Ix and the PCMH (Patient-Centered Medical Home)


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This report was published prior to the dissolution of the Center for Information Therapy in November of 2009.

I am sharing this document as a writing sample and a resource on the patient-centered medical home (PCMH).

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Ix and the PCMH (Patient-Centered Medical Home)

  1. 1. November, 2009  www.ixcenter.org        Ix is a registered trademark of the Center for Information  Therapy, Inc.  Information Therapy and the  Patient‐Centered Medical Home  (PCMH) This piece on the patient-centered medical home is the second report on Ix implementation produced by the IxCenter’s Methodical Library of Ix Research. Group Health Cooperative’s Pioneer Sponsorship provided seed funding for the IxCenter to begin the work of creating reports for the research library. Through this project, we are building a database of relevant research that integrates the peer-reviewed literature with everything we can learn from more organic innovations not being tested through prospective studies. By rigorously merging these two types of research, we can guide Ix implementers regarding where to invest resources for future Ix initiatives. Cindy Throop, MSW  Josh Seidman, PhD  Center for Information Therapy 
  2. 2. Introduction This paper outlines and summarizes what is currently known about the synergy between information therapy (Ix®) and the patient-centered medical home (PCMH). While the idea of the PCMH grew out of the medical home model, discussion of how to increase ‘patient-centeredness’ in practice continues. Information therapy, or Ix, provides a patient-centered filter through which one can evaluate the potential of the PCMH to meet the continuous and dynamic information needs of patients and their caretakers. Information therapy is the timely prescription and availability of evidence-based health information to meet individuals' specific needs and support sound decision making. Ix prescriptions are specifically targeted to an individual's needs at a particular moment in care and are delivered as part of the process of care. The paper begins with a brief overview of the PCMH, elaborates the definition of Ix, and outlines the areas in which they meaningfully intersect. The growing evidence base associated with the PCMH is summarized. The future of the patient-centered medical home is discussed. For example, how will health 2.0 influence the future direction, or directions, of the PCMH? How does Ix inform the implementation and evolution of the PCMH? The Patient-Centered Medical Home The patient-centered medical home is an approach to medical practice that emphasizes the importance of comprehensive, coordinated, “whole person” primary care. Seven joint principles of the PCMH were endorsed by the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) in 20071: • Personal physician • Quality and safety • Physician directed medical practice • Enhanced access to care • Whole person orientation • Payment to support the PCMH • Care is coordinated and/or integrated Also in 2007, the National Partnership for Women and Families (NPWF) released recommendations for consumer principles to guide the development and implementation of the medical home model of care2. Several of the consumer principles emphasize the important role that patients and their caregivers play in ongoing health care management: • Patients and clinicians are partners in making treatment decisions. • Open communication between patients and the care team is encouraged and supported. • Patients and their caregivers are supported in managing the patient’s health. The evolving PCMH emphasizes the partnership between the patient and their clinicians, as well as the role of the patient’s family where appropriate. Central to this relationship is the communication – or sharing – of health information. For the purposes of this report, the graphic below provides a view of the 7 AAFP principles, with the addition of the NPWF consumer principles. 2   
  3. 3. The Rela ationship The Patient Th he Care Proce ess The System o of Care • personal physician • whhole person  • qu uality and saf fety • payment to s support  • physician directed  or rientation • enhanced acces ss to  the PCM MH medicall practice • coordinated/  care • availability o of data  integrated care rtner • patients  as par necessary to provide  n •ccommunicatio on  continuous s care support Informa ation The erapy (Ix x) To think abo the role of Ix in facil out litating a suc ccessful PCM model, it is helpful to break dow the MH t o wn different ele ements gettin the right information to the right person at th right time ng n t he e. Ix: the R Right Information The right in nformation is about the c s content of th message. Is the inform he mation accur rate, comprehens sive, and cre edible? Is it understanda able and acti ionable? Ix: the R Right Pers son Information should be tailored to th needs of t individua patient. M n t he the al