The Patient-Centered Medical Home and Health Information Technology

Introduction

Health information technology (HIT), an indispensable component of the patient-centered medical home (PCMH) (or Medical Home), is essential for the model to reach its full potential. The Medical Home “is a model of care articulated by principles that embrace the aspirations of the Institute of Medicine, the design of the Future of Family Medicine new model of care and the Wagner Care Model, and the relationship desired by some of this Country's largest employers for their employees.” ¹ The American Academy of Pediatrics developed the term Medical Home in 1967 to describe a method of archiving a child's medical record in a single place and a partnership approach to healthcare with children's families to offer accessible, coordinated, and compassionate care. In its contemporary form, PCMH is guided by seven core principles (Table 1) ² and has been adopted by major organizations in the United States, including the American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association. The objective of PCMH is to provide quality, comprehensive, and cost-effective services. Care is facilitated through HIT, electronic medical records (EMRs), disease registries, and health information exchange to guarantee that patients receive care when and where they need and want in a linguistically and culturally appropriate manner. ³

A strong HIT infrastructure can help practices carry out the goals of PCMH as it can facilitate better access, communication, and clinical services. Such an infrastructure can also enhance the practice's ability to report on performance measures to Medical Home accreditation programs, such as that run by the National Committee for Quality Assurance (NCQA), one of the largest programs in the country. Each practice submits clinical (e.g., patient education, disease monitoring, prescription reconciliation) and service (e.g., scheduling, access, communication) data based upon six standards set by the NCQA so that it can assess whether it is functioning as a Medical Home and if so to what degree (Table 2). Practices are awarded one of three levels of recognition based upon how many criteria they meet. Improved HIT can help a practice transform from providing traditional primary care into a PCMH and achieve the highest level of NCQA recognition, but the key to this transition is to utilize HIT with the goal of making care highly patient-centered.

Patient-centeredness is often understood as a contrast to doctor-centered, technology-centered, or disease-centered and is commonly a misunderstood concept. ⁴ Many “definitions of patient-centered care seek to make the implicit in patient care explicit. Such definitions are, we recognize, oversimplifications which help in teaching and research but fail to capture the indivisible whole of a healing relationship.” ² In this article, we pose the following questions: How does a practice balance building a solid HIT infrastructure while continuing to be patient-centered in the transition to PCMH? How can various aspects of HIT be utilized to emphasize the relationship between patients and providers? We argue that EMRs, workflow processes, and interoperable systems, although time-consuming, expensive, and challenging, can help providers offer high-quality patient-centered services consistent with the PCMH model. Using data collected from presentations by civilian and military medical providers, researchers, physician organizations, and other key PCMH stakeholders at a Medical Home workshop held in Alexandria, VA in June 2010 and a literature review, we challenge the idea that being patient-centered is incompatible with being technology-centered and suggest that these two concepts must go hand-in-hand for Medical Home to succeed and be sustained. After examining specific HIT abilities to make care more patient-centered, we close with a discussion of how “meaningful use” (HIT objectives that providers must meet to qualify for federal monetary bonuses) can facilitate the compatibility of the concepts of patient-centeredness and technology-centeredness in PCMH.

EMRs and Registries

Traditionally, EMRs have been used to document patient encounters and therefore are focused on individual patient care. However, with the coming of PCMH and the focus on primary care as a solid foundation for more cost-effective and quality healthcare overall, EMRs need to take on new roles for providers to offer patient-centered services. ⁵ Unfortunately, many EMR systems do not address these roles adequately just yet.

Individual patient care and managing population health are two key features of the PCMH model. To do so appropriately, there are two different tools that are essential: standardized visit templates and electronic patient registries. Having these systems speak to one another is critical for efficiency and for providing medical professionals with the most up-to-date information about their individual patients and their panel. Patient registries can allow providers, or in some cases care coordinators, to search through their patients and determine who needs to come in for a follow-up, who is due for preventative services such as immunizations, who needs further education, and who is the “sickest of the sick.” Care coordination is a core principle of the PCMH model. A nurse can handle it, or an entirely new position in the practice may be created just to do coordination. Care coordination ensures that services not previously offered or only offered sporadically by providers during the traditional 15-min visit are now consistently offered to all patients. To be patient-centered, it is important that registries can perform queries in order to provide practitioners with alerts and information, such as patients needing preventative care or all patients with high blood pressure needing further education. One of the major advantages of electronic patient registries is that they can be kept current if they are connected to an EMR system. As patients' charts are updated during office visits, virtual visits online, or telephone encounters, the registry is updated concurrently.

Carilion Clinic, a healthcare organization headquartered in Roanoke, VA, has had success using patient registries for care coordination. Carilion employs 600 physicians representing more than 60 specialties and serves several counties in southwest Virginia. It runs 37 primary care practices with 180 providers and has a primary service area of 653,717. ⁶ Care coordinators in the practices act on the information provided in patient registries and search on a daily basis for patients discharged from the hospital, those in need of preventative care, and those who are the “sickest of the sick.” Doing so has led to a 30% improvement in childhood immunization rates and modest increases in hypertensives and diabetics who now have controlled blood pressure in the six PCMH pilot practices in Carilion. The goal of care coordination is to encourage patients to become more proactive in their care by offering them follow-ups and reminders through phone calls and other communication means and referring them for additional education when necessary.

