In addition, working with EHR vendors was not always easy, Minichiello says. "Some systems needed significant reconfiguration and some vendors were easier to work with than others. The main challenge was reporting capabilities. We would go to the vendors and say 'we need this report for diabetic care' and they did not understand what that was."
The EHR may be a necessary tool for a medical home. But many practices adopting it have an ambivalent view of the technology. "The EHR is both a help and a hindrance," says Christine Sinsky, M.D., an internist at Dubuque, Iowa-based Medical Associates Clinic and Health Plans. A long-time proponent of the medical home concept, Sinsky says the industry must rethink its approach to preventive medicine. Becoming enamored of the EHR won't help much, she says. "The EHR is a tool and a first step, but it's not the No. 1 priority. If you don't have access and continuity, and you don't plan and manage care, it doesn't matter if you have an EHR. If you don't proactively manage diabetes, having an EHR won't fix it. If you don't provide same day access, an EHR won't help. Those two elements are 80 percent of the benefit of having a medical home."
Bright shiny piece
Sinsky praises the practice's EHR, from McKesson, for its capacity to enable information sharing, receive lab results directly, and provide patients copies of their clinical note. "With the EHR, I can give the patients a copy of their cumulative labs and they can see their lipid profile over the last three tests. They love that." However, the EHR is not always conducive to the workflow and role changes called for in a medical home, she says. "Technology is the bright shiny piece people look at, but the medical home is more about organization and teams."
Toward that end, Sinsky's clinic has revamped the way it delivers care. During office visits, for example, both the physician and nurse are present, interacting with the patient and their chart. "There's a disconnect between what the EHR is designed to do and what we need it to do," she says. "It's designed as if the physician is sitting in front of the screen. It's designed as if all the data entry is by the physician, as opposed to the team. We are handcuffed by the technology." At Medical Associates Clinic, both the nurse and physician add data to the chart during the visit. However, the different versions of the chart do not sync up in real time, requiring Sinsky to refresh her screen, which takes her back to the opening page of the entire system. "I have to go through a long process to get to the screen I was at," she says. "It's best when the physician can give undivided attention and have an assistant who can do most of the documentation. Our tools are not aligned with that."
The practice has approached McKesson about this and other EHR-related issues, but response has been slow in coming, Sinsky says. "If you make a lot requests to a vendor, they get lost," she says. "It took us years to get a 'back button' so you could go back to your previous screen."
When asked to comment, McKesson's Jim Reynolds, a product manager with the company's physician practice group, replied that, "we are invested in the product and its future. We are spending millions of dollars preparing the next version of the product that will be meaningful use compliant, ICD-10 ready and meet some customer requested changes."
Trapping data within a practice may be hard, but the chore pales in comparison with tracking health information outside the medical home's walls. "Hospitals do not always let us know when one of our patients is admitted," sighs Spangler, of Family Medical Associates. "They are supposed to ask a patient who their primary care physician is, but they don't always ask. Or if they do, it may not be documented in their system. We get admission information about 50 to 60 percent of the time. It's a great unknown and a heated topic between family medicine and the hospital." The area is building a new health information exchange, a service which Spangler hopes can bridge some of the communication gaps between the medical home and other providers. "We need a data exchange and we are so far from where we need to be."
Medical home economics pose another challenge above and beyond I.T. It's a sore subject for Volpe, the solo physician. He figures the model costs upwards to $100,000 annually for a primary care physician to adopt. "It is mostly 'lost opportunity' cost," he explains. Simply put, if the physician spends extra time with each patient discussing chronic conditions and personal matters affecting their health, he is losing office visits. "Taking extra time is gratifying to me, but it doesn't increase reimbursement."
Maintaining a solo practice is challenging financially, he acknowledges. "Being able to find people who can work as hard as we need them to work for such a low salary is the biggest hurdle," he says. "The teenage baby-sitter makes more per hour than her mom working at a medical office." But Volpe's encouraged by the growth in payer incentive plans in support of the medical home.
In New York, for example, the state's Medicaid plan pays an extra $6 per member per month to physicians operating a medical home. "That is $72,000 a year if you have a panel of 1,000 patients," he says. "That makes a difference."