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Empowering Health IT for the Medical Home
by David C. Kibbe, MD MBA
The basic premise of the medical home concept is continuous, uninterrupted care that is managed and coordinated by a personal provider with the right tools that will lead to better health outcomes.
In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, released the Joint Principles of the Patient-Centered Medical Home. In this document they state the characteristics of the Patient Centered Medical Home:
- Personal Relationship
- Team Approach
- Comprehensive
- Coordination
- Quality and Safety
- Expanded Access
- Added Value
While these characteristics, in theory, may be achieved without the use of health information technology (health IT), it is also true that their realization is more likely to occur if health IT is successfully deployed. Health IT can be an empowering facilitator to the establishment of a medical home, a fact supported by experience.
What is not obvious are the best ways in which health IT should be deployed to reach the objectives of the medical home desired by patients, providers, and payers. Nor is it clear that "one size fits all" when trying to match health IT products and services with the desired characteristics, and to do so in a manner that is affordable and sustainable across a variety of practice types, large and small.
Rather than attempt to list products or suppliers of health IT, e.g. electronic medical records, EMRs, as single "solutions" to the problem of transforming practices into medical homes, we suggest here that a wiser approach is to describe the capabilities that health IT ought to provide or enhance if a medical practice is to become a successful medical home. This approach has the advantage of being vendor-neutral, allowing for innovation, variation and choice in reaching the goal of the agreed upon medical home principles and characteristics listed above.
The list below of Empowering Health IT for the Medical Home is not intended to be complete or exclusive. Over time it may expand or be modified according to the evolution of both the concept of the medical home and the technologies themselves. This flexibility is necessary in a time of constant change. However, we believe this is a reasonable description of the health IT that will empower medical practices to become medical homes in the near future.
We define Empowering Health IT for the Medical Home as computer hardware, software, and related technology that provides or enhances:
1) The capability for electronic storage, transmission, and exchange of relevant personal health data and information, such that this information is accessible at the times and places where clinical decisions will be or are likely to be made, and such that this accessibility improves the patients’ continuity of care experience between and among various settings of care and different episodes of care. Accessibility of personal health information and continuity of the care experience are linked benefits of health IT that confers the capability of computerized data storage and transmission of the relevant information to the point of care.
Examples include EMRs, PHRs and e-Prescribing software products and services. Population registries are also examples of health IT that can provide or improve this capability.
2) The capability of the provider, patients, and other members of a person’s health care team to communicate with each other and amongst themselves in the processes of care delivery and care management, such that a team approach that assures coordination, quality and safety of care is encouraged and made possible, and that access to care is increasingly available to patients both online and in person.
Examples include EMRs, interactive web portals, and online communications platforms that are designed to provide communications such as secure email, online scheduling, and access to personal health records, PHRs.
3) The capability of providers and their practices to collect, store, measure, and report on the processes and outcomes of individual and population performance and quality of care , and that can be used to inform both providers, patients, and payers through reports and graphic displays on the success of efforts to make quality improvements in attaining evidence-based levels of care, especially for chronic conditions and diseases.
Examples include EMRs, patient and population registry applications or services, outcomes databases with reporting services, and participation in data aggregation and reporting programs established for quality improvement or pay-for-performance by health plans and others.
4) The capability of providers and their practices to engage in decision support for evidence-based treatments and tests , and offers this capability at or close to the point of care, as well as in a manner that is understandable and directly useful to patients and consumers through outreach reminders and alerts, education, and online tools and methods.
Examples include EMRs equipped with alerts and reminders, patient registry applications and services, PHRs that provide decision support tools, and other online services that accept and process personal health data for the purpose of evidence-based guidance for testing, treatment, and health maintenance.
5) The capability of consumers and patients to be informed and increasingly literate about their health and their medical conditions , and to appropriately self-manage with monitoring and coaching from providers. Health IT that successfully provides or improves this capability will remove barriers and impediments to data, information, and tools that can contribute to a person meeting his or her wellness or health promotion goals, and will put in place bridges that close the gaps in collaboration and coordination between the medical home provider and patients.
Examples include PHRs and web services, including some that are linked to EMRs and registry applications, that facilitate and direct patient education, information gathering, and make use of personal health data for actionable efforts to improve health and treat diseases and condition.
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Do you believe that home monitoring of vital signs with transmission to a database monitored by a healthcare practitioner should be included in the medical home? There are many existing systems for this: the Health Hero Health Buddy, HomMed’s telehealth systems, the Intel Healthguide, the RTX Telehealth Monitor, and others.
