Under the medical home model, "A primary care physician is the orchestrator of care for individuals, especially for those with chronic diseases," says Mitch Morris, M.D., national leader, health information technology for Deloitte Consulting, New York. The model also calls for "bringing together all the different resources in the community to advance the wellness of an individual and the community," he says. That means a primary care physician is the hub or "home," carefully coordinating care with a team of specialists.
"I.T. is the glue that holds it all together," Morris says.
Paul Grundy, M.D., president of the Patient-Centered Primary Care Collaborative, a Washington-based group that advocates the medical home model, shares that view. "I.T. is really the key to supporting the doctor/patient relationship and making it more efficient, safer and more effective," he says. "This is simply about restructuring the way health care is delivered to catch the efficiency of technology."
Grundy, who's also director of health care transformation at IBM Corp, Armonk, N.Y., predicts that the federal government's definition of "meaningful use" of electronic health records that will be used to determine who qualifies for Medicare and Medicaid EHR incentive payments likely will support goals very similar to those of the medical home model.
Many observers say that a missing link for achieving the goals of the medical home model is a new method of paying physicians that rewards them for keeping patients, especially the chronically ill, healthy and out of the hospital. But rather than wait for such a payment mechanism to go beyond experiments and become ubiquitous, a growing number of physician group practices are moving ahead with implementing elements of the model. Those elements include using EHRs equipped with decision support, providing PHRs with patient self-monitoring features and enabling data exchange among primary care physicians and specialists involved in a team approach to treatment.
SOME PIONEERS
Queens-Long Island Medical Group, a 300-physician practice in Garden City, N.Y., is phasing in the medical home model, with an initial focus on leveraging the use of electronic health records. "We see EHRs as the backbone of the medical home concept," says Robert Fortini, R.N., chief medical affairs officer.
Meanwhile, a medical home project at the Brown University Center for Primary Care and Prevention is linking EHRs with PHRs and "studying how to make PHRs more useful in the day-to-day lives of patients," says Charles Eaton, M.D., the center's director. And leaders at the University of Oklahoma School of Medicine are helping to develop a health information exchange designed to support data sharing among team members involved in medical homes, says David Kendrick, M.D., the Tulsa-based school's director of community medical informatics. "The patient-centered medical home remains to be well defined from an engineering point of view," he says. "So we're trying to get to that point."
At Queens-Long Island Medical Group, the medical home push got started about three years ago because doctors got fed up with their highly inefficient workflows, says Suneel Parikh, M.D., a physician champion for the effort.
In the old model of care, all inquiries-such as prescription refill requests, referral inquiries and patient complaints-came to the physicians, creating bottlenecks. "Between handling the business of the day, dealing with phone calls and cleaning up at the end of the day, doctors were getting out of here at 9 p.m." Fortini says.
By adopting a "care team approach" to providing better service to patients, messages are now directed to those who can take quick action. For example, a nurse handles prescription refill requests. Using an EHR from Chicago-based Allscripts, she can determine, for example, whether the medication can be automatically refilled for three months if the patient meets certain criteria. The nurse then sends the doctor a task alert within the EHR, asking him to approve the refill by clicking an electronic signature. Once approved, the prescription then is forwarded to the pharmacy electronically or by phone. "These alerts happen during my regular workflow as I'm seeing patients," Parikh says. "I get task notifications in real time."
The EHR enables all clinicians involved in treating a patient to access the same, complete information, which is essential to the medical home approach, the physician adds.
"If a specialist sees the patient, he can click a button that carbons the primary care practitioner on their evaluation," Fortini adds. "So when the primary care physician goes into the record, on their task list is a 'review document task' from the specialist."
The EHR includes decision-support templates that doctors use when treating patients, especially the chronically ill. For example, a template for ordering insulin for a diabetic includes an algorithm for calculating the right dose based on the patient's lab results. "The templates help me to thoroughly go over everything that I need to know about the patient," Parikh says.
Although all of the practice's sites now use the EHR, so far, five of its 16 primary care locations have fully adopted the medical home model. The New York practice is hopeful of earning incentive payments from payers once it completes rolling out the medical home model at all these sites. So far, it has commitments from two major payers to launch pay-for-performance programs based on the medical home model for preventive medicine, Fortini says.
Next, the practice wants to implement a patient portal that incorporates a PHR that can share patient-generated information with its EHR.
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