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September 13, 2010

Patient-Centered Medical Homes: An Old Concept Gets Recharged
By Alice Shepherd
For The Record
Vol. 22 No. 17 P. 12

HIT plays a major role in this approach that relies heavily on clinical decision-support tools to engage patients in the management of their own care.

A patient-centered medical home (PCMH) is a model of delivering healthcare that revolves around and engages the patient. It facilitates a partnership between patients, providers, and when appropriate, patients’ family members. The idea originated in 1967 when the American Academy of Pediatrics (AAP) introduced the medical home concept to coordinate the care of children with chronic conditions. All information related to the care of a child was housed in a central repository, and one provider was responsible for overseeing all care.

In 2002, the AAP expanded the medical home concept to include the following operational characteristics: accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective care. By 2005, the American College of Physicians (ACP) had developed an advanced medical home model, which involved the use of evidence-based medicine, clinical decision-support tools, the Chronic Care Model, medical care plans, “enhanced and convenient” access to care, quantitative indicators of quality, HIT, and performance feedback.

In 2007, the ACP, the AAP, and the American Academy of Family Physicians joined with the American Osteopathic Association to issue “Joint Principles of the Patient Centered Medical Home” in response to a request from several large employers seeking to create a more effective and efficient model of healthcare delivery. No longer a pediatric concept only, a PCMH now provides care for people of all ages and medical conditions.

What Exactly Is It?
One challenge to understanding the PCMH model is the term “home,” which is usually associated with a place where patients stay, such as a nursing home. In reality, a PCMH is just a primary care practice.

So what’s behind the term? “It’s a place where patients can feel at home as they access a familiar team of individuals for comprehensive care,” says Ewa Matuszewski, CEO of Medical Network One, a physicians’ services organization and interactive health management service provider. “The primary care provider is always a member of the team. Depending on the patient’s needs, the other members may be an RN to coordinate patient training and learning, a certified diabetes educator, and various other specialists and professionals. In addition, PCMH patients can take advantage of wellness programs and even provide operational suggestions through focus groups. More and more family practices are embracing this model.”

“The PCMH model provides care that is centered on the whole person—more accessible, more focused on outcomes, and more deeply involved in engaging patients in their own management, particularly for chronic illnesses,” says Peter Basch, MD, FACP, medical director of ambulatory EHR and HIT policy at MedStar Health, a nonprofit community-based healthcare organization serving the Baltimore/Washington, D.C. region.

In 2006, the Patient-Centered Primary Care Collaborative (PCPCC) was created as a coalition of more than 600 major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians, and others to develop and advance the PCMH. The collaborative has defined the following seven components that make up a comprehensive PCMH model:

Care coordination: “The primary care provider takes personal responsibility and accountability for the ongoing care of patients,” says PCPCC Executive Director Edwina Rogers. “He or she agrees to look after the whole person, both physical and mental health, and coordinates the patient’s care throughout the entire healthcare delivery system, including hospitals, specialists, home health, and other providers the patient may use during his or her lifetime.”

Integrated peer team model: Each patient’s care team is assembled around that particular patient’s needs.

Access: “It’s easy to make appointments, including same-day appointments; expanded hours are available; there is a 24-hour call center; and e-mail and phone consultations are provided,” says Rogers.

HIT: The PCMH utilizes the latest technologies and evidence-based medical approaches and maintains updated EMRs and PHRs.

Patient engagement and care; participatory engagement: “Patients are given a treatment plan, are sent reminders, and have access to their medical records as well as to counseling and self-help information,” says Rogers. “The provider conducts regular checkups with patients to identify looming health crises and initiate preventive measures.”

Patient feedback: The patient experience is measured through surveys and other tools.

Disclosure: The PCMH’s quality and efficiency information is publicly available.

The Role of HIT
“Because the PCMH model is designed with a heightened focus on outcomes, it allows HIT to shine,” says Basch. “A PCMH needs information in real time or near real time at the point of service in order to generate patient-centered data on which to take immediate action.”

One operational characteristic of a PCMH, as defined by Basch, is that its patients are treated as a population, not just an ad hoc group that has chosen to come to a particular practice. HIT is essential for optimal management of that population’s care. “For example, visit-based care is not just a reaction to a patient’s perception of illness but also provides the PCMH team with an opportunity to address other care needs,” says Basch. “If, for instance, a patient is complaining of foot pain, the physician uses the electronic health record to check if that individual also happens to be overdue for labs, radiology, and the like. With visit-based care there is an almost laserlike focus on outcomes, to take the opportunity to go beyond providing a service, to carefully look at the patient’s outcomes metrics and spend time to focus on outcomes.”

