Patient Journey Record Systems (PaJR) for Preventing Ambulatory Care Sensitive Conditions

This chapter articulates key considerations for the translation of the concept of the Patient Journey Record Systems (PaJR) into real world systems. The key concept lies in the ‘discovery’ of the use of patient narratives to locate the phase of illness in a patient journey. We describe our developmental framework of in the context of Ambulatory Care Sensitive Conditions (ACSC) for older patients with multiple morbidity, who are at a high risk of hospitalizations and other adverse health outcomes. The framework addresses the feasibility and usability of an information technology based solution to avert adverse outcomes of hospitalization when this is potentially avoidable by activities in primary care. Key considerations in the PaJR knowledge systems are the design and implementation of robust expert knowledge and data support systems. The patient, caregiver, physician and care team perspectives drive clinical usability and functionality requirements. Experts from computer science domains in artificial intelligence, expert systems, and decision support systems ensure the requirements for the functionality of underlying systems architecture are met. We explore this transdisciplinary perspective and ways in which coherence might be achieved among the many practitioners and expert domains involved in a developmental framework for PaJR. We make a case for the implementation of PaJR systems as part of a universal move to electronic user driven health care.