Scaling the PCMH Delivery Model with Automation


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The patient-centered medical home continues to make progress. Much remains to be learned about the most effective techniques for building and maintaining a PCMH. But three conclusions can already be drawn from the pilots that have already been done:

1) Successful medical homes will have to perform population health management;
2) They will need a variety of health IT tools to do that and to coordinate care effectively; and
3) They will have to gain the cooperation of the other providers in their medical neighborhoods.

Major changes in practice workflow and work roles must accompany the proper use of information technology. In the end, practices must be completely reengineered to provide effective, patient-centered medical homes—and the environment in which they operate must also change to permit seamless care coordination. But all of this change can be less painful and lead to more productive results if practices use the right combination of technologies to scale population health management.

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Scaling the PCMH Delivery Model with Automation

  1. 1. phytel | whitepaperThe Patient-Centered Medical Home:Scaling the PCMH Delivery Modelwith Automation
  2. 2. ContentsThe Patient-Centered Medical Home................................................................................3The PCMH Background Challenges and Solutions.................................................................................................. 7Role of Information TechnologyAutomation ToolsConclusion........................................................................................................................13
  3. 3. The Patient-Centered Medical Home:Because of the current national focus on accountable careorganizations (ACOs), attention has shifted away from the patient-centered medical home (PCMH), an approach designed to rebuildprimary care and improve care coordination. Nevertheless, the PCMHmodel is continuing to grow and to attract support from providers,payers, and consumer groups.According to a recent survey by the Medical Group Management Association (MGMA), 70% ofprimary care physicians and non-physician providers are transforming their practices into patient-centered medical homes or are interested in doing so. Twenty percent of the respondents saidthey’d already been accredited or recognized as a PCMH.1The National Committee for Quality Assurance (NCQA), which has recognized 4,400 physicianpractices as PCMHs, lists three dozen health plans that use NCQA recognition in their PCMHincentive programs.2 The Joint Commission, URAC, and some Blue Cross Blue Shield plans havegiven their PCMH stamps of approval to many other practices.Meanwhile, commercial payers have 63 PCMH pilots going across the country,3 and the Centersfor Medicare and Medicaid Services (CMS) is participating in multi-payer PCMH projects in eightstates.4 Altogether, more than 30 states are involved in PCMH demonstrations.5 And the VeteransHealth Administration has embarked on an ambitious three-year program to build PCMHs in morethan 900 primary care clinics.61. Madeline Hyden, “70 Percent of Study Participants Moving Toward PCMH Model, MGMA Research Reveals,” MGMA blog post, July 20, 2011.2. NCQA, “Health Plans Using Recognition,” accessed at Patient-Centered Primary Care Collaborative, “PCMH Pilots and Demonstrations,” accessed at Centers for Medicare and Medicaid, “Multi-payer Primary Care Practice Demonstration Fact Sheet,” accessed at Paul Grundy, Kay R. Hagan, Jennie Chin Hansen and Kevin Grumbach, The Multi-Stakeholder Movement For Primary Care Renewal And Reform. Health Affairs, 29, no. 5 (2010): 791-798.6. Sarah Klein, “The Veterans Health Administration: Implementing Patient-Centered Medical Homes in the Nation’s Largest Integrated Delivery System,” The Commonwealth Fund, September 2011.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 3
  4. 4. A study of seven PCMH demonstration projects reported that the strategyresulted in reductions in ER visits ranging from 15% to 50% and decreasesin hospital admissions ranging from 10% to 40%.Initial Results Are Promising savings from its PCMH model at $3.7 medical neighborhood. million for a return on investment of moreEarly evidence shows that the PCMH can Conversely, some observers view the PCMH than two to one. And the Johns Hopkinsimprove access to high-quality care and as an essential building block of ACOs. PCMH program realized annual net Medicarethe management of chronic conditions. That is because ACOs must be primary- savings of $1,364 per patient.9For example, one study of care provided care driven and patient-centered—theunder PCMH principles found patients key characteristics of PCMHs—in order towith diabetes had significant reductions in Two Key Challenges succeed in a risk-bearing environment.12-13cardiovascular risk; patients with congestive For medical homes to be successful in Another key to the success of both PCMHsheart failure had 35% fewer hospital days; improving the quality and reducing the and ACOs is the automation of populationand asthma and diabetes patients were more cost of care, they need the cooperation health management. The goal of populationlikely to receive appropriate therapy.7 of outside specialists and hospitals. Yet health management is to keep patients as the other