Laying the foundation
Making the medical home model work requires a number of moving I.T. parts: An EHR is foundational, but practices moving into the medical home space find they need assorted bolt-on technologies to succeed. That's the case at Elmhurst (Ill.) Clinic, a 100-physician multi-specialty group practice. The practice garnered Level III recognition for five of its primary care sites in 2008 (the recognition is site-specific), representing about 35 physicians, says Donald Lurye, M.D., CEO. It uses an EHR from NextGen. Although the medical home status only applies to its primary care sites, being a multi-specialty group on a common EHR platform is an advantage, particularly when it comes to the tracking of referrals and follow-ups with specialists that is a key element of the model, he says. "With a common medical record, if I send you to the surgeon he can look up your chart and see my concerns," Lurye says. "Often specialists are unclear as to why a patient is there to see them. Here it's much smoother."
Elmhurst Clinic has added on other I.T. tools to assist with the model. It uses an automated appointment reminder system, from Phytel, which scours the practice's scheduling system and provides HIPAA-compliant phone call reminders. The Phytel system also provides a data mining service which analyzes the practice's database for patients "with certain conditions who need things done on a regular basis," says Lurye. It's driven by some 30 protocols, on such profiles as a patient whose blood sugar scores fall outside a certain range who has not been in for a visit during the recommended timeframe. The automated reminder calls free up valuable staff time, Lurye says.
The practice has also deployed refill management software, from HealthFinch. The program works in conjunction with the EHR. "Refill management is a big part of the primary care physician's day," Lurye says. "They may average about 15 refill requests per physician per day." The software's "RefillWizard" automates the process, taking refill requests-which originate with a patient or the pharmacy-and matching them up against a set of standing orders created by primary care physicians. If the request meets certain guidelines, a staff nurse is authorized to grant the refill request. "Physicians don't have to touch them," Lurye says. In other instances, however, the system will alert the practice that indeed a patient has to come in for a visit before a refill can be granted. "Some may be overdue for testing. This helps with the chronically ill patients."
Both steps-averting unnecessary physician attention and staying on top of the needs of patients with chronic conditions-are a boost to the practice, both clinically and financially, Lurye adds. He figures that a typical primary physician might free up 45 minutes a day, or more, by not having to research and act on certain refill requests. "The system decreases phone calls, gets refills out faster, and removes variation if you have staff members interpreting a physician order," he notes.
By identifying patients overdue for visits, the practice also boosts its visit volume. "We have added over 2,000 visits in some months that we might not have had otherwise without the reminders. But we are not pulling in patients for superfluous reasons.
"These are people with heart disease and diabetes. This is substantive work."
The importance of I.T. to the medical home model is underscored time and time in the daily operations, physicians and practice managers say, so keeping the system up and running is crucial.
A strong I.T. support team is almost as vital as the EHR itself, says Meryl Moss, chief operating officer at Coastal Medical, a 75-physician group practice in Providence, R.I. and winner of 2012 Ambulatory HIMSS Davies Award. The Level III medical home deployed an EHR from eClinicalWorks in 2006. Three years later, it decided to change its business model after holding a strategic planning retreat. "We wanted to transition from acute episodic care-we were waiting for patients to call us and weren't managing the needs of the population. We wanted to focus on prevention, getting our sickest patients in and keeping them out of ER. We had been waiting until they were sicker than they should have been to see us. The EHR gave us a tool to manage our patients in a different way."
The EHR-which is integrated with a practice management system for scheduling and billing-runs on a client/server platform, with a redundant data center off-site. To keep it running, the practice employs six full-time staff members in its I.T. department, Moss says. "You never want to be down and we have never been down." In addition, the practice employs two full-time EHR trainers, clinically trained staff who know the EHR inside and out. "They make sure everyone is realizing the full functionality of the software," Moss says, adding that the group is about to hire a third trainer. "The trainer is one of the keys to success."
Beyond a strong EHR and support team, the medical home model requires data exchange, particularly with outbound referrals to consulting specialists, and in many cases, with local hospitals. For groups like Elmhurst Clinic, the task is eased by having specialists in house. But many primary care physicians do not have the luxury.
Volpe, the Marcus Welby-inspired solo physician, relies heavily on his EHR's integrated fax capabilities to stay in touch with the outside world. If one of his patients is admitted to the hospital, he gets a fax with some of the particulars, a file which flows automatically into his EHR.
Likewise, Volpe sends outbound faxes to specialists to whom he is referring, such as care summaries, or in the case of pending surgeries, request for clinician surveys about what's going to happen. Gathering up pertinent information about the surgery is all part of the new role for the medical home primary care physician, says Volpe, who routinely conducts pre-surgical care visits to make sure everyone understands the procedure and any potential landmines.