His surgical surveys covers such topics as the relevant diagnosis leading to the surgery, the related ICD-9 and CPT codes, basic questions about when and where the surgery will occur, what kind of anesthesia will be administered, how long the procedure will last, and what pre-operative testing or documents the surgeon needs. Surgeons complete the survey and fax it back, where it lands in Volpe's record.
"It's information gathering and processing," Volpe says. "The worst thing is if a patient comes in and I don't know anything about the surgery coming up. How can I do a pre-op evaluation if I don't know what will happen? If I don't, we might have to tell the patient to come back another time, and they have to deal with baby-sitting and parking all over again."
Some practices seeking that higher level of data exchange are looking beyond the fax. Legacy Health, a Portland, Ore.-based delivery system of six hospitals, is looking to build a private health information exchange, says CIO John Kenagy. Legacy has adopted the medical home model in 18 primary care clinics spanning about 65 physicians. They use an integrated ambulatory/inpatient/ED EHR, from Epic. And the hospital can exchange data with other providers in the area also on Epic, through the vendor's proprietary exchange service. "That's done easily," Kenagy attests.
But many referrals go elsewhere, and to connect with those practices, Kenagy is building a private exchange, using software from Certify Data. The exchange will serve purposes beyond the medical home, with most initial use for handing inbound lab orders from the community. But in time, the medical home physicians could use the set-up to move continuity of care records back and forth between specialists.
The third leg
The EHR and data exchange are two legs of the medical home stool; quality reporting is the third. Reporting capabilities are a must for NCQA recognition and beyond that, many payers tie report production to whatever reimbursement incentives they offer.
Spangler, the practice manager at Family Medical Associates, runs a number of reports directly from the group's EHR, from Greenway Medical Technologies. The group runs reports to see which patients are overdue for visits. "We have a large diabetic population," she says. "If the patient has not been seen for six months, and their A1C is high, we can generate a report with their contact information and call or send a letter," she says.
The group routinely runs a number of such condition-specific reports, enabling it to identify, for example, female patients over the age of 50 who have not had a mammogram, or hypertension patients overdue for office visits.
Tickling patients
The group also uses the EHR's built-in "tickler" capability to track patients. If a patient is sent for an outside lab, the staff enters a request for an electronic reminder to follow-up and make sure the lab was done, Spangler adds.
As an added lure to patients, the practice has expanded its service lines, now offering its own lab, bone density testing, allergy services, dietary counseling and a weight loss clinic. It's also hiring a psychotherapist to join its physicians, physician assistants and nurse practitioners. "You need a practice team" to make the medical home work, Spangler says.
That very notion of a "practice team" is what makes the medical home so distinct from conventional primary care. Many who have embraced the model say it requires everyone in the group practice to play new roles. And as Volpe notes, the requirements can be demanding. At his solo practice, he is propped up by "1.8 to 2.1 FTEs," including his wife, a nurse who works two days a week. "Everyone in the practice does everything," he says. "The medical assistant doubles as office manager. She takes vital signs, records chief complaints, helps with pre-authorizations, attends meetings, and reaches out to patients via e-mail or snail mail. Another medical assistant is cross-trained as a billing person."
Medical homes also create a new role for physicians, who must yield a certain amount of autonomy and responsibility in exchange for delivering better care and having more face-time with patients. "In the medical home, the care shifts from having the physicians being the center of focus to the patient," says Moss, the Davies winner. "It shifts from the physician being the sole person to interact with the patient to a team. Now patients meet with the pharmacist and the nurse care manager. The medical assistant who used to put people in the room is now helping reconcile meds."
This new role for physicians is just one of the many challenges facing practices which embrace the model. Physician adoption of the EHR-and the new workflows-can be a sticking point. And EHR limitations can hinder the effort as well. Then there are practical matters of cost and dealing with the bevy of organizations outside the medical home.
EHR ambivalence
One part of upstate New York is attempting to meet those challenges head-on. The Adirondack Region Medical Home Pilot Program launched in 2009, driven by state grant funds aimed at increasing EHR adoption and boosting clinical outcomes.
More than 200 physicians in 31 independent primary care practices are participating, says Pam Minichiello, project director at the Massachusetts eHealth Collaborative, a consulting firm enlisted to help drive EHR adoption. The effort has already reached some milestones, not the least of which is meeting NCQA requirements. "The grant required practices to achieve Level II and 29 practices got to Level III," she says.
The practices had all adopted EHRs-from nine different vendors-before the effort, but with varying degrees of optimization, Minichiello recalls. "Some were still setting up templates," she says. Changing physician attitudes about proper documentation was a challenge. "Many used structured documentation but only minimally, and were also doing dictation. Others had no lab interface. They were not used to quality metrics. Getting all that in place and increasing their utilization was the hardest part."