providers in a PCMH’s “medicalA study of seven PCMH demonstration healthy as possible, thereby reducing the neighborhood” may not be inclined toprojects reported that the strategy resulted in need for expensive ER visits, hospitalizations, cooperate because their incentives are notreductions in ER visits ranging from 15% to and procedures.14 As will be explained later, necessarily aligned with PCMH goals.10 While50% and decreases in hospital admissions it is impossible for providers to manage the PCMH is designed to manage populationranging from 10% to 40%.8 Another paper population health effectively without the health and avoid unnecessary care, thebased on the experience of Group Health use of automation tools such as patient revenue of specialists and hospitals dependsCooperative, a large integrated delivery registries and analytic and care management on the volume of services they provide.system, showed that the PCMH model applications.increased patient satisfaction and staff Because of this barrier, some experts say,morale and improved quality without raising PCMHs cannot achieve their full potentialcosts.9 unless they are incorporated into ACOs.11 The latter organizations not only have theIn fact, the PCMH model has been shown same incentives that medical homes do,to reduce overall costs. Community Care but they also comprised of both primaryof North Carolina, for example, leveraged care physicians and specialists. So, whethera medical home approach to save $435 multispecialty groups, independent practicemillion for the state’s Medicaid and SCHIP associations, or health care systemsprograms. Geisinger Health System (which sponsor ACOs, they should, in theory, fosterincludes a health plan) estimated its net cooperation between the PCMH and its7. PCPCC, “Evidence of the Effectiveness of PCMH on Quality of Care and Cost.”8. Kevin Grumbach, Thomas Bodenheimer, and Paul Grundy, “The Outcomes of Implementing Patient-Centered Medical Home Demonstrations: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies,” August 2009, paper prepared for PCPCC.9. Ibid.10. Paul A. Nutting, Benjamin J. Crabtree, William L. Miller, Kurt C. Stange, Elizabeth Stewart and Carlos Jaen, “Transforming Physician Practices to Patient-Centered Medical Homes: Lessons From the National Demonstration Project,” Health Affairs, March 2011, 30:3;439-445.11. Grundy, Hagan et al., op. cit.12. Fields et al. 2010.13. Paul Grundy, Kay R. Hagan, Jennie Chin Hansen and Kevin Grumbach, The Multi-Stakeholder Movement for Primary Care Renewal and Reform. Health Affairs, 29, no. 5 (2010): 791-798.14. Suzanna Felt-Lisk and Tricia Higgins, “Exploring the Promise of Population Health Management Programs to Improve Health,” Mathematica Policy Research Issue Brief, August 2011, accessed at | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 4
  5. 5. PCMH Background:There are many definitions of the PCMH. One of the best comes fromDavid Nash, MD, dean of the Jefferson School of Population Health atJefferson University in Philadelphia:“The patient-centered medical home (PCMH) is essentiallydelivery of holistic primary care based on ongoing, stablerelationships between patients and their personal physicians. Itis characterized by physician-directed integrated care teams,coordinated care, improved quality through the use of diseaseregistries and health information technology, and enhancedaccess to care.”15A March 2007 joint statement by medical societies representing pediatricians, family physicians, and internistscalls the PCMH “an approach to providing comprehensive primary care for children, youth, and adults.”16 Thechief components of the PCMH include:•  A personal physician who is the first contact for his or her patients and who provides continuous and comprehensive care•  A physician-led care team that takes collective responsibility for care•  A “whole person” orientation, meaning that the personal physician will provide for all of a patient’s health needs and arrange referrals to other health professionals as needed•  Care coordination across all care settings, facilitated by information technology and health information exchange•  An emphasis on delivering high-quality, safe care in partnership with patients and their families•  Enhanced access to care through open scheduling, expanded hours, and improved communication among physicians, staff, and patients via secure e-mail and other modes•  Additional reimbursement to reflect the value of the PCMH’s activities and the costs of setting up the necessary infrastructure.NCQA has further defined the PCMH by establishing a set of criteria that practices must meet to becomeNCQA-certified medical homes. These criteria have become increasingly important because most PCMHdemonstration projects use them as a measurement tool,17 and some health plans require NCQA certificationfor incentive payments to practices.1815. David Nash, “Healthcare Reform’s Rx for Primary Care,” MedPage Today, Aug. 18, 2010, accessed at American Academy of Family Practice, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, “Joint Principles of the Patient-Centered Medical Home,” March 2007.17. Bruce E. Landon, James M. Gill, Richard C. Antonelli, and Eugene C. Rich, “Prospects for Rebuilding Primary Care Using the Patient-Centered Medical Home.” Health Affairs 29, No. 5 (2010): 827–834.18. Blue Cross Blue Shield Association, slide presentation, “The Patient-Centered Medical Home: BC/BS Pilot Initiatives,” slides 22 and 24.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 5
