Decades later, the grown-up Volpe-who's certified in pediatrics, geriatrics and internal medicine-is attempting to recreate that type of doctor-patient relationship in his own solo practice in Staten Island, N.Y.
There are a couple of key differences. Volpe documents his care with an electronic health record, having abandoned the paper charts ubiquitous during the Welby era. And unlike Welby, who practiced in an era all but devoid of pre-authorizations, high deductibles and insurance plan second-guessing, Volpe must contend with the economic realities of modern medicine. That's why he has fashioned his practice around the "patient-centered medical home" model of care delivery. The model-in place at a growing number of primary care practices-attempts to temper the volume-based mania of fee-for-service medicine with a preventive approach designed to be more meaningful-and effective-for patients and physicians alike. The model can also reduce care costs, which is why growing numbers of payers are incentivizing it.
In the medical home model, the primary care practice is the quarterback for a patient's care, coordinating services outside the practice, tracking outcomes, trying to reduce unnecessary expenses and potentially share in the rewards for doing so. Some medical home practices are even eyeing at-risk payment contracts.
Volpe describes the emerging care delivery model this way: "A medical home is like a real home," he explains. "If you live in a home, everyone cares about everyone else. Everyone in the home pitches in to make sure everyone succeeds. You migrate that idea to the physician office. So the front desk isn't brusque with people and the staff asks patients about their families, about the daughter who just went to college."
But the bar is set pretty high for practices trying to earn medical home designation. Attaining medical home status the National Committee for Quality Assurance-the industry's gold standard, one recognized by both CMS and commercial payers-requires meeting not only hefty I.T. requirements but upending traditional staff roles to boot. Those I.T. requirements include an EHR as an absolute prerequisite for more sophisticated versions of the model, with a patient portal, data exchange, and analytical capabilities running a close second.
In many ways, the medical home is the industry's testing ground for a connected industry. Physicians who embrace it say they can meet the so-called "triple aim" goals touted by the federal government of better care, better access and better outcomes.
Humble beginnings
Although versions of the medical home date to the late 1960s (the American Academy of Pediatrics introduced the term in 1967), many point to 2008 as the year when the idea began to gel. That's when NCQA launched its patient-centered medical home recognition program, a status which serves as the industry seal of approval. The early iteration of the program required no EHR, but subsequent versions did, says Mina Harkins, assistant vice president, recognition programs, at Washington, D.C.-based NCQA. "Primary care is the focus, internal and family medicine," she says. "It's not for specialties. We are focused on a practice that is treating the whole person with both preventive care and chronic care."
To date, just over 4,900 group practices-encompassing 23,000 physicians, physician assistants and advanced nurse practitioners-have attained NCQA recognition as a medical home.
About 75 percent of the practices are at NCQA's Level III, the highest, and about 20 percent are at Level I, she says. To attain the highest level, practices must document their capability in a wide number of areas, including enhanced access for patients, use of evidence-based medicine, and tracking referrals. NCQA's scorecard for the recognition is a complex matrix (and requires renewal every three years). About 5 percent of applicants don't make the grade, Harkins says. "This is a lot of work," she acknowledges. "Most practices take it very seriously, but there are a few where the doctor told the manager to apply just for some health plan incentive and they don't pass."
The major primary care member associations, including the American Academy of Family Physicians and the American Academy of Pediatrics, have endorsed the model and offer their members tool-kits to help them revamp their operations and gain recognition, Harkins adds. While I.T. is only part of the package, Level III is designed to incorporate EHR meaningful use criteria, she says. "If you are using a certified EHR and attesting successfully, you've met about half the requirements," she says.
Attaining Level III status-a prerequisite for many payer incentive programs-is a time-consuming but critical exercise. For Family Medical Associates of Raleigh (N.C.), the impetus was that the state's Blue Cross Blue Shield plan tied medical home status to a new quality program that increased reimbursement, says Janet Spangler, practice administrator at the nine-provider group, which has already attested for Stage 1 meaningful use.
Spangler describes attaining the recognition as very difficult. "We spent three extremely intense months completing the documentation," she says. "The language NCQA uses for standards is up for a lot of interpretation. But as soon as you are stumped, they call you right back." The application process entailed sending proof of both capability and actual use. For example, to meet the mark on patient access, the practice had to provide both its access policy and a screen shot of its scheduling system showing the number of appointments left open for same-day access. "We sent 950 pages of documentation the first time," Spangler says, about half of which described policy and the other half showed I.T. capability. "Meaningful use is a piece of cake in comparison."
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."
Free time
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.
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."
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."
