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Wiring Up Our Home

April 23, 2012
by Mark Hagland
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Pioneers of the Patient-Centered Medical Home concept see a mix of strategic process and IT success factors involved

The patient-centered medical home concept is moving forward nationwide, with countless variations on a general theme, along with some universals. Healthcare and healthcare IT leaders agree: wiring up this home means putting all the strategic, process, and technology pieces together for success.

The concept of the patient-centered medical home (PCMH) is one that is so philosophically natural that in many ways, it’s a bit strange that it’s taken so long to emerge in healthcare. At its core, the PCMH is about a multidisciplinary, primary care-based patient care team taking charge of a patient’s care (as well as engaging the patient in their own care), and leveraging health information technology, health information exchange, care coordination strategies, and other tools to provide care management across the continuum of care. What’s unusual about that? Yet as anyone who knows how healthcare delivery really works realizes, aligning all those incentives, impulses, and strategies has required an evolution across healthcare payment systems, care management, and technology development, that has only begun to really bear fruit in the past few years.

And while primary care-based care management had begun to evolve forward even a decade ago, it’s only been since 2003 that the Washington, D.C.-based National Committee for Quality Assurance (NCQA) initiated its Physician Practice Connections and Patient-Centered Medical Home (PPC-PCMH) Recognition Program, with several levels of recognition and a complex set of requirements to achieve that recognition. A number of medical specialty societies and medical associations are also involved in helping to develop models and other PCMH supports. NCQA, on its website, defines the PCMH as “a healthcare setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family,” the NCQA notes, “Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.”

What’s fascinating now is that, more than ever before, PCMH development is advancing beyond what was practical even five years ago, based on improved information technologies, increasingly sophisticated care coordination techniques, shifting hospital-physician relationships, and emerging policy imperatives.

As a result, more and more organizations are developing patient-centered medical homes. There are as many situations and community and market characteristics as there are PCMHs. But here are a few examples of IT-facilitated PCMHs whose leaders are making a difference in healthcare right now.

> In Beaumont, Texas, James L. “Larry” Holly, M.D., and his colleagues at Southeast Texas Medical Associates (SETMA), have received numerous awards and recognitions for their pioneering PCMH and care management work. Among other things, Holly and his colleagues renamed and reframed the hospital discharge summary into a post-hospital treatment plan, using it as an anchor, along with wellness promotion, care management (including the self-developed creation of disease management templates for care management at the individual physician level), and, very innovatively, the use of performance dashboards with regular real-time feedback to the group’s physicians regarding the patients they care for under their PCMH program. One absolute key has been the leveraging of both the organization’s core EHR (from the Horsham, Pa.-based NextGen Healthcare) and business intelligence and analytics capabilities to support both the PCMH itself, and what the group has branded as the SETMA Model of Care, aimed at care quality optimization.

> At the Richmond, Va.-based Bon Secours Health System, Robert Fortini, R.N., P.N.P., vice president and chief clinical officer of the Bon Secours Medical Group, reports that his 400-physician medical group has achieved NCQA level-three status for eight of its 40 primary care practices (under a 100-practice total umbrella), representing 35 physicians so far, with consistently 90-plus (out of 100) achievement scores under the NCQA program. Leveraging the group’s EHR and also care management software from the Dallas-based Phytel, Fortini and his colleagues have been applying those tools to identify patients under their care by clinical risk level, and monitor both their compliance with medical orders and prescriptions, and their physicians’ oversight of the care of those patients. “The key foundation” in IT facilitation for the PCMH, Fortini says, “is the ability to use the data that you capture discretely” to identify patients at greatest risk or who are non-compliant with PCP referrals to specialists.