  6. 6. Medical Home Certification care management with information, helps qualify a practice as a PCMH—theThe medical home certification process tools, and resources group must collect and submit patientgrew out of another NCQA program that experience data using a specially designedrecognizes physicians for effectively using •  Track and coordinate care: Track PCMH version of CMS’ Consumerinformation technology and managing and coordinate tests, referrals, and Assessment of Healthcare Providers andpopulation health, and the PCMH 19 transitions of care Systems (CAHPS) survey.22certification criteria also focus on health IT. •  Measure and improve In June 2012, NCQA announced plansThe NCQA standards measure access and performance: Use performance to launch a specialty practice recognitioncommunication, patient tracking and registry program that will encourage specialistsfunctions, care management, patient self- and patient experience data for to work more closely with primary caremanagement support, electronic prescribing, continuous quality improvement.21 practices to coordinate care—in other words,test tracking, referral tracking, performance As many of these criteria require the use to make the medical neighborhood morereporting and improvement, and advanced of health information technology, it is friendly to medical homes. Again, health ITelectronic communications.20 noteworthy that NCQA made a conscious plays a prominent role in the criteria, manySpecifically, the NCQA’s 2011 criteria attempt to align them with the government’s of which are aligned with the proposedfor recognition as a PCMH consist of 27 requirements for Meaningful Use in its Meaningful Use stage 2 requirements.23elements in six domains, as follows: electronic health record incentive program.•  Enhance access and continuity: NCQA also placed a much greater emphasisAccommodate patients’ needs with on improving the patient experience thanaccess and advice during and after it did in its 2008 PCMH requirements. The 2011 recognition criteria incorporatehours, and provide patients with the Institute of Healthcare Improvementteam-based care (IHI)’s Triple Aim, which includes patient-•  Identify and manage patient centeredness, quality improvement, andpopulations: Collect and use data decreased cost of care.for population health management NCQA has also developed an optional Distinction in Patient Experience Reporting•  Provide self-care support and to help practices capture patient and familycommunity resources: Assist feedback. To earn this distinction—whichpatients and their families in self-19. NCQA, “Physician Practice Connections,” accessed at NCQA, “Physician Practice Connections—Patient-Centered Medical Home,” accessed at NCQA, “NCQA Patient-Centered Medical Home 2011,” brochure, accessed at Ibid.23. Ken Terry, “Medical Specialists Encouraged to Use More IT,” InformationWeek Healthcare, June 13, 2012, accessed at | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 6
  7. 7. Challenges and Solutions:A PCMH must build a number of scalable core competencies.To scale population health management, the care team in the practice must ensure that patients receive thepreventive and chronic care recommended in evidence-based guidelines; that patients’ conditions are trackedin a systematic way; that the practice reaches out to noncompliant patients and those who don’t regularly seetheir doctor; that the practice provides patient education and self-management coaching; and that steps aretaken to address poor health behaviors.Because relatively few physician practices operate in this mode, the systematic application of populationhealth management has been largely left to employers, health plans, and disease management companies.The PCMH represents, in part, an effort to make physicians and patients central to this process. The Agencyfor Healthcare Research and Quality (AHRQ) has even coined a term for this new approach: practice-basedpopulation health (PBPH).24A 2008 study of the preparedness of large group practices to become medical homes showed that mostlacked key elements of the required infrastructure and practice approach.25 Yet these groups have far moreresources to make the necessary changes than small practices do. A recent study showed that small andmedium-size groups (under 10 doctors) have only about one-fifth of the capabilities required in a PCMH.26This is not to say that small practices cannot become medical homes. Some have achieved amazing featsof self-transformation. But, even if they already have EHRs, small practices may not be able to afford otherPCMH components, such as dedicated care coordinators and care managers. To expand their hours andprovide after-hours access to patients, they must incur additional labor costs. And, as previously noted, theymay find it difficult to persuade specialists and hospitals to cooperate with them on care coordination.In the AAFP’s TransforMED pilot, which ran from 2006 to 2008, the three dozen participating practices—someof them quite small—managed to achieve a number of PCMH goals. However, a report on their effort pointedout that the pace of change is exhausting for practices and that they must have an “adaptive reserve” to keepgoing down the path of self-transformation. In addition, the report underlined the difficulty that doctors mayhave in assuming new roles vis-à-vis their