Further, the non–visit-based care envisioned by the PCMH model depends heavily on HIT. “Non–visit-based care has to be fully integrated with clinical decision support because the provider has to take advantage of every contact with the patient to address care opportunities,” says Basch. “Secure e-mail, secure messaging, or encrypted e-care are required components of the HIT infrastructure.”

HIT is necessary for generating the reports whose data show how to improve a PCMH’s metrics and which can demonstrate that improvement to patients, payers, and employers.

Finally, HIT allows providers to analyze reports efficiently and communicate insights to multiple providers promptly. In fact, a PCMH cannot qualify with the National Committee for Quality Assurance (NCQA) unless it has HIT. Specifically, NCQA Standard 2, Patient Tracking and Registry Functions, states the following concerning a PCMH:

• uses data system for basic patient information (mostly nonclinical data);

• has clinical data system with clinical data in searchable data fields;

• uses the clinical data system;

• uses paper or electronic-based charting tools to organize clinical information;

• uses data to identify important diagnoses and conditions in practice; and

• generates lists of patients and reminds patients and clinicians of services needed (population management).

Rogers cites decision support as the primary component in a PCMH’s HIT system. “The primary care provider needs decision-support tools to monitor the patient population,” she says. “This includes best practices, disease management, medication management, easy access to lab results, and medical record reminders. That information has to be timely, flagged, in the provider’s face, and presented in a way so it can be sliced and diced to show which patients are moving into a danger zone.”

“Currently, the most important tool to support the PCMH model is a population registry,” says Matuszewski. “It monitors patient wellness and illness from birth all the way through to end of life and gives the PCMH a handle on what has occurred in the patients’ relationship with the practice team. It’s essential for creating reports on specific populations in order to identify gaps in care and for sending reminders to patients on the services they need. The registry includes vital information on immunizations; preventive exams, labs, and screenings; eye exams for diabetics, and the like. During visits, a member of the practice team uses the population registry to record data on height, weight, and blood pressure, and it can automatically calculate BMI [body mass index]. Lab work, whether from a hospital or lab vendor, enters the registry via automatic feeds. Finally, the registry is also a tool used for specialist referral tracking.”

Unlike an EMR, a registry is inexpensive and simple to implement, says Matuszewski. “While EMR deployment requires a great deal of preparation, such as template creation, a population registry only requires the loading of demographics and payer information and then it’s ready to enter the data points,” she explains. “On average, a Web-based population registry costs about $80 per month, or about $1,000 a year, compared with the $60,000 to $70,000 investment for an EMR.”

She recommends implementing a population registry prior to acquiring an EMR because the EMR’s capabilities should augment the functionality of the registry. The EMR and the registry should be fully integrated, whether through an interface provided by the EMR vendor or a plug-in or patch specifically programmed for that purpose.

While an electronic population registry reduces the potential for errors and facilitates data manipulation and report creation, Matuszewski has seen several PCMHs in Michigan that operate successfully using hard-copy card indexes and Excel spreadsheets to monitor their patients’ journey through wellness or illness. “If you haven’t mastered an electronic registry, it doesn’t mean that your quality improvement strategies are lax,” she says, “but you can become a more effective and efficient organization if you have an electronic population registry or an EMR system that can generate population reports for you.”

Other HIT components that increase a PCMH’s effectiveness and efficiency are e-prescribing (one of the NCQA standards) and a Web portal where patients can request appointments, e-consults, and prescriptions and otherwise communicate with their care team via a HIPAA-secure system. NCQA Standard 9, Advanced Electronic Communications specifies the availability of an interactive website, among other requirements.

The true care coordination envisioned by the PCMH model depends heavily on electronic systems. “In traditional care settings, the primary care doctor is just another member of a care team, but no one is calling the shots or attempting to reconcile differences between recommendations by providers,” says Basch. “In a PCMH, the primary care provider oversees all the information whether it makes its way into the medical record during visits or through lab interfaces or health information exchanges. The information has to populate the data fields as discrete structured data so it can be analyzed and reported on. Demographic information for creating reports and sending reminders typically derive from practice management systems via an interface to the electronic health record.”

