Any healthcare organization that's moving toward accountable care and value-based reimbursement-which is to say, almost any healthcare organization-may soon be calling on its information technology staff (if it hasn't already) to support the patient-centered medical home.

“Accountable care organizations that aren't built on a strong base of medical homes are going to struggle because they don't have an infrastructure built around quality reporting, teamwork and proactively managing their patients,” says Amy Mullins, M.D., medical director of quality improvement for the American Academy of Family Practice, which has long supported the medical home model as a way of keeping patients well, rather than merely treating them when they're sick.

Emphasizing care coordination, prevention and careful management of chronic illness, the medical home is headed toward being the national norm, driven by the need to lower cost and improve quality. But to get there, it needs certain types of IT support (see list, page 31) that right now are available only to the most advanced primary care practices.

"There's a lot of frustration out there," says Michael Barr, M.D., executive vice president of quality measurement and research for the National Committee for Quality Assurance (NCQA), which promotes the medical home model and assesses how well primary care practices are adhering to it. "Technology has gotten to the point where we should be able to do a lot of things most of us still can't do."

Barr, an internist, still practices part-time and is frustrated that he has to send patients to the emergency room with a printout of their records, rather than transmitting the records electronically. He wants to be able to share relevant pieces of the EHR-not the entire encyclopedia of the patient's medical history-with specialists, and to be able to assess quickly which of his patients need certain lab tests, imaging studies or vaccinations.


The Denmark model

A medical home is a care model in which primary care physicians, nurse practitioners and care managers work together to coordinate care, particularly for high-cost chronically ill patients. Coordinated care depends on advanced IT capabilities in many ways, from tracking preventive care to sharing records and treatment plans among multiple providers.

Medical homes can be formally recognized as such, through organizations like the Joint Commission, the Accreditation Association for Ambulatory Health Care, and the NCQA, which has the most established program. Almost 9,000 practices have NCQA recognition, encompassing more than 40,000 clinicians. The Joint Commission's newer program has accredited 136 organizations as medical homes, with more than a thousand care sites. Some practices adopt the model but don't bother going for any type of organizational seal of approval. But a payer may require NCQA or other recognition before a practice can receive reimbursement specifically for coordinating care and maintaining patients' health-activities that often cut into traditional fee-for-service income.

When medical home-style care is recognized and reimbursed by payers, it's usually via a monthly fee per patient, either instead of or in addition to fees for specific services. The medical home fee pays for a care manager or care coordinator who makes sure patients are getting the routine tests, exams and treatments that keep them out of crisis, thereby reducing emergency room and inpatient care costs. Accountable care organizations are an expanded version of the medical home, encompassing specialists, hospitals and home care, with a similar financial imperative to keep patients well.

To see how information technology can enable a high-performance medical home, Paul Grundy, M.D., suggests taking a look at Denmark, possibly the most connected health system in the world and with a rock-solid primary care foundation. Grundy is often called the "godfather of the patient-centered medical home" because of his single-minded promotion of the concept as IBM's global director of healthcare transformation and in his role founding the Patient-Centered Primary Care Collaborative (PCPCC), the field's primary research and advocacy organization.

With a single electronic health record system for the whole country, which has a population of about 5.6 million, Danish physicians can manage most care from the patient's home with digital teleconferencing and home health workers. Primary care physicians act as patients' representatives when dealing with specialists, rather than gatekeepers to discourage the use of advanced care. The country has closed many of its hospitals, and those that remain are wired to the max. Patients are free to stay in them as long as they feel they need to, but most prefer at-home care.

IT innovations abound. For example, high-tech drug packaging signals to the EHR when it's been opened, so the system knows who's taking their meds and who isn't. "In the U.S., the pharmacy knows that a medication has been picked up, and the patient knows whether they've taken it, but the doctor doesn't have a clue," Grundy says. "When doctors have that information, the conversation can turn to why the patient isn't taking his pills."

The U.S. isn't Denmark, and with its vast and diverse population, complex health economy and patchwork of state and federal regulations, it may never achieve the same kind of systemic success. But the medical home model is catching on here. According to the PCPCC's most recent annual review of the field, released in January 2015, almost 21 million patients in the U.S. are being served through a medical home model, up from 5 million in 2009. Forty-four states have medical home pilots or wider initiatives, up from 18 five years ago, and medical home incentive payment programs jumped to 114 from 26 during the same period.

A growing body of peer-reviewed evidence supports the effectiveness of the model. Of 14 studies published in the past two years, most found improvements in whatever metric they were studying, according to the PCPCC report. Specifically, of 10 studies that looked at cost reduction, six found improvements. Of 13 that looked at utilization, 12 found improvements. Two out of three found improvements in quality. Four studies looked at access and four others at patient satisfaction: All eight found improvements.

A study published last July, looking at medical home services provided to Medicare beneficiaries nationally, showed an almost 5 percent reduction in total payments, mostly due to a drop in payments to hospitals. Emergency department visits also decreased.

Statewide medical home initiatives in Colorado, Minnesota, Missouri, Oklahoma, Oregon, Rhode Island and Vermont all have shown significant drops in spending and utilization of high-cost services, as well as improvements in care.


