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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.

> At the 10-physician, three-office Vanguard Medical Group based in Verona, a town in northeastern New Jersey, Thomas McCarrick, M.D., has been helping to lead his colleagues through the stages of PCMH development, beginning with his office’s involvement in a pilot project two years ago with Horizon Blue Cross Blue Shield of New Jersey, which had brought 35 physician practices together, in collaboration with the New Jersey Academy of Family Physicians (the New Jersey chapter of the American Academy of Family Physicians) around diabetes care management. The physicians in two of the three offices that now comprise Vanguard (the group merged three separate practices a little over a year ago) learned a great deal through participating in the pilot, McCarrick notes, including how intensely complex report development and sharing and data-sharing between physician groups and health plans can be without robust EHR and other clinical information systems. An absolutely critical lesson learned, McCarrick says, is that “To use informatics today requires being able to interface a variety of tools and applications.” He foresees integration and interoperability of clinical information systems as a major hurdle for ongoing PCMH development.

> In New Orleans, a variety of organizations have been collaborating in order to ensure the success of the PCMH concept. Eboni Price-Haywood, M.D., M.P.H., the co-executive director of Tulane Community Health Centers (TCHC), as well as that organization’s CMO and CIO, has been involved from the start in a community-wide, PCMH-modeled, demonstration project involving New Orleans’ safety-net clinics, and which was created in the wake of Hurricane Katrina, with the goal to improve care quality for underserved populations. The TCHC organization, through that program, was incentivized to pursue NCQA PCMH recognition, and its six sites achieved NCQA recognition by early 2009. In addition, under Dr. Price-Haywood’s leadership, TCHC has been collaborating with the Crescent City Beacon Community (CCBC) Program, also based in New Orleans, on an initiative to leverage clinical IT in order to improve chronic care management for area patients. Anjum Khurshid, M.D., program director and principal investigator for the CCBC program, and Maria Ludwick, the CCBC’s chronic care management lead, have been working with nearly 50 different primary care clinics, including TCHC’s clinics, on that initiative. Price-Haywood, Khurshid, and Ludwick all agree that getting the right information to flow between clinicians at the right points in the care delivery process is vital to the success of the PCMH concept, especially as supported at the community level. Not surprisingly, they are also involved in the community-wide health information exchange to support the concept.

There are also some integrated health systems that are so large and comprehensive that they can pursue the PCMH concept across their enterprises, to strong effect. One of these is the vast 20-hospital University of Pittsburgh Medical Center (UPMC) health system, which encompasses more than 400 physician offices and outpatient locations, more than 3,200 employed physicians, and even its own provider-owned health plan (UPMC Health Plan). The folks at UPMC, both on the provider and payer side, have been pursuing multiple strategies to leverage IT to support their PCMH development. Among other tools, the folks at UPMC are leveraging the interoperability platform from the Pittsburgh-based dbMotion (in which UPMC also has a financial stake) to facilitate physicians’ instant ability to view the patient record across multiple sites and systems within the vast UPMC enterprise.


The healthcare leaders developing these different patient-centered medical home models are obviously working across very different organizational structures, hospital-physician relationships and arrangements, and local healthcare markets and communities. They are also moving forward across dramatically different levels of information technology development and adoption. Yet all those interviewed for this article agree that there are some universal IT elements required for success with any PCMH.

One industry expert who has a strong grasp of such elements is Joe Damore, vice president of The Implementation Collaborative, a division of the Charlotte-based Premier health alliance. Damore, who has spent more than 30 years in healthcare management, including multiple stints as a hospital CEO, is currently heading up the Premier division that is supporting alliance members’ efforts to build accountable care organizational and care management vehicles.

Damore sees five absolutely key IT foundations for medical homes. “The first,” he says, “is creating an electronic record at the hospital and in the physician practice, as a base. Then, you’ve got to build that record so that it crosses the continuum of care. And you can either do that by creating an HIE, or through an integration engine. A small number of organizations”—he cites UPMC as one of the few—“are creating their own integration engines, but most don’t have the capital to create their own,” he notes. “The third element,” Damore says, “is that you’ve got to create a population health data management engine in order to measure population health and the effectiveness of your tools,” and to be able to assess costs of care, for such chronic illnesses as diabetes and congestive heart failure.

The fourth and fifth elements, Damore adds, are predictive modeling, in order to proactively assess which patients in one’s program are most at risk; and a consumer portal to allow for patient-clinician communication.

SETMA’s Larry Holly, M.D., whose organization already has several of those elements in place, though not all, says that “there are a few essentials. Number one, they need an integrated delivery network where the same EHR is used at all points of care. Number two,” he says, “they need quality and metrics mechanisms at all points to make sure that the critical tasks are being performed and the critical quality points are being monitored and improved. We give our physicians all their metrics; and it’s not to be punitive, it’s to help them.”

James L. "Larry" Holly, M.D.