Basch cites an example of a how an older EMR system with poorly structured data produced inaccurate reports. “When my practice first began using an EMR 13 years ago, the table of problem list was used to house everything about the patient, including family history, past history, and procedures,” he says. “EMRs were not yet mature enough to provide separate tables for all those fields. When we began to run reports on our patients, they seemed to indicate that we had hundreds of people who were diabetics when in fact the software was misreading a family history of diabetes for a diagnosis of diabetes. If the reports are wrong, they cannot be used for sending reminders to patients or trusted as the basis for measuring performance.”

Wanted: New Payment Model
“The [PCPCC] believes that the PCMH model will improve the health of patients and the viability of the healthcare delivery system,” says Rogers. “However, its success depends on a better way of compensating clinicians. Since the primary care provider performs many time-consuming duties to ensure coordination of care and the accuracy and completeness of the medical record, he or she has to be compensated for that extra effort.”

If that’s to be the case, changes will have to be forthcoming. “The key to promoting the PCMH model is to restructure primary care reimbursement,” Rogers says. “That includes compensation not only for face-to-face consultations but also for those conducted over e-mail or phone, monthly fees for services associated with the coordination of care and monitoring of test results and procedures performed by other providers, implementation of a hybrid model of payment to include fee-for-service based on hours of contact with the patient, and performance-based incentives and compensation for achieving measurable and continuous patient improvements. Only then can the PCMH model succeed in improving quality of care and controlling the unsustainable rising costs of healthcare.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.


PCMHs Taking Shape Across the Country
Hundreds of patient-centered medical home (PCMH) demonstration projects and pilots are under way nationwide. Here are three examples of how the PCMH philosophy is beginning to make an impact on the healthcare scene:

• Boeing recently completed a pilot called the Intensive Outpatient Care Program. It enrolled employees and pre-Medicare retirees and their spouses with the goal of improving quality of care and substantially reducing spending for the predicted highest-cost quintile of the company’s Puget Sound employees and their adult dependents. The project was designed by Mercer Health & Benefits and managed by Renaissance Health in partnership with Regence BlueShield of Washington, Healthways, ValueOptions, and leaders of three physician groups.

Each care plan was developed in partnership with the patient and executed through in-person, phone, and e-mail contacts, including frequent outreach by an RN, education in self-management of chronic conditions, rapid access to and care coordination by the provider team, and the direct involvement of specialists.

 After the first 12 months, functional status scores, Health Plan Employer Data and Information Set intermediate outcomes scores, depression scores, patients’ experience-of-care scores, and employees’ absenteeism scores improved significantly compared with baseline. Compared with a control group of Boeing employees who did not receive their primary care from the PCMH physician groups, unit-price-standardized per-capita spending dropped by an estimated 20%. Qualitative results included the refinement of care managers’ patient engagement skills, more proactive care and care coordination, and more convenient patient access to providers.

• Colorado is the site of a two- to three-year multistate, multipayer PCMH pilot that began in May 2009. The PCMH model is being tested in 16 family medicine and internal medicine practices in Colorado and Cincinnati. The Colorado Clinical Guidelines Collaborative serves as the convening organization and provides technical assistance, including in-office coaching, learning communities, and innovative technology. Participating stakeholders include health plans, business groups, employers, state agencies, hospitals, the American Academy of Family Physicians, the American College of Physicians, the Colorado Academy of Family Physicians, and the Colorado Medical Society. Funding is provided by the Colorado Trust and the Commonwealth Fund.

• Also in May of last year, the Maine Patient-Centered Medical Home Pilot began as a first step toward statewide implementation of the PCMH model. In this demonstration, the Patient-Centered Primary Care Collaborative is working with 26 participating practices, all the state’s major private payers, and Medicaid to pilot an alternative payment model that recognizes and rewards practices for demonstrating high-quality and efficient care. Success of the pilot will be evaluated by nationally recognized measures of quality, efficiency, and patient-centered measures of care that reflect the six aims of quality care (safe, effective, timely, efficient, equitable, and patient centered) identified by the Institute of Medicine.

The ultimate goal is to sustain and revitalize primary care to improve health outcomes and reduce costs. The convening organizations are the Maine Quality Forum, Quality Counts, and the Maine Health Management Coalition. Other participating stakeholders include health plans, several physician associations, Consumers for Affordable Health Care, University of Maine employees, and the Maine Nurse Practitioner Association.