scaling the pcmh delivery model with automation

The Patient-Centered Medical Home:

Scaling the PCMH Delivery Modelwith Automation

phytel | whitepaper

Contents

the patient-Centered Medical home ...............................................................................3

The PCMH Background

Challenges and Solutions .................................................................................................7

Role of Information Technology

Automation Tools

Conclusion .......................................................................................................................13

According to a recent survey by the Medical Group Management Association (MGMA), 70% of

primary 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 said

they’d already been accredited or recognized as a PCMH.1

The National Committee for Quality Assurance (NCQA), which has recognized 4,400 physician

practices as PCMHs, lists three dozen health plans that use NCQA recognition in their PCMH

incentive programs.2 The Joint Commission, URAC, and some Blue Cross Blue Shield plans have

given their PCMH stamps of approval to many other practices.

Meanwhile, commercial payers have 63 PCMH pilots going across the country,3 and the Centers

for Medicare and Medicaid Services (CMS) is participating in multi-payer PCMH projects in eight

states.4 Altogether, more than 30 states are involved in PCMH demonstrations.5 And the Veterans

Health Administration has embarked on an ambitious three-year program to build PCMHs in more

than 900 primary care clinics.6

the patient-Centered Medical home: Because of the current national focus on accountable care organizations (ACOs), attention has shifted away from the patient-centered medical home (PCMH), an approach designed to rebuild primary care and improve care coordination. Nevertheless, the PCMH model is continuing to grow and to attract support from providers, payers, and consumer groups.

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1. 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 http://www.ncqa.org/tabid/131/Default.aspx.

3. Patient-Centered Primary Care Collaborative, “PCMH Pilots and Demonstrations,” accessed at http://www.pcpcc.net/pcpcc-pilot-projects.

4. Centers for Medicare and Medicaid, “Multi-payer Primary Care Practice Demonstration Fact Sheet,” accessed at

http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf.

5. 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.


initial results are promising

Early evidence shows that the PCMH can

improve access to high-quality care and

the management of chronic conditions.

For example, one study of care provided

under PCMH principles found patients

with diabetes had significant reductions in

cardiovascular risk; patients with congestive

heart failure had 35% fewer hospital days;

and asthma and diabetes patients were more

likely to receive appropriate therapy.7

A study of seven PCMH demonstration

projects reported that the strategy resulted in

reductions in ER visits ranging from 15% to

50% and decreases in hospital admissions

ranging from 10% to 40%.8 Another paper

based on the experience of Group Health

Cooperative, a large integrated delivery

system, showed that the PCMH model

increased patient satisfaction and staff

morale and improved quality without raising

costs.9

In fact, the PCMH model has been shown

to reduce overall costs. Community Care

of North Carolina, for example, leveraged

a medical home approach to save $435

million for the state’s Medicaid and SCHIP

programs. Geisinger Health System (which

includes a health plan) estimated its net

savings from its PCMH model at $3.7

million for a return on investment of more

than two to one. And the Johns Hopkins

PCMH program realized annual net Medicare

savings of $1,364 per patient.9

two Key Challenges

For medical homes to be successful in

improving the quality and reducing the

cost of care, they need the cooperation

of outside specialists and hospitals. Yet

the other providers in a PCMH’s “medical

neighborhood” may not be inclined to

cooperate because their incentives are not

necessarily aligned with PCMH goals.10 While

the PCMH is designed to manage population

health and avoid unnecessary care, the

revenue of specialists and hospitals depends

on the volume of services they provide.

Because of this barrier, some experts say,

PCMHs cannot achieve their full potential

unless they are incorporated into ACOs.11

The latter organizations not only have the

same incentives that medical homes do,

but they also comprised of both primary

care physicians and specialists. So, whether

multispecialty groups, independent practice

associations, or health care systems

sponsor ACOs, they should, in theory, foster

cooperation between the PCMH and its

medical neighborhood.

Conversely, some observers view the PCMH

as an essential building block of ACOs.

That is because ACOs must be primary-

care driven and patient-centered—the

key characteristics of PCMHs—in order to

succeed in a risk-bearing environment.12-13

Another key to the success of both PCMHs

and ACOs is the automation of population

health management. The goal of population

health management is to keep patients as

healthy as possible, thereby reducing the

need for expensive ER visits, hospitalizations,

and procedures.14 As will be explained later,

it is impossible for providers to manage

population health effectively without the

use of automation tools such as patient

registries and analytic and care management

applications.

7. 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 http://www.mathematica-mpr.com/publications/pdfs/health/PHM_brief.pdf.

