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Engaging the Patient

February 21, 2011
by Jennifer Prestigiacomo
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Putting the Patient in the Center of Care Means a Total Restructuring of Care Delivery

In efforts to produce cost savings and better care, the medical home model will likely create difficulties in patient-physician communication, as well as outside the walls of the organization

Despite providers' enthusiasm for the patient-centered medical home (PCMH) as a model with which to coordinate patient care and reduce medical costs, challenges in funding and IT infrastructure remain obstacles to the full realization of that promising concept.

Still, the idea continues to grow among providers; indeed, the growth from just one nationwide program-that of the Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH) program from the Washington, D.C.-based National Committee for Quality Assurance (NCQA)-shows the concept gaining favor across the country. The number of PPC-PCMH-recognized sites skyrocketed from 2008 to 2009 and almost quadrupled from 2009 to 2010 to reach its current tally of 1,498 healthcare organizations and 7,557 recognized physicians. What's more, currently, 27 multi-stakeholder Medicare-Medicaid Advanced Primary Care Demonstration Initiative pilots are underway in 20 states, according to the Washington, D.C.-based Patient Centered Primary Care Collaborative (PCPCC). The pilot will conclude at the end 2011, offering interested parties the opportunity to assess the viability of the PCMH concept, at least in the context of that particular initiative.


James L. Holly, M.D., CEO of Southeast Texas Medical Associates (SETMA) in Beaumont, prides his organization on its NCQA tier-three medical home status and its AAAHC (Accreditation Association of Ambulatory Health Care) accreditation for ambulatory care and the medical home. He likens the medical home model to a relay race, one in which primary care physicians hand off the baton, or treatment plan, to their patients, in order to allow them to participate in managing their own care. “They [patients] are empowered and enabled to pursue and perform; there's going to be value no matter how good the care is,” says Holly.

Not only are patients more integrated in their own care, the cost savings resulting from the coordination of doctor visits and medical testing can be significant, according to David Gans, vice president of innovation and research at the Denver-based Medical Group Management Association (MGMA). “From a hospital's perspective, if a majority of patients in their community were part of the patient-centered medical home, [they'd see an] overall reduction of ED visits,” he says. “Rather than invest in bricks and mortar, we can restructure care delivery, so that the patients [who are ultimately cared for] in the hospital are truly sick.”


This rosy picture of healthcare delivery doesn't come without its own set of challenges. Integrating patients into their own care can at times be difficult, as physicians aren't used to communicating medical information in writing to patients, according to Robert Murry, M.D., Ph.D., medical director of informatics at Hunterdon Medical Center in Flemington, N.J. It will be an extraordinary challenge when providers are required to deliver a care summary for 50 percent of patient visits to meet Stage 1 meaningful use requirements, he adds. Holly, however, believes it's the providers' job to promote health literacy among their patients and not to accept the current level of literacy. “We can elevate their literacy where we can talk to them in a collegial fashion and where they need interpretation, we can give them that, but [patients] are not stupid,” he says.

Another challenge with regard to the PCMH model is the nuts and bolts of health information exchange (HIE), according to John Bender, M.D., the medical director of the NCQA-recognized tier-three medical home Miramont Family Medicine in Ft. Collins, Colo. Bender observes that the free market wasn't able to fully support EHR adoption and HIE in the past, and that's why he believes the federal government stepped in with the Health Information Technology for Economic and Clinical Health (HITECH) Act. He likens the expansion of HIEs to building out driveways to main roads. “In my clinic I feel we've built our driveway out, and we're just waiting for the road,” he says. “But in other clinics, the road can be built and they're going to have to build their driveway out to it. It depends how well-funded an individual clinic is.”

MGMA's Gans adds that information exchange will most likely be on a push basis at first with organizations and offices connecting via virtual private networks (VPNs), which will then grow to a more advanced push-pull model of information exchange. But he notes that this advancement will need standardized directories and communication requirements, which contributes to overhead. “A freestanding physician's office has much more difficulty sustaining a patient-centered medical home unless it's a part of a demonstration,” says Gans. “It takes a foresightful health system with sufficient capital to understand how they're going to provide these services and at what cost.”


On the horizon this year for the PCMH will be patient portals, according to those interviewed for this story. Both Bender and Holly are excited to unveil their portals later this year, which will allow patients to schedule appointments, refill medications, and send secure messages to physicians. “It [will] really cut down on the phone traffic, which frees up the staff to do other things that are revenue-generating,” Bender says. “It gives the consumer more power in the healthcare marketplace and makes them feel like they have more of a say in what's going on, and that's a good thing.”

Healthcare Informatics 2011 March;28(3):16-18

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