Minimally, taailored infor rmation takes into ac ccount patie sex, age, and current health issue or concern Further, information ent es ns. , n should be taailored to the learning st e tyle and learning prefere ences of the p patient, as w as literac level, well cy health belief and value Optimal Ix is deliver according to the stag of behavio change of the fs, es. red ge or individual fo their curr or rent health is ssue(s). Ix: the R Right Time e Last, but no least, Ix is provided to the patient at the right time, meani it is targe ot ing eted to the appropriate moment in care for the patient at any given poi in time: e int chronic  primary  screeening/  acut te care/  care/  end d‐of‐life  prevention pre‐ p diagnosis deccision  secondary y  care c diag gnosis maaking preventionn Ix is relevan to the ongoing health status and p nt promotes pre evention inst tead of solel focusing o ly on disease, or c chronic care, manageme ent. Continu of patien care is enh uity nt hanced by ad ddressing all l possible mo oments in car and provi re iding inform mation tailore to that moment in car This incl ed re. ludes the informa ation that pat tients receiv between m ve medical visits This is wh s. here Ix plays an importa role s ant in supportin the PCMH ng H. 1   
  4. 4. pre‐visit self‐ during visit management prevention after visit The Role of Ix in the Patient-Centered Medical Home Information therapy (Ix), like the PCMH, focuses on the patient as the center of care. Information therapy is tailored to each patient’s specific needs, learning styles, and preferences. Ix “follows” the patient over time, providing the right information at the right time (including between health care visits) to support informed decision-making in daily life. Information therapy promotes self-care, self-management, and self-triage to maintain health, well-being, and safety between clinic visits. The Physician-Patient Relationship In the PCMH, the physician is not “in charge” of care management, per se. Rather, the patient and physician are equal partners in care. The patient is a partner in treatment decisions and is expected to play a central role in managing their own health. Ultimately, patients spend the vast majority of their time outside of the traditional medical encounter. Patients need support, including information, to manage their health between clinical visits. Daily health habits, such as diet and exercise, influence health status. 2   
  5. 5. The Patient Care coordination, care integration, and enhanced access to care rely on a combination of consistent relationships with the same health care providers over time and the documentation and use of comprehensive and up-to-date information about the patient. Continuous care requires the availability of patient health data across medical settings to facilitate care coordination. The whole person orientation involves the “moment in care” that is relevant to the patient at any given time. This includes preventive services, acute and chronic care, and end of life care. It also includes “pre-visit” and “after-visit” care. The right time for a patient to receive information is related to their ongoing health status and circumstances. The consumer principles incorporate patient preferences at all stages of the care process, from selecting a team lead to preferred modes of communication. Emphasis on two-way communication and information sharing includes shared decision-making, support for patient self-management, and ongoing patient access to health data. This is consistent with the information therapy approach, which emphasizes patient preferences, patient engagement in decision-making and ongoing health management. The Care Process The PCMH recognizes health care as a continuous process. While the current U.S. medical system has evolved to reward quantity of care over quality of care, the PCMH represents a shift towards rediscovering patient outcomes as an appropriate measure of success. Continuous care requires uninterrupted patient access to caregivers and health information. Embedding information into the care process is critical to health care quality. Quality and safety rely on getting the right information to the right person at the right time. Information given to the patient should be accurate, credible, understandable, and actionable to the patient. Likewise, information elicited and collected from the patient should be accurate and comprehensive, since diagnosis and treatment recommendations vary according to personal characteristics, comorbidities, and risk factors. Access to information-for both the provider and patient-are a component of what is necessary open communication. The System of Care The system of care recognizes patient outcomes as a key indicator of quality care. While the current system is primarily based on fee-for-service, the PCMH requires a different payment structure. The system of care should reward positive short- and long-term patient outcomes. This includes the availability of health data and information across medical providers and recognizing the patient as an ongoing source of information and data validation. Tailoring Ix within the PCMH Ix is prescribed based on relevant patient information. With major federal investments about to be made in health information technology (HIT), specifically electronic health records (EHRs), it is important to define the most critical pieces of patient information that are needed to most effectively provide Ix. The following is a list of the most basic information that should be included in the EHR to facilitate the provision of Ix: 3   
