My Care Guide

iOS app for person-centered care planning

My Care Guide is a unique mobile app for iPhone and iPad that puts you at the center of defining and participating in health care planning that inevitably includes many detours, expected and unexpected, guided by many advisors during your personal journey. Within our current healthcare environment these care plans are usually created by doctors and other health practitioners when we are their “patients”. However, we are not always patients. And when we are patients being treated for acute or chronic health conditions, care plans created for our treatment should be an integral part of our personal health journey. A person-centered care plan adopts this broader, long-term view for wellness that is guided by our personal team of doctors, therapists, family caregivers, and supportive friends.

A care plan addresses specific health problems or concerns, defines measurable goals, and includes interventions, medications or other activities that you should perform or are performed by members of your care team. You may contribute activity data (weight, blood pressure, blood glucose, pain score, etc.) that helps your care team evaluate progress, or lack of progress, toward your goals. All aspects of shared care plans are available on your iPhone or iPad, and changes to the care plans are updated in real-time from your care team’s health record system. My Care Guide is based on three complementary technologies that are uniquely suited for putting the person at the center of wellness and care planning: HL7 FHIR®© standard for EHR interoperability, CDS Hooks for providing real-time guidance on your progress, and the Apple CareKit™ and HealthKit™ frameworks for tracking and completing your care plan tasks. Person-centered care for women, with initial focus on maternity care, is the first clinical application for My Care Guide app pilot testing.

Benefits for you and your care team

My Care Guide enables you to create and share personalized goals and activity plans, and receive guidance for wellness and health care that put you at the center supported by your care team. My Care Guide also enables your health care team members to share their care plans with you, all in the palm of your hand on your iPhone!

My Care Guide improves care and care planning with the following capabilities:

  • Share care plans using the HL7 FHIR®© standard
  • Collect and share Patient Reported Outcomes (PRO), including:
    • Health-related quality of life (including functional status)
    • Symptoms and symptom burden (e.g. pain, fatigue)
    • Experience with care
    • Health behaviors (e.g., smoking, diet, exercise)
  • Collect and share health data from your wearable and connected devices that are focused on your goals and care plans
    • e.g. your care activities include measuring blood pressure if you have hypertension, or blood glucose if you are diabetic
  • Receive guidance that helps you achieve your goals
    • Progress assessments on your goals (e.g. weight loss, blood pressure, blood glucose, etc.)
    • Care plan activity tips, suggestions, warnings, reminders, etc.
    • We will build an an ecosystem of partner organizations that provide condition-specific guidance, integrated into My Care Guide using the CDS Hooks standard.

My Care Guide app components

My Care Guide features

Five primary functions of My Care Guide are organized into the five toolbar tabs in the iOS app interface. These features are interrelated and their integrated capability enables you to more effectively coordinate care planning with your extended care team, and receive personalized guidance that helps you to achieve your goals.

  • My Health – Overview of all your goals, health conditions/concerns, and current medications.
  • My Guide – Suggestions and actionable recommendations from one or more Clinical Decision Support (CDS) services.
  • Care Plans – Detailed contents from your care plan(s) including relationships with your health concerns, goals created by you and your care team to address those concerns, and planned activities for reaching the goals.
  • Care Activities – From your care plan(s), current scheduled activities for you to perform including medications, procedures, appointments, and outcome assessments. The care activities are integrated with, and presented using, the excellent Apple CareKit™ app views.
  • Care Teams – Listing of all your care team members and how to contact them, including doctors, therapists, yoga coaches, family members – whomever you choose to include or are included as part of your healthcare provider team(s). Care teams are represented using the HL7 FHIR standard, and presented via the Apple CareKit™ app views.

Introducing Briana

Briana Chen photo Briana Chen is a fictitious person, but with a story that is intended to describe a realistic journey for a 28 year-old “millennial” woman who is committed to a healthy lifestyle while receiving care and medication for mild hypertension. She and her husband, Andrew, are ready to start their family and Briana recently became pregnant. This is where her journey begins while using My Care Guide app on her iPhone 7 to coordinate her personal goals and plans for wellness with the plans created by her family physician, Dr. Anderson, and her OB/ GYN, Dr. Rattle.

