific basis of their respective areas of knowledge, but also on the knowledge about that particular person and his problems (see Figure 1, left side). The languages to be used by professionals will be chosen by them, however, through semantic interoperability processes, they need to be doubly translated into the language of the WHO International Classification Family Reference Classifications (Madden, Richard; Sykes, Catherine; Ustun, Bedirhan, nd), and for the language of the Omaha System (Gao & Kerr, 2016; Topaz et al., 2014). The first ensures that WHO's requirements for language uniqueness are met; the second ensures an adequate level of communication among all caregivers, so as to ensure the necessary dialogue space.

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