  6. 6. • gender • stage of behavior change regarding • age specific behavior or issue • family composition • health beliefs and values • learning style and preferences • co-existing conditions • current and past conditions • current health risks • current and past medications • current dietary and exercise habits • current and past test results • patient health goals • current disease status Having the above data available allows health care professionals to deliver Ix prescriptions before, during, and after the medical visit. For example, the EHR can also be set up to provide automated reminders. For example, 7 days after ordering a test, a reminder can be sent to both the provider at the patient. The Evidence Base for the PCMH   Group Health Cooperative (Group Health), based in Washington State, implemented a PCMH redesign demonstration project within its health care system as a means of improving patient experience, lessening staff burnout, improving quality, and reducing costs. While previous patient- centered efforts at Group Health resulted in increased patient access and satisfaction, they also resulted in unsustainable increases to physician workload. The PCMH redesign included a substantial health care workforce investment to reduce the size of patient panels. This allowed for longer office visits and created time for staff to perform coordination and outreach activities, including pre-visit communication and chart review. Also, where appropriate and compatible with individual patient preference, e-mail and telephone encounters were utilized as an alternative or complement to in-person visits. Finally, the connection between salaries and number of patients seen was ‘broken’ to allow physicians to see fewer patients without a corresponding reduction in pay. Findings from the first year of the demonstration are positive. The quality of health care and patient experience increased while fewer PCMH staff reported high emotional exhaustion. Patients and physicians relied more on email and phone communication and utilized more specialist visits. However, emergency visits decreased. One year into the study, there was no significant increase in cost; the reduction in unnecessary in-person visits and emergency room visits offset the increased staff costs. Unpublished data for year two demonstrate cost savings in the redesign effort. The evidence base for the PCMH is growing in strength. The AHRQ Innovations Exchange, a central repository for innovative programs in health care, includes resources related to PCMH implementation and findings. Two of the ‘innovation profiles’ reviewed for this paper found positive outcomes with PCMH implementation in vulnerable populations. Outcomes included improved patient satisfaction, access to care, disease-related health outcomes, and adherence. Fewer emergency department visits and hospitalizations were reported3. The Center for Excellence in Primary Care is another resource for information on innovation, specifically within primary care. The center is a collaborative effort between the University of California, San Francisco, the Department of Family and Community Medicine, and the Permanente Medical Group. A recent overview of PCMH evaluation findings suggest increased health care quality and access with decreased emergency department visits and hospitalizations and decreased costs. 4   
  7. 7. It is impossible to determine the impact of individual elements of the PCMH in driving these outcomes; indeed, the entire goal of the broad-based PCMH approach is that it must include a wide array of patient-centered care management components. However, every PCMH initiative includes at least some Ix elements. In other words, the Ix interventions are necessary but not sufficient ingredients to achieving the benefits of the PCMH model. The Future of the PCMH The Connected Medical Home The Connected Medical Home, developed by Joe Kvedar, MD at the Center for Connected Health, is a ‘2.0’ version of the PCMH4. It is designed specifically for patients with chronic conditions; it is based on design principles involving patient monitoring, patient involvement, coaching, and optimized provider involvement. The Connected Medical Home provides: • ongoing, accurate physiologic information (via patient monitoring) • physiologic information to the patient (as well as their provider) • coaching based on physiologic information • optimized provider involvement (i.e., involving the provider only when necessary) Beyond utilizing