Visit templates can facilitate team-based coordinated care by collecting and exchanging information among care team members and ideally between the practice and other facilities. They are used during visits so that providers can document a patient's history, vitals, diagnosis and prognosis, and laboratory or imaging results among other important pieces of information that will help the best direction for care. Ziegelstein and Zaczek ⁷ argue “coordination of care and sharing of health information among all team members is important to the whole-person orientation of the medical home model.” The 15-min primary care visit does not allow a provider sufficient time to offer all needed or expected services, but a team-based approach to care that involves physicians, mid-level providers, nurses, technicians, and other practice staff working together can offer a more efficient and effective visit. ⁸ A standardized visit template designed for PCMH would include a simple user interface and easily retrievable data as well as immediately actionable data, such as being able to order a test at the click of a button if the data indicate it is needed. Visit templates facilitate a patient-centered focus by enabling practitioners to uniquely identify patients according to their needs, including language preferences, care preferences, and preferred methods of education like face-to-face classes versus self-learning. ⁹

Standardizing a visit template means using a language that can be easily used and understood by all team members. This can decrease redundancy in the office visit. A quote from a patient's e-mail to his primary care provider about his visit in the hospital stresses the need to use a template that is accessible by all staff: “I can't recall the names of everyone I've spoken to. At last count, I gave my history to 328 people and a gerbil, who was the only one who took notes.” ⁴ A visit template in the context of PCMH can guide the practitioner to better engage the patient in the visit, possibly through a series of health- or behavior-related questions, which is critical given that the model aims to increase patients' involvement in their own care. However, a balance must be reached between computable data (drop-down menus, discrete data fields) and free text narratives in EMRs. Free text narratives allow for the care team to document patients' words and recollections as they experienced them, thus offering providers a better sense of how the patients view their ailments or illnesses, but they can also lead to limitations such as difficulty finding past patient data because free text is not easily searchable.

Interoperability

A key part of the PCMH model is the flow and exchange of information between primary care providers, specialists, care team members, and patients. This movement facilitates PCMH core principles of care coordination, whole-person orientation, and being able to offer comprehensive services. Greg Wright, the Senior Vice President for Solutions IMC, Inc., points out, “It is one thing in the military treatment center of the group practice where you have everybody under the same roof and the same record system, but when you go out to specialists and into the free market and patient behavior selecting their own treatment providers, interchange is going to be crucial.” ¹⁰ The difficulty of interoperability is illustrated by the Military Health System's efforts to build Medical Homes in the three branches: Navy and Marines, Army, and Air Force. Approximately 70% of care provided to Department of Defense beneficiaries (active duty, retirees, and their families) is delivered outside of Military Treatment Facilities (MTFs) by civilian providers who accept TRICARE, the Department of Defense's healthcare program for beneficiaries that offers several healthcare plans. ¹¹ (TRICARE Standard has no enrollment fee and is more closely a type of preferred-provider organization with deductibles, co-pays, and out-of-plan additional costs. TRICARE Prime is closer to a health maintenance organization with an enrollment fee, lower deductibles, co-pays, and out-of-plan costs, and greater flexibility in selecting healthcare providers. TRICARE for Life is for beneficiaries who are eligible for Medicare and is a first-payer.) The majority of primary care takes place at MTFs, but military providers find it difficult to get information back from TRICARE providers about their patients, which decreases their ability to make the best treatment decisions because they are missing crucial information. All MTFs use the Armed Forces Health Longitudinal Technology Application, an enterprise-wide EMR utilized in all fixed and deployed MTFs worldwide, but civilian providers most likely do not use the Armed Forces Health Longitudinal Technology Application, making information exchange very cumbersome and time-consuming.

For Medical Homes to realize their full potential at providing highly patient-centered care, it is essential that medical records can be transferred efficiently between providers. For example, at Carilion Clinic, when a patient sees a provider who does not use EPIC, its EMR system for outpatient and in-patient services, the information from that encounter is not automatically inputted into a patient's chart. A care coordinator or nurse will need to request that encounter's note and manually put it into the chart so it remains up-to-date. In the rural areas that Carilion serves this is certainly a problem given that there are few providers overall, and of these, many operate independently outside of the Carilion system. Interoperability is essential as it increases efficiency, ensures that patients do not have to repeat their information to multiple providers, and ensures that they do not undergo costly tests, labs, and imaging procedures that are needlessly repeated or unnecessary altogether.