A study of seven PCMH demonstration projects reported that the strategy resulted in reductions in ER visits ranging from 15% to 50% and decreases in hospital admissions ranging from 10% to 40%.


“The paTienT-cenTered medical home (pcmh) is essenTially delivery of holisTic primary care based on ongoing, sTable relaTionships beTween paTienTs and Their personal physicians. iT is characTerized by physician-direcTed inTegraTed care Teams, coordinaTed care, improved qualiTy Through The use of disease regisTries and healTh informaTion Technology, and enhanced access To care.”15

A March 2007 joint statement by medical societies representing pediatricians, family physicians, and internists

calls the PCMH “an approach to providing comprehensive primary care for children, youth, and adults.”16 The

chief 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 become

NCQA-certified medical homes. These criteria have become increasingly important because most PCMH

demonstration projects use them as a measurement tool,17 and some health plans require NCQA certification

for incentive payments to practices.18

15. David Nash, “Healthcare Reform’s Rx for Primary Care,” MedPage Today, Aug. 18, 2010, accessed at http://www.medpagetoday.com/Columns/21750.

16. 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.

pCMh Background: There are many definitions of the PCMH. One of the best comes from David Nash, MD, dean of the Jefferson School of Population Health at Jefferson University in Philadelphia:


19. NCQA, “Physician Practice Connections,” accessed at http://www.ncqa.org/Default.aspx?tabid=141.

20. NCQA, “Physician Practice Connections—Patient-Centered Medical Home,” accessed at http://www.ncqa.org/tabid/631/Default.aspx.

21. NCQA, “NCQA Patient-Centered Medical Home 2011,” brochure, accessed at http://www.ncqa.org/LinkClick.aspx?fileticket=ycS4coFOGnw%3d&tabid=631.

22. Ibid.

23. Ken Terry, “Medical Specialists Encouraged to Use More IT,” InformationWeek Healthcare, June 13, 2012, accessed at

http://www.informationweek.com/healthcare/policy/medical-specialists-encouraged-to-use-mo/240001986.

Medical home Certification The medical home certification process

grew out of another NCQA program that

recognizes physicians for effectively using

information technology and managing

population health,19 and the PCMH

certification criteria also focus on health IT.

The NCQA standards measure access and

communication, patient tracking and registry

functions, care management, patient self-

management support, electronic prescribing,

test tracking, referral tracking, performance

reporting and improvement, and advanced

electronic communications.20

Specifically, the NCQA’s 2011 criteria

for recognition as a PCMH consist of 27

elements in six domains, as follows:

• Enhance access and continuity: Accommodate patients’ needs with access and advice during and after hours, and provide patients with team-based care

• Identify and manage patient populations: Collect and use data for population health management

• Provide self-care support and community resources: Assist patients and their families in self-

care management with information, tools, and resources

• Track and coordinate care: Track and coordinate tests, referrals, and transitions of care

• Measure and improve performance: Use performance and patient experience data for continuous quality improvement.21

As many of these criteria require the use

of health information technology, it is

noteworthy that NCQA made a conscious

attempt to align them with the government’s

requirements for Meaningful Use in its

electronic health record incentive program.

NCQA also placed a much greater emphasis

on improving the patient experience than

it did in its 2008 PCMH requirements.

The 2011 recognition criteria incorporate

the Institute of Healthcare Improvement

(IHI)’s Triple Aim, which includes patient-

centeredness, quality improvement, and

decreased cost of care.

NCQA has also developed an optional

Distinction in Patient Experience Reporting

to help practices capture patient and family

feedback. To earn this distinction—which

helps qualify a practice as a PCMH—the

group must collect and submit patient

experience data using a specially designed

PCMH version of CMS’ Consumer

Assessment of Healthcare Providers and

Systems (CAHPS) survey.22

In June 2012, NCQA announced plans

to launch a specialty practice recognition

program that will encourage specialists

to work more closely with primary care

practices to coordinate care—in other words,

to make the medical neighborhood more

friendly to medical homes. Again, health IT

plays a prominent role in the criteria, many

of which are aligned with the proposed

Meaningful Use stage 2 requirements.23

To scale population health management, the care team in the practice must ensure that patients receive the

preventive and chronic care recommended in evidence-based guidelines; that patients’ conditions are tracked

in a systematic way; that the practice reaches out to noncompliant patients and those who don’t regularly see

their doctor; that the practice provides patient education and self-management coaching; and that steps are

taken to address poor health behaviors.