the latest technology, the Connected Medical Home involves participatory medicine to engage patients in taking a more active role in managing and monitoring their own health, particularly when it comes to chronic conditions. Chronic conditions, to varying degrees, can be managed by patients using home health care equipment and require less in-person medical check-ins. Continual monitoring and correction prevent declines in health status which can result in complications and/or hospitalizations. The combination of the PCMH, health 2.0, and participatory medicine both require and enable the patient to play an even greater role in managing their daily health. They work with their physician to develop a tailored program of home care and monitoring. Continual data feedback via home health equipment provides the foundation for an ongoing communication loop where the patient learns to monitor their own health while the physician receives regular status updates. Additional communication occurs based on changes in health status. The Virtual Health Home The Virtual Health Home: the Dashboard for Health and Health Care outlines the Virtual Health Home5, which is also a ‘2.0’ expansion of the PCMH. It is more preventive in nature than the Connected Health Home. The Virtual Health Home acknowledges the role, not only of the doctor, but also of the health environment surrounding the patient on a daily basis. The health environment consists of things like diet, exercise, stress management, air quality, relationships, and support groups. The Virtual Health Home works from the patient perspective to align health care services with other factors affecting their health. The basic functions of the Virtual Health Home are: • patient view of clinical records • information prescriptions (Ix) • decision aids • guided self-management plan • guidance for late-life care 5   
  8. 8. The key component of the Virtual Health Home is the “dashboard,” where patients use technology to manage their health from their own, personalized perspective. The Virtual Health Home dashboard could include any combination of the following, depending on patient needs and preferences: • wellness and prevention plans • healthy living resources • social networks and 2.0 • monitoring and incentives • family history and genomics • predictive modeling and self-management scores • caregiver access • reminders • virtual care The Virtual Health Home is ideal for people who are relatively healthy, do not have complex care needs, and enjoy taking charge of their own health care, including preventing the development of chronic disease. To some extent, the Virtual Health Home operates independently of the health care system, but participation in proactive preventive care could be encouraged by their physician and/or health system. CONCLUSION Ultimately, patients will decide what their medical home looks like and where it resides. Current conceptions of the medical home, by definition of being ‘patient-centered,’ will evolve along differing trajectories. Regardless of a focus on prevention or chronic care management, Ix is a necessary component of the continuous care process. Health information, including the data it is based upon, will ultimately need to be portable to meet the care needs of the patient wherever they happen to be, whether it is at home or on vacation. In fact, this is a critical component of the patient and family engagement section of the “meaningful use” of electronic health records, which will influence provider adoption of HIT for the next several years. These data and information will support the ability of health care providers to provide appropriate care, as well as supports the patient in ongoing self-care and health management. As the shift of care shifts from quantity to quality, patient health and patient experience will increasingly become the goals of care delivery. The patient-centered medical home has the potential to become a unifying framework for guiding the evolution of the health care delivery system, both in terms of participatory medicine and health 2.0 technology. 6   
  9. 9. References 1. Patient-Centered Primary Care Collaborative: Joint Principles of the Patient Centered Medical Home. http://pcpcc.net/content/joint-principles-patient-centered-medical-home. 2. National Partnership for Women and Families. Patient-Centered Medical Home: Consumer Principles. http://www.nationalpartnership.org/site/DocServer/Advocate_Toolkit- Consumer_Principles_3-30-09.pdf?docID=4821. 3. Agency for Healthcare Research and Quality. AHRQ Health Care Innovations Exchange. http://www.innovations.ahrq.gov/. 4. Health Care Blog, The. The Connected Medical Home: Health 2.0 Says "Hello" to the Medical Home Model. http://www.thehealthcareblog.com/the_health_care_blog/2008/12/the-connected-m.html. 5. Kemper, Don and Leslie Kelly Hall. 2009. The Virtual Health Home: The Dashboard for Health and Health Care. Boise, Idaho. Healthwise.     Ix is a registered trademark of the Center for Information Therapy, Inc. See www.IxCenter.org. 7