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The medical home is widely regarded as the future of primary care: a model where the physician keeps track of each patient's details, communicates whenever and however is most efficient (whether it's an office visit, a phone call, or an e-mail), and generally shares with the patient the responsibility for keeping him or her as healthy as possible. After five years of groundwork figuring out what a medical home should be, Blue Cross Blue Shield of Michigan last year designated 1,800 physicians (about 36 percent of the primary-care physicians in the BCBSM network) as having medical home practices-one of the largest such efforts in the country. They receive a premium of 10 to 20 percent on each office visit, to repay them for the extra time, trouble and (especially) information technology expense associated with being a medical home. In the first year, medical homes had modest improvements in their cost and quality of care, with slightly lower rates of ER visits, inpatient admissions, and radiology usage for their patients compared with other groups. Thomas Simmer, M.D., has been overseeing the effort.

On transformation

You must give these changes time. You need to balance the technology focus with the rest of the clinical care focus because rushing the technology solutions forward can result in patients feeling less satisfied with their experience.

On technology and performance

When you look at implementing technology, capturing performance gains is critical. Many physicians find the process of implementing I.T. so difficult that they decide not to make any changes to practice because that would just be too much for them.

On the holes in EHRs

Keeping patient registries [lists of all patients who have a certain diagnosis] is the first step in managing conditions like diabetes and congestive heart failure. We were surprised that EHRs didn't have that capability. The vendors viewed the EHR as a vault of protected information, but not as a population management tool, which is precisely where electronic tools prove most beneficial.

On consistency

One of our physician organizations that had an EHR created an analytic team to search the records for the presence of diabetes, and they found 90 different ways to represent it. Another group was examining how to use their EHR to determine if a patient had been given aspirin. They also found 90 different ways to represent that. Although both groups had EHRs, neither had the functionality to produce those lists.

On meaningful use

The federal government has done an amazing job on the criteria. Their timeline is very ambitious and I think they've underestimated the challenge.