staff.27Experts have made several suggestions about how smaller practices might be able to turn themselves intomedical homes.28 One possibility is to use the kind of “practice transformation” consultants that were availableto half of the practices in the TransforMED pilot. The government could also create regional extension centers,akin to agricultural extension centers, to help doctors over the hump. And both North Carolina and Vermonthave successfully used community resource centers to supply shared care coordination services that smallpractices could not afford on their own.2924. U.S. Agency for Healthcare Research and Quality, “Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care,” July 2010.25. Diane R. Rittenhouse, Lawrence P. Casalino, Robin R. Gillies, Stephen M. Shortell, and Bernard Lau, “Measuring The Medical Home: Infrastructure in Large Groups,” Health Affairs 27, No. 5 (2008): 1246-1258.26. Diane R. Rittenhouse, Lawrence P. Casalino, Stephen M. Shortell, Sean R. McClellan, Robin R. Gillies, Jeffrey A. Alexander and Melinda L. Drum, “Small and Medium-Sized Physician Practices Use Few Patient-Centered Medical Home Processes,” Health Affairs 30, No. 8 (2012): 1575-1584.27. Paul A. Nutting, MD, MSPH, William L. Miller, MD, MA, Benjamin F. Crabtree, PhD, Carlos Roberto Jaen, MD, PhD, Elizabeth E. Stewart, PhD and Kurt C. Stange, MD, PhD, “Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home.” Annals of Family Medicine 7: 254-260 (2009).28. Landon, Gill et al., op. cit.29. Ibid.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 7
  8. 8. Building the Medical How Much Will It Cost? a PCMH. The costs of tracking patients andNeighborhood improving quality—both health IT-intensive Most PCMH demonstrations sponsored byWhile these approaches might help practices tasks—were particularly high. In total, the health plans use a mixed or hybrid paymentbuild medical homes, their success as PCMHs community health centers that functioned as model to reimburse physicians for the extrawill still be determined by how well they medical homes added $2.26 per patient per work and expense of providing a medicalcollaborate with other providers. The potential month in operating costs, or about $500,000 home. They pay physicians fee-for-servicerole of ACOs in this area has already been per month for the average clinic.35 for the clinical work they do, plus a fixedmentioned. But it may not be necessary to wait care coordination payment for each patient But the authors observed that anotheruntil ACOs are widespread to begin improving and some kind of quality incentive. While study of an integrated delivery system’s usethe ecosystem in which the PCMH operates. other approaches have been suggested, little of a PCMH showed that it saved $18 perUnder a $20.75 million grant from the Center data exists on how well they might work in patient per month in averted hospitalizationsfor Medicare and Medicaid Innovation, encouraging PCMH activities. 31 and ER visits. Most of those savingsVHA Inc., the national health care network, accrued to payers, indicating the need There’s also no agreement on how high theTransforMED, and Phytel, a technology for reimbursement sufficient to cover the care coordination fee should be in the hybridcompany that specializes in automated, infrastructure costs of PCMHs. model. For example, the North Carolinaprovider-led population health improvement Medicaid program paid primary care doctors As noted earlier, some PCMHs that are partsolutions, are working together on a project a coordination fee of $2.50 per patient per of integrated delivery systems have loweredto expand the PCMH concept to the patient- month. In contrast, in a multi-payer pilot in 32 costs and achieved a return on investment.centered medical neighborhood. The goal is Pennsylvania, the state required payments But it’s unclear whether that model wouldto connect acute-care hospitals with primary of $4 per patient per month to practices work for smaller, unaffiliated practices. Whatcare, specialty, and subspecialty practices to that had attained level 3 NCQA certification is clear is that the cost of creating anddeliver higher-quality, more patient-centered as medical homes. Some estimates of 33 maintaining a medical home could be muchcare at an affordable cost.30 appropriate care coordination fees are much lower if the practices were highly automated.VHA, TransforMED, and Phytel anticipate that higher.34 This approach requires the intelligent usetheir combined work across 16 communities One reason for the uncertainty about these of health information technology. By linkingwill save Medicare up to $53 million over a fees is that not much is known about the together some currently available health ITthree-year period. TransforMED, the leading costs of establishing a PCMH. A recent tools, physician groups can automate muchPCMH expert, will apply Phytel’s population study of federally funded community health of the work that might otherwise be toohealth management solutions, and VHA centers found that a fully functioning PCMH costly and difficult for them to do. Moreover,will contribute its knowledge of quality was associated with an operating cost per automating the manual processes of caremanagement and ambulatory care strategies patient per month that was 4.6% higher than coordination and care management makesfor hospitals. the cost of operating a similar center without it possible to scale the medical home to practices of every size.30. Phytel press release, “VHA, TransforMed and Phytel Awarded $20.75 Million Health Care Innovation Grant,” June 20, 2012.31. Katie Merrell and Robert A. Berenson, “Structured Payment for Medical Homes,” Health Affairs 29, No. 5 (2010): 852-858.32. Grundy, Hagan et al., op. cit.33. BCBSA, “The Patient-Centered Medical Home,” op. cit., slide 25.34. Robert A. Berenson, “Payment Approaches and Cost of the Patient-Centered Medical Home,” presentation at PCPCC meeting, July 16, 2008, slide 25.35. Robert S. Nocon, Ravi Sharma, Jonathan M. Birnberg, Quyen Ngo-Metzger, Sang Mee Lee, and Marshall H. Chin, “Association Between Patient-Centered Medical Home Rating andOperating Cost at Federally Funded Health Centers.” JAMA. 2012;308(1):60-66.