Unifying a Patient-Centered Medical Home

“We can now pull all the kids who have a BMI greater than 85th percentile and are considered overweight or obese, and we can target those kids,” says Heidi Moore, M.D., co-owner of Mountainview Pediatrics. She adds that her practice sponsors several obesity community programs like a teen “Biggest Loser” and other healthy eating programs. For asthma prevention, Mountainview Pediatrics uses clinical decision rules to identify the chronic asthmatics and make sure they are taking preventative medications. The Northern Adirondack Pod has also had nurses receive asthma certification to help with patient education.

Heidi Moore, M.D.

Within the Northern Adirondack Pod, the five pediatric offices use a 24-hour call service out of Cleveland, Ohio, to give a layer of service for parents to use before utilizing the ER, which Ashline believes has diverted a significant number of ER visits.

Mountainview Pediatrics reaches out to its patients in a variety of ways, including its Facebook page and a patient portal. To connect to the community, the practice posts health lectures, drug recalls, and other customer relation items to its Facebook page. “We have this mass community campaign called Sick Happens, where we’ve tried to create a community dialogue about emergency room visits—what’s appropriate for ER visits and what’s appropriate for primary care visits,” says Moore.

Patients can request immunization forms, request appointments, and request medical records through the Mountainview portal. Moore hopes in the future to have additional functionality to route all messaging to the patient chart and to have some communication be more easily routed to the front office staff.

Quality Reporting Challenges
Physicians are capturing 45 measures across six disease states in their practices, says Ashline. “That’s been a real grueling process for physicians because you could document something in a written note, and now we’re saying to document it, but in a discreet data field, so we can capture that information,” she says. “It’s been a real challenge in the physician community—not because they don’t want to—but because it’s a different way of doing documentation.”

The Adirondack Medical Home Pilot enlisted the support of the Massachusetts eHealth Collaborative when it was first awarded the $7 million HEAL NY Grant in 2009 to help with EHR selection, implementation, adoption, and meaningful use reporting. "Meaningful use reporting is not a simple, straightforward process—the metrics are open to interpretation, and many of the metrics an organization might chose to report on are not directly supported by the EHRs built-in reporting capabilities," says Dennis Weaver, M.D., HEAL 10 program services director for the Adirondack Medical Home Pilot. "With the Quality Data Center [QDC] we just upload our raw EHR data and they handle all of the aggregation, analytics and reporting, applying the latest reporting best practices as they go. It’s an excellent quality reporting tool for our pilot.”

MAeHC has taken a hands-on approach to the pilot, going into physician offices to do workflow evaluations and data remediations, and to streamline documentation to create one standardized location for documentation. “Template development was a huge portion of it,” says Pam Minichiello, R.N., project director and MAeHC lead on the Adirondacks pilot, “where within their individual EHR we develop one place within their documentation template where they can document the key elements that we needed for the reporting.”

Pam Minichiello, R.N.

To glean some early results from the pilot, the three pods did an interim dashboard last August targeting a few key measures. However, practices were not consistently storing data in the same places within the EHR, and therefore, data was not able to be compared across the board. “We just started the QDC analysis on the data, and it’s difficult to measure that performance at this early stage because what we’re really measuring right now is the quality of the data we’re receiving rather than the performance of the pod or the individual provider,” says Minichiello. Ashline does say though, that ED utilization data has shown that visits have gone down.

MAeHC is also the implementation agent and regional extension center (REC) for New York State to help practices achieve meaningful use. Minichiello says 85 percent of the pilot practices have already attested to Stage 1 meaningful use. “HIXNY has a direct connection into the MAeHC QDC, so we will actually be taking the data directly from the EHRs,” says Minichiello. “It will go into the QDC for processing, and then we will be able to supply the pods and practices with a portal where they can go in and view the measurements across their own pods, practices, and provider to provider.”

The Adirondack Medical Home Pilot has eight EHR vendors currently involved in the pilot, which bring its own interfacing challenges. “I think the most important thing would be to have one EHR,” says Moore. “We have [eight] EHRs across our pilot, and trying to get interfaces for [eight] EHRs is exponentially hard.”