Success in Pennsylvania

Geisinger Health System, Danville, Pa., has been operating on a medical home model, called ProvenHealth Navigator, since 2006, and is widely regarded as one of the most successful U.S. medical home proponents. Teams in 93 sites care for almost 400,000 patients. Geisinger uses sophisticated predictive analytics to identify which patients will benefit from certain interventions and employs telemonitoring to track key health indicators.

For example, many Geisinger patients with congestive heart failure use Bluetooth-enabled scales that transmit their daily weight to nurse managers, who can spot sudden gains that foreshadow a crisis. Immediate intervention has contributed to a 44 percent reduction in 30-day re-admission rates among those patients.

Interactive voice response systems call other patients and ask them questions; answers that indicate a problem trigger a return call from a nurse. Autodialers call all patients on their birthdays if it's the year for them to have a routine screening, like a Pap smear or a colonoscopy.

"We know the state of each of our patients all the time," says Thomas Graf, M.D., chief medical officer for population health and longitudinal care service lines.

But even Geisinger doesn't have all the information it needs. Most payers won't share data, and when they do, it's for the entire Geisinger system, rather than for individual physicians or even office sites. Graf can get complete, detailed information only from Geisinger's own health plan, which covers only a third of medical home patients. As a result, he can't combine the payers' utilization data with Geisinger's EHR data to identify gaps in care.


Homes of all sizes

Medical homes don't have to be the size of Geisinger. Nusrat Khan, M.D., who trained at the Cleveland Clinic and is board-certified in both internal medicine and pediatrics, brought the medical home model to his one-physician practice in Weatherford, Texas. With one physician assistant and an office manager, he cares for about 9,000 patients. Their primary electronic tools are an EHR from AmazingCharts and a set of Excel spreadsheets.

About 40 percent of the practice's patients fall into the high-risk/high-cost categories the medical home is designed to manage, and so far its IT tools do a reasonable job of tracking them. Khan says his biggest technology gap is in communicating with the "medical neighborhood": home health, hospice and specialist care. "If you can't easily exchange information with them, you're out of sync with the 'outer circle,' and you can't provide good medical home care."

A health information exchange would help-the Weatherford area doesn't have access to one currently-and so would telemedicine capabilities, which would allow Khan to do virtual house calls with patients receiving home health services.

Khan welcomes patients who use electronic tools to gather their own health information. "It helps me understand what hurdles they may be facing, and what they're doing," he says. He does his best to incorporate patient-supplied data into his EHR, but says it's an awkward process.

Effective medical home care rests partly on identifying the patients who will benefit the most from the increased attention that's built into the model. That's not always a straightforward process.

Mullins, the medical director of quality improvement for the American Academy of Family Practice, was part of a medical home practice in Tyler, Texas, before taking her post at the AAFP. The payers who worked with the practice provided lists of "top utilizers"-patients who cost the most-and based reimbursement partly on whether the practice reduced those costs. While many were the usual suspects-diabetic, hypertensive, asthmatic-cost didn't always tell the whole story. Sometimes the list included someone who'd been in an accident or had a complicated pregnancy and was otherwise healthy. That individual's costs were probably going to plummet the following year no matter what.

On the other hand, the payers weren't as effective at identifying what Mullins calls the scariest patients: the "medium risk" group that's on the verge of developing those costly conditions. "You don't see them often, but they're going to be your high-risk patients next year," she says.

The only solution, Mullins says, is to treat all patients using the medical home model, whether their insurer reimburses that way or not. "It's not a specific way to treat a certain patient, but a way to practice medicine."

Mullins went through a change in EHRs-from GE's Centricity to Epic- while in her medical home practice, and it was a jolting one. "We had built some fantastic data mining capabilities to do quarterly trend data on our top metrics" in Centricity, and it took about a year to be able to get comparable data out of Epic. "When you don't have access to the data, you realize how much you rely on it," she says.

Mullins sees a huge potential for the kind of interoperability that would allow physicians to take in health data from their patients' smartphones, or easily import a CD of their X-rays into the office EHR. "You can't get the information from point A to point B to make it usable," she says.


Keeping data fresh

Medical home physicians say that fresh data will have the biggest impact on their ability to keep patients healthy. "If I had half an hour without a patient and was wondering how I'm doing with my diabetics, I'd like to be able to click a couple of buttons and get that answer," says Yul Ejnes, M.D., an internist with Coastal Medical in Cranston, R.I., an NCQA-recognized medical home that cares for about 120,000 patients, more than 10 percent of the state's population. "If I don't like what I see, I'm more likely to react and do something about it, but it's not easy to take action when the data is several months old."



The IT tools and capabilities medical homes need most are:

* EHRs

* Patient registries

* Health information exchange

* Risk stratification

* Automated patient outreach

* Referral tracking

* Patient portals

* Telehealth/telemedicine

* Remote patient monitoring

* Advanced population analytics

* Cognitive computing

Source: Paul Grundy, M.D., Patient Centered Primary Care Collaborative

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