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 8
  9. 9. Role of Information Technology:Observers agree that information technology, including the EHR, isessential to the PCMH’s success. But EHRs lack some of the featuresrequired to do practice-based population health.AHRQ cites the inability of most EHRs to generate population-based reports easily; to present alerts andreminders in such a way that providers will use them rather than turning them off; to capture sufficientlydetailed data on preventive care; and to interoperate with other clinical information systems.36Some EHR vendors are moving to correct these deficiencies. For example, some applications allow usersto adjust the level of alerts to their own needs and tolerance levels. And, while another report points to thedifficulty of using the registries embedded in some EHRs,37 those are also being improved to help physiciansmeet the meaningful use criteria.Nevertheless, practices need a variety of health IT tools beyond EHRs to meet AHRQ’s requirements forPBPH.38 These include the ability to:•  Identify subpopulations of patients•  Examine detailed characteristics of identified subpopulations•  Create reminders for patients and providers•  Track performance measures•  Make data available in multiple forms.36. AHRQ, “Practice-Based Population Health.”37. Nutting, Miller et al., op. cit.38. AHRQ, “Practice-Based Population Health.”PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 9
  10. 10. Automation Tools be filtered by payer, activity center, provider, health condition, and care gaps. The sameA growing number of practices use external, filters could be applied to patients with aweb-based registries to supplement their particular condition, such as diabetes, to findEHRs. These registries compile lists of out where the practice needed to improvesubpopulations that need particular kinds its diabetes care and to prepare actionableof preventive and chronic care, such as reports for care teams on individual patients.annual mammograms for women over40 or HbA1c tests at particular intervals Other IT tools that will also be importantfor diabetic patients. The continuously include online health risk assessments,updated data in the registries comes from automated education materials and healthEHRs, practice management systems, labs, coaching, automation of actionable data forand pharmacies. Evidence-based clinical care teams, automation of care managementprotocols, which can be customized by reports, and biometric home monitoring ofphysician practices, trigger alerts in the patients with serious conditions.registries. When a registry is linked to anoutbound messaging system, patients are As an example, the following table showsnotified by automated telephone, e-mail, or how information technology can be used totext messages to contact their physician for automate population health appointment. Some registries can alsosend actionable data to care teams prior topatient visits.39To be an effective tool for population healthmanagement, a registry should include all ofa practice’s patients, and be patient-centric, To be an effectivenot condition-centric. It should also have asophisticated rules engine that combines tool for populationdisparate types of data with evidence-based health management, aguidelines, generating reports that providemany different views of the information. For registry should includeexample, the entire patient population could all of a practice’s patients, and be patient-centric, not condition-centric.39. Ken Terry, “Do Disease Registries=$$rewards?” Medical Economics, Nov. 4, 2005, accessed at | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 10
  11. 11. Identification of Automation Opportunities in the Manual Care Management Process Care Team Process Step for “At-Risk” Patients Manual Tasks Automation Opportunities 1. Identify “at-risk” patients • Review charts of patients scheduled for • Utilize algorithms and data mining to identify upcoming office visits all patients within provider panel with care gaps, irrespective of visit date or payer • Review charts of patients associated with a specific payer contract with “pay-for- • Stratify and prioritize patients based on risk performance” incentives evaluation algorithms 2. Document gaps in care • Review multiple screens and fields within EMR • Create reports across multiple sources of data and Patient Management System to identify care for entire provider panel population to identify gaps and appointment dates care gaps based on evidence-based algorithms • Review paper charts for additional information • Flag patients with upcoming visits 3. Communicate gaps in care to • Discuss