Because relatively few physician practices operate in this mode, the systematic application of population

health 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 Agency

for Healthcare Research and Quality (AHRQ) has even coined a term for this new approach: practice-based

population health (PBPH).24

A 2008 study of the preparedness of large group practices to become medical homes showed that most

lacked key elements of the required infrastructure and practice approach.25 Yet these groups have far more

resources to make the necessary changes than small practices do. A recent study showed that small and

medium-size groups (under 10 doctors) have only about one-fifth of the capabilities required in a PCMH.26

This is not to say that small practices cannot become medical homes. Some have achieved amazing feats

of self-transformation. But, even if they already have EHRs, small practices may not be able to afford other

PCMH components, such as dedicated care coordinators and care managers. To expand their hours and

provide after-hours access to patients, they must incur additional labor costs. And, as previously noted, they

may 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—some

of them quite small—managed to achieve a number of PCMH goals. However, a report on their effort pointed

out that the pace of change is exhausting for practices and that they must have an “adaptive reserve” to keep

going down the path of self-transformation. In addition, the report underlined the difficulty that doctors may

have in assuming new roles vis-à-vis their staff.27

Experts have made several suggestions about how smaller practices might be able to turn themselves into

medical homes.28 One possibility is to use the kind of “practice transformation” consultants that were available

to 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 Vermont

have successfully used community resource centers to supply shared care coordination services that small

practices could not afford on their own.29

Challenges and Solutions: A PCMH must build a number of scalable core competencies.


24. 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.


Building the Medical Neighborhood

While these approaches might help practices

build medical homes, their success as PCMHs

will still be determined by how well they

collaborate with other providers. The potential

role of ACOs in this area has already been

mentioned. But it may not be necessary to wait

until ACOs are widespread to begin improving

the ecosystem in which the PCMH operates.

Under a $20.75 million grant from the Center

for Medicare and Medicaid Innovation,

VHA Inc., the national health care network,

TransforMED, and Phytel, a technology

company that specializes in automated,

provider-led population health improvement

solutions, are working together on a project

to expand the PCMH concept to the patient-

centered medical neighborhood. The goal is

to connect acute-care hospitals with primary

care, specialty, and subspecialty practices to

deliver higher-quality, more patient-centered

care at an affordable cost.30

VHA, TransforMED, and Phytel anticipate that

their combined work across 16 communities

will save Medicare up to $53 million over a

three-year period. TransforMED, the leading

PCMH expert, will apply Phytel’s population

health management solutions, and VHA

will contribute its knowledge of quality

management and ambulatory care strategies

for hospitals.

how Much will it Cost?

Most PCMH demonstrations sponsored by

health plans use a mixed or hybrid payment

model to reimburse physicians for the extra

work and expense of providing a medical

home. They pay physicians fee-for-service

for the clinical work they do, plus a fixed

care coordination payment for each patient

and some kind of quality incentive. While

other approaches have been suggested, little

data exists on how well they might work in

encouraging PCMH activities.31

There’s also no agreement on how high the

care coordination fee should be in the hybrid

model. For example, the North Carolina

Medicaid program paid primary care doctors

a coordination fee of $2.50 per patient per

month.32 In contrast, in a multi-payer pilot in

Pennsylvania, the state required payments

of $4 per patient per month to practices

that had attained level 3 NCQA certification

as medical homes.33 Some estimates of

appropriate care coordination fees are much

higher.34

One reason for the uncertainty about these

fees is that not much is known about the

costs of establishing a PCMH. A recent

study of federally funded community health

centers found that a fully functioning PCMH

was associated with an operating cost per

patient per month that was 4.6% higher than

the cost of operating a similar center without

a PCMH. The costs of tracking patients and

improving quality—both health IT-intensive

tasks—were particularly high. In total, the

community health centers that functioned as

medical homes added $2.26 per patient per

month in operating costs, or about $500,000

per month for the average clinic.35

But the authors observed that another

study of an integrated delivery system’s use

of a PCMH showed that it saved $18 per

patient per month in averted hospitalizations

and ER visits. Most of those savings

accrued to payers, indicating the need

for reimbursement sufficient to cover the

infrastructure costs of PCMHs.

As noted earlier, some PCMHs that are part

of integrated delivery systems have lowered

costs and achieved a return on investment.

But it’s unclear whether that model would

work for smaller, unaffiliated practices. What

is clear is that the cost of creating and

maintaining a medical home could be much

lower if the practices were highly automated.