Network security requirements compound the problem of difficult information exchange. PCMH involves information sharing among extremely diverse sectors and stakeholders, which may have very different security requirements. Therefore, high-functioning EMR systems must be able to adapt to varied security landscapes in order to protect against threats. ¹² Care coordination involves primary care practices, specialists, hospitals, other care facilities, and community resources. This means that barriers to information assurance must be overcome as “information sharing in the PCMH requires joint work that builds trust, fosters governance, and bridges organizational boundaries.” ¹³ In 2005, the Health and Information Technology Standards Panel was developed as a “partnership among public and private sector organizations to help pursue President Bush's vision of establishing a nationwide system of Electronic Health Record sharing.” ¹⁴ One of the panel's goals was to achieve healthcare interoperability by harmonizing HIT standards for easier and safer information exchange. Patients must be assured that if they participate in a Medical Home their personal health information will be secure as it is transferred between providers. Technology is now seen as a route to improving healthcare. Personal health records can enable patients and providers to establish new ways of collaborating and provide a basis for transforming the U.S. healthcare system, but federal policies must be put into place to protect patients' information. ¹⁵

Meaningful Use

“Meaningful use” means providers must demonstrate that they are using certified EMR technology in ways that can be measured significantly in quality and in quantity. In 2009, the Health Information Technology for Economic and Clinical Health Act authorized incentive payments through Medicare and Medicaid to providers and hospitals when they utilize an EMR to achieve specified improvements in healthcare delivery. Congress and the Obama administration have committed $27 billion over 10 years to provide financial incentives for the creation of a nationwide system of EMRs to better monitor and track care in an attempt to cut costs through decreased resource utilization and fewer redundant or unnecessary procedures. ¹⁶ The American Recovery and Reinvestment Act of 2009 identifies three main components of “meaningful use”: (1) the use of a EMR in a meaningful manner, (2) the use of EMR technology for electronic exchange of health information to improve the quality of healthcare, and (3) the use of EMR technology to submit clinical quality and other measures. ¹⁷

It is not enough just to implement an EMR, but to qualify for financial incentives, providers must make sure that their EMR meets certain objectives and measures and is designed to promote policy priorities aimed at improving healthcare. One example is that the use of electronic prescribing has been shown to improve safety and efficiency. Also, the use of health information exchange improves care coordination. ¹⁸ The Centers for Medicare and Medicaid Services has issued a three-step “meaningful use” agenda that will take place over a 5-year period: Stage 1 (2011–2012) sets the baseline for electronic data capture and information sharing, whereas Stage 2 (implemented in 2013) and Stage 3 (implemented in 2015) will expand this baseline and be developed through future rule making. The final Centers for Medicare and Medicaid Services Meaningful Use Rule divides the initial 25 “meaningful use” objectives into two categories: A group of 15 objectives that medical professionals must meet and a “menu set” of 10 procedures from which they can choose any five to defer in Stage 1. In Stage 2, providers must continue to use all functionality from the first stage but will also be required to use an EMR to send and receive information such as lab orders and results. In Stage 3, providers must fulfill criteria from previous stages plus incorporate clinical decision support for national high-priority conditions and be able to access comprehensive patient data to improve population health. (As of June 2011, Stages 2 and 3 have not been defined in detail. Physician organizations and the public are still proposing recommendations.)

“Meaningful use” can lead to significant changes in how HIT is used in everyday medical practices. The mission of the Final Rule is “to push the entire healthcare system forward while giving doctors and healthcare systems the flexibility to find their way.” ¹⁹ David Blumenthal, the National Coordinator for Health Information Technology under President Obama, has stated ¹⁹ that more relaxed requirements and a graded agenda were issued because “We want providers to become meaningful users; we want providers to be able to get on this escalator and stay on it.” However, it is imperative to remember that “these efforts are not regulated to a particular department or function, but they require collaboration amongst all stakeholders. These are not ‘IT projects' but rather transformative initiatives that also involve clinical staff, the quality improvement function, and senior management and the leadership team.” ¹² When setting out on this initiative, it is worth investigating the similarities in requirements between PCMH and “meaningful use” in the areas of health information exchange, electronic prescribing, medication safety, and quality measures and understanding several of the two programs' objectives overlap in that they aim to make healthcare more patient-centered, engaging, safe, and ultimately cost-effective.

Conclusions

HIT supports many facets of the PCMH model and works to enhance the patient-centeredness of care. Reid et al. ²⁰ stated that PCMH “emphasizes the core attributes of primary care (access, longitudinal relationships, comprehensiveness, and coordination)…maximizes the use of advanced information technology, and aligns reimbursement methods with improved patient access and outcomes.” In this article, we have shown that technological improvements and patient-centeredness go hand-in-hand. They are not separate concepts in medicine, but rather we need to realize that they must work together in order to transform the healthcare system as a whole. Focusing on either technology or either patient-centeredness will not get us very far in this transformation process. In PCMH, HIT plays a role that has expanded much more than just documentation and tracking. ²¹ It is used for improving population health, implementing quality improvements, and making workflows more effective and reliable in practices. HIT can provide added value services to all patients, and now providers are able to receive financial benefits through incorporating high-functioning EMRs into their practices through “meaningful use.” Several of the core PCMH principles, such as team-based care and care coordination, depend on innovative technologies. HIT plays an essential role in effectively turning the intent and objectives of the PCMH model into routine practices and will help Medical Homes achieve their full potential at providing high-quality care.