Yes, I believe this can be an important aspect and feature of a medical home. I would not require it of all medical homes, however. DCK
This is an important post. I have heard much about the patient centered medical home of late and I think it is fair to say that if it is implemented without the IT components mentioned above (including the remote monitoring component mentioned in the follow on), it is likely to be much less efficient and less likely to achieve the goals of increased performance at lower cost. Earlier this year, on the Connected Health discussion site, I posted on this topic and suggested the phrase connected medical home might be the most fitting for a holistic view of success. See http://www.connected-health.org/about-us/get-connected-discussion/discussion/connected-health-and-the-medical-home-savior-or-distraction.aspx
Joe,
As always, you provide words of wisdom. I was particularly struck by the following excerpt you wrote:
“Most writings on the medical home emphasize the care team and refer in passing to the idea of monitoring. Our work at the Center for Connected Health suggests that the emphasis should be in the other direction; for the right patients, instituting the use of monitoring and messaging technologies with proper integration to providers will result in improved population management, take some of the burden off of primary care physicians and keep costs in check. So perhaps the right concept is the connected medical home.”
My take here is that beyond a few conceptual white papers, there’s been little thought given or even early experimentation with to how to implement information and communication technologies in the medical home.
This isn’t a criticism, but rather an observation about the early stage of medical home development.
Dear Vince and Joe and Amy: I will add home monitoring as one of the examples under the “communications” capability, as well as under the capability for patients and consumers to be informed and increasingly literate about their medical conditions. The medical home ought to be “connected” and should create the environment for participatory medicine to thrive. Thanks for your comments. DCK
This is a key discussion. I heartily agree that home monitoring needs to be a key component of a “connected” PCMH to better achieve an activated, engaged patent. Home monitoring information should be available to all the appropriate members of a coordinated care team and minimize any burden for providers in getting this data through an integrated communication platform. I believe this capability is important for all five of capability categories points David has outlined above.
To change tracks a bit, thought should be given to the role of home care providers in the PCMH. As our aging population needs more home care (Hospital at Home thinking) there is an important role for home care providers as part of the coordinated PCMH care team. Home care providers can have a role in properly training patients in the use of home monitoring devices and support the connected PCMH by helping to facilitate the flow of that information to other providers.
Vince and David: This is an important topic. I agree with David that “these home base tools” should not be a requirement. Web-base PHR and EMR are available now aday, if not free for the basic functionalities. Having home base tools is certainly nice, but providers will calculate the overhead cost in their financial cash flow. Again, these should not hinder the great concept of medical home. LCN
I really hope we get this over in the UK sometime soon.
My mother is 73, diabetic with arthritis and glaucoma… it is really difficult for her to get to all the medical appointments she needs, most of which are testing that could be done remotely.
Cola K.
If I were a provider getting started using the PCMH, I would avoid the capital cost and complexity of monitoring hardware in patients’ homes. I would consider first either a robo-call system or even human dialed call system for key data collection. In most cases there really only a few things you need to know on a daily basis — and only a few pieces of info your disease managment staff can manage. For example, daily weights for CHF, weekly PHQ9s for depression, maybe daily physical activity for coaching.
It is probably as important to be offering reminders and encouragement to patients as it is to collect lots of data that no one can ever possibly use.
Would you really want daily blood sugar or just quarterly A1C? Daily BP? For an interesting alternative view see – http://www.iom.edu/Object.File/Master/59/180/Tang.pdf
Coordination and communication, from the patient’s perspective, is still in my opinion the most important point of all that must be addressed, no matter what the setting or technology.
This week, my son, had an evaluation for back surgery. Great facility, great reputation, highly recommended surgeon’s group, etc. However, he has been asked to provide the same personal information at least 3 times already, and we’ve been in the surgeon’s office only one time this week. On the day prior to surgery, he was asked AGAIN to bring his Driver’s license and insurance card to the center!! They photocopied it only two days prior..
Amusing, yet tiring to say the least.
Think of the $ spent to ask for this same information repeatedly and do something with it… (who knows what)
Health IT… Hmmm.. Even if it’s in the system,whether an EMR or not, it has to be used!. This info was entered into their system, but for some reason, maybe out of habit, they continue to ask for it again and again!
Comfort level? Maybe for them, but it has worn us OUT!
I am hearing and seeing much about what a EMR should be able to do/provide and agree. What I am not seeing is how the lack of technology and basic computer & keyboard skills will be addressed as related to individual patients. Many pts today lack computers and cannot afford online access. Where are the plans to address the basic issues of connectivity in the home necessary if we are to successfully include the pts in the EMR, self-managment process?