Bon Secours Medical Group’s Fortini emphasizes that a lot of the challenges involved in success with the PCMH model are basic blocking-and-tackling challenges, such as making sure that PCMH patients actually go to see the specialists to whom their PCPs refer them. He cites a study published last year in Medical Economics that examined the behaviors of Medicaid patients and found that 28 percent of the Medicaid patients urged by their PCPs to schedule a specialist appointment never do so, while 30 percent of the 72 percent who do schedule a specialist appointment never show up for that appointment. It’s in ensuring such compliance—which is conceptually very simple but as a practical matter often difficult to achieve—that PCMHs will succeed or fail in improving clinical outcomes over time, he notes.

And Eboni Price-Haywood adds that “You really have to understand the intricacies of how the organization works at baseline. And that requires that you develop a multidisciplinary team with expertise; it’s not a top-down approach, it has to be a bottom-up approach to programming. And you need to make sure that the physicians are heavily engaged throughout the process, because they can make or break your project.”

Eboni Price-Haywood, M.D.


As for what CIOs, CMIOs, and other healthcare IT leaders and executives need to understand and do, those interviewed for this story agree that the list is rather a long one, and includes cultural and human process elements as well as IT ones.

Says Bon Secours’ Fortini, “First of all, you have to be patient; it’s a change of culture entirely [to leverage EHRs and other clinical IT in any shift to a PCMH model of care], and it’s not technologically perfect—wireless systems go down, and there are mandatory fields that have to be completed; so it initially adds to the average amount of time the physician needs to spend with this every day. Over time, as they become more comfortable with the systems, that time factor goes away; and they also experience the benefit of the clinical decision support and the other positive elements. In my experience, there’s a three-to-six-month period of pain and angst,” Fortini testifies, “and then there’s a period of time after that point where optimization starts to occur. And that’s when you start being able to use a registry for proactive outreach, for developing high-risk referral systems, for creating better patient flow, for communicating with your patients.”

At the vast UPMC health system, interoperability has been and continues to be the watchword, says Darcy Waechter, vice president, information services division/ambulatory e-record, for the system. UPMC, she notes, has committed itself firmly to using the dbMotion interoperability platform in order to connect all appropriate caregivers, and especially to give physicians and other clinicians the information needed to support their care decisions in real time, across a health system that particular patients may have accessed at a wide variety of points and places.

In addition, she notes, she and her colleagues have developed a constellation of medical home reports anchored in the health system’s outpatient record (from the Verona, Wis.-based Epic Systems Corporation), “a report portfolio that has allowed us to provide data on the measures the medical home requires, in reports on their patient populations that are pushed out to the physicians every quarter,” in the areas of diabetes, hypertension, asthma, congestive heart failure, chronic obstructive pulmonary disease (COPD), and chronic renal failure. In addition, UPMC supports a physician portal that allows doctors to log in and see all of their reports at any time. (In fact, UPMC physicians, through the dbMotion platform, can see all needed data not only across the Epic outpatient e-record, but also across the inpatient e-record from the Kansas City-based Cerner Corp.)

That means, says Anne Docimo, M.D., chief medical officer of the affiliated UPMC Health Plan, that “Basically, any provider, whether in an office or hospital or anywhere else, has the data they have in an e-record format. Meanwhile,” Docimo notes, “ the payer will have a much more complete view of the patient, if the patient was admitted to a hospital across town or in Florida, or wherever—pharmaceutical data, hospitalizations, wherever.” And, because of the fact that the health system has its own affiliated plan, Docimo confirms that the health plan is able to provide a broad variety of claims-based data to physicians whose patients are UPMC Health Plan members, adding to the richness of what is available to help manage the care of patients with chronic illnesses. That indeed is where care management is headed, those interviewed for this article agree.

Indeed, at the broadest level, says Jody Cervenak, a director at the Pittsburgh-based consulting Aspen Advisors, and a former IT executive at UPMC, where the patient-centered medical home concept is headed is “enabling that connected community. Even in a closed system,” she says, “you’ll still have connections outside that system. And how does health information exchange help the patient, and enable better continuity of care? Because the PCP or coach wants to understand what the discharge orders were. How does that flow through health information exchange? And how does information on a patient wanting to lose weight or quit smoking, how does that information flow? Those are all complicated questions, because we’re still struggling with the basics,” she adds.

In the meantime, Cervenak urges, CIOs, CMIOs, and other healthcare IT leaders need to be “organizing their plans of care, and be really effective in analyzing, understanding, your patient populations. And then a really simple, basic step is enabling secure communication, both within your practice and medical home team. So it means developing plans of care, understanding your populations, and enabling a strong communication network.” What’s clear, she and all those interviewed for this story agree, is that the patient-centered medical home concept will only be successful over time if PCMH programs can fully leverage the broad range of IT tools and strategies needed to wire up the medical home to best support its highly committed clinicians. ◆

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