gaps in care with provider as part of • Automate provider-level reports on patients treating providers visit preparation process with care gaps • Prepare cover sheet for paper chart • Automate creation of patient care summaries for use in visit and between-visit management 4. Communicate treatment needs to • Make phone calls to patients, often by nurses •Utilize automated technologies to generate patients as well as other staff, which only reach a limited outreach by phone, email and/or text according number of patients to patient preference for all patients in provider panel with preventive and/or chronic care gaps • Mail reminder letters for preventive care 5. Assessment of “at risk” patients • Conduct assessments during office visits or • Send all patients online health risk assessment over the phone using paper or other tools that tool; results can be used for individual and may or may not integrate with EMR population management activities • Offer online health risk assessment part of patient portal 6. Educate patients about treatment • Generate printout of patient treatment plan at • Offer patient treatment plans and education plan and care needs end of visit; may be handed to patient or mailed tools through secure patient portal for ongoing patient support • Make phone calls to patients for treatment plan follow up • Push reminders and other communications to individual and subpopulations of patients through patient portal as well as phone, e-mail, and textPHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 11
  12. 12. Medical homes can use automation tools to support the efficient functioningof care teamsHealth risk assessment (HRA) is fundamental the need for chart reviews. The summaries, include the ability to track, monitor, andbecause it serves as the basis for the generated by registries, will remind providers engage patients; to tailor interventions tointerventions to be applied to patient of a patient’s care gaps and the need to different segments of the population; topopulations. HRA stratification enables work with him or her on modifying health measure performance for quality reporting;practices to sort their patients into three behavior. Care teams can also streamline the to automate care coordination; to ensurecategories: healthy people, people in early visit preparation process by identifying care that care gaps are filled; and to do all of thisstages of chronic diseases, and people with opportunities and having patients get tests without increasing the workload of doctors oradvanced chronic diseases. These groups done before visits. staff members.are always changing. Those who are well To support the work flow of care managers,today may be sick tomorrow, and those who medical homes can deploy softwarehave an early stage of disease today may that automatically sets priorities for theirbe in a more advanced stage tomorrow. So communications with patients, based on theregular administration of HRAs can help keep severity of their condition. Using data frommedical homes apprised of which patients EHRs and registries, this type of applicationare likely to need additional care in the future. can tell a care manager whether he or sheTo reinforce the lifestyle modification needs to call a patient directly or whethermessages delivered in the office visit, medical electronic messaging will should use tailored communications Biometric home monitoring, which has beenand interventions to achieve and sustain around for more than a decade, is finallybehavior change. These include online starting to get some financial support fromeducational materials that may be linked to health plans.40 As a result, it may be feasibleHRAs, along with automated reminders to for medical homes to start using it to keeppatients. Practices can also take advantage tabs on their sickest patients with suchof the new mobile technologies, such as chronic conditions as heart failure, diabetes,smart phones and texting, as well as patient and high-risk pregnancy. Because doctorsWeb portals that may be attached to EHRs. don’t have time to monitor the continuousMedical homes can also use automation stream of data, this would be a natural tasktools to support the efficient functioning of for care teams. These include accurate and The benefits of using these health IT toolsusable patient data summaries to minimize40. Ibid.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 12
  13. 13. ConclusionThe PCMH continues to make progress. Much remains to be learned about the mosteffective techniques for building and maintaining a PCMH. But three conclusions canalready be drawn from the pilots that have already been done:Successful medical homes will have to perform population health management; they willneed a variety of health IT tools to do that and to coordinate care effectively; and theywill have to gain the cooperation of the other providers in their medical neighborhoods.Major changes in practice work flow and work roles must accompany the properuse of information technology. In the end, practices must be reengineered to provideeffective, PCMHs—and the environment in which they operate must also change topermit seamless care coordination. But all of this change can be less painful and lead tomore productive results if practices use the right combination of technologies to scalepopulation health management.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2012 Phytel All rights reserved. 13