My Care Guide appYou will learn more about Briana’s journey with person-centered care and the challenges that she must manage when diagnosed with gestational diabetes during her pregnancy. For now, we’ll use Briana’s story to introduce the features of My Care Guide. Our app is still under development and not yet available on the Apple App Store, but we are actively seeking collaboration with healthcare providers or other organizations that share our vision for a mobile app that empowers Briana and others like her to realize the benefits of improved person-centered care. Contact Dave Carlson for more information about how to join Briana’s journey with My Care Guide.

My Care Guide for your personal health goals and plans

A personal care plan includes health concerns, goals, care plan activities, and care team members that are defined and maintained by a user of My Care Guide app. Briana has expressed a health concern about her lower back pain, added goals and activities to continue Yoga and running during her pregnancy, and included her husband and Yoga coach as part of her care team.

Each of these My Care Guide scenarios may be used independently, or in combination.  Many other person-centered care user stories are possible, see a list below for possible applications. A personal health plan is created and maintained by the My Care Guide app user, whereas most other care plans are created and maintained by a person’s healthcare team using their organization’s EHR system, then shared in this app via an HL7 FHIR standard interface.

My Care Guide for managing chronic conditions

Care plans for chronic conditions are usually created and managed by a person’s primary care provider, often in collaboration with other members of the care team that depend on which condition(s) are present. There are many examples where person-centered care would be beneficial, especially when multiple conditions are present, such as hypertension, diabetes, obesity, arthritis, Chronic Obstructive Pulmonary Disease (COPD), etc.

Briana’s primary care plan addresses mild hypertension with activities and medications prescribed by her primary care provider, Dr. Anderson.

My Care Guide for maternity care

Briana recently became pregnant and is very excited about the birth of her first child! Briana’s OB/GYN, Dr. Rattle, creates a new Maternity Care Plan that includes prescriptions for Folic Acid and Vitamin D, plus a schedule for routine appointments based on practice guidelines. During her 8-week prenatal exam, Dr Rattle informed Briana that she has early symptoms of gestational diabetes. He tells her that about 5 to 10 percent of all pregnant women get gestational diabetes and she should be able to control it with careful attention to diet and exercise, plus regular monitoring of her blood sugar. Briana’s maternity care plan is updated with these activities, appointments are created with an endocrinologist and a dietician, and they are added as members of her care team. Using My Care Guide enables Briana to be engaged as an active member of the maternity care team and manage her combined activities from a growing set of care plans defined by several provider organizations. All of these care plans are based on HL7 FHIR standards to support interoperability, coordination, and automated decision support.

My Care Guide for Veterans

We have a particular commitment for supporting and improving person-centered care for Veterans. Providing seamless care for a Veteran is especially challenging because it often requires several healthcare providers to coordinate care for multiple chronic health conditions, and includes care team members from both within and outside of the VA healthcare system. See My Care Guide for Veterans for a more detailed description and Veteran-specific care plan scenarios, including Meghan’s Journey. Similar to Briana, Meghan is also using My Care Guide to support her healthy pregnancy, but she is faced with additional health care challenges resulting from her combat deployment in Afghanistan.

All of Briana’s care planning data are represented using the HL7 FHIR standard and stored on a cloud server that is protected using OAuth2 security. Where applicable, the FHIR data are mapped to Apple CareKit for display. Click on the app screen image to open a slideshow viewer with more screens, or play a short video with narrative describing how Briana would use this app. Both will be updated periodically as Briana’s care plans are expanded to demonstrate person-centered care coordination.

Briana’s Care Guide

App Video

My Care Guide user stories

Our first user story focuses on Briana’s journey with pregnancy and maternity care. But we are also developing other stories for potential My Care Guide users who are similarly committed to person-centered care while coordinating with their team of caregivers. If you and your organization are interested in collaborating on development or pilot testing My Care Guide app, contact Dave Carlson.

Examples of person-centered care that could be supported by My Care Guide include:

  • Personal wellness goals and planning (e.g. Weight loss or achieving fitness goals)
  • Pregnancy and maternity care
  • Managing chronic conditions (e.g. Diabetes, Hypertension, or Congestive Heart Failure)
  • Pediatric and family care
  • Surgery preparation and recovery (e.g. knee replacement)
  • Cancer treatment
  • Behavioral health care (e.g. Depression, PTSD, substance abuse)
  • Aging in the home
  • Palliative care and hospice