This approach requires the intelligent use

of health information technology. By linking

together some currently available health IT

tools, physician groups can automate much

of the work that might otherwise be too

costly and difficult for them to do. Moreover,

automating the manual processes of care

coordination and care management makes

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 and Operating Cost at Federally Funded Health Centers.” JAMA. 2012;308(1):60-66.


AHRQ cites the inability of most EHRs to generate population-based reports easily; to present alerts and

reminders in such a way that providers will use them rather than turning them off; to capture sufficiently

detailed data on preventive care; and to interoperate with other clinical information systems.36

Some EHR vendors are moving to correct these deficiencies. For example, some applications allow users

to adjust the level of alerts to their own needs and tolerance levels. And, while another report points to the

difficulty of using the registries embedded in some EHRs,37 those are also being improved to help physicians

meet the meaningful use criteria.

Nevertheless, practices need a variety of health IT tools beyond EHRs to meet AHRQ’s requirements for

PBPH.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.”

role of information technology: Observers agree that information technology, including the EHR, is essential to the PCMH’s success. But EHRs lack some of the features required to do practice-based population health.

To be an effective tool for population health management, a registry should include all of a practice’s patients, and be patient-centric, not condition-centric.


automation tools

A growing number of practices use external,

web-based registries to supplement their

EHRs. These registries compile lists of

subpopulations that need particular kinds

of preventive and chronic care, such as

annual mammograms for women over

40 or HbA1c tests at particular intervals

for diabetic patients. The continuously

updated data in the registries comes from

EHRs, practice management systems, labs,

and pharmacies. Evidence-based clinical

protocols, which can be customized by

physician practices, trigger alerts in the

registries. When a registry is linked to an

outbound messaging system, patients are

notified by automated telephone, e-mail, or

text messages to contact their physician for

an appointment. Some registries can also

send actionable data to care teams prior to

patient visits.39

To be an effective tool for population health

management, a registry should include all of

a practice’s patients, and be patient-centric,

not condition-centric. It should also have a

sophisticated rules engine that combines

disparate types of data with evidence-based

guidelines, generating reports that provide

many different views of the information. For

example, the entire patient population could

be filtered by payer, activity center, provider,

health condition, and care gaps. The same

filters could be applied to patients with a

particular condition, such as diabetes, to find

out where the practice needed to improve

its diabetes care and to prepare actionable

reports for care teams on individual patients.

Other IT tools that will also be important

include online health risk assessments,

automated education materials and health

coaching, automation of actionable data for

care teams, automation of care management

reports, and biometric home monitoring of

patients with serious conditions.

As an example, the following table shows

how information technology can be used to

automate population health management.

39. Ken Terry, “Do Disease Registries=$$rewards?” Medical Economics, Nov. 4, 2005, accessed at http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=190114

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Care team process Step

for “at-risk” patients Manual tasks automation Opportunities

1. Identify “at-risk” patients

2. Document gaps in care

3. Communicate gaps in care to

treating providers

4. Communicate treatment needs to

patients

5. Assessment of “at risk” patients

6. Educate patients about treatment

plan and care needs

• Review charts of patients scheduled for

upcoming office visits

• Review charts of patients associated with

a specific payer contract with “pay-for-

performance” incentives

• Review multiple screens and fields within EMR

and Patient Management System to identify care

gaps and appointment dates

• Review paper charts for additional information

• Discuss gaps in care with provider as part of

visit preparation process

• Prepare cover sheet for paper chart

• Make phone calls to patients, often by nurses

as well as other staff, which only reach a limited

number of patients

• Mail reminder letters for preventive care

• Conduct assessments during office visits or

over the phone using paper or other tools that

may or may not integrate with EMR

• Generate printout of patient treatment plan at

end of visit; may be handed to patient or mailed

• Make phone calls to patients for treatment plan

follow up

• Utilize algorithms and data mining to identify

all patients within provider panel with care gaps,

irrespective of visit date or payer

• Stratify and prioritize patients based on risk

evaluation algorithms

• Create reports across multiple sources of data

for entire provider panel population to identify

care gaps based on evidence-based algorithms

• Flag patients with upcoming visits

• Automate provider-level reports on patients

with care gaps

• Automate creation of patient care summaries

for use in visit and between-visit management

•Utilize automated technologies to generate

outreach by phone, email and/or text according

to patient preference for all patients in provider

panel with preventive and/or chronic care gaps

• Send all patients online health risk assessment

tool; results can be used for individual and

population management activities

• Offer online health risk assessment part of

patient portal

• Offer patient treatment plans and education

tools through secure patient portal for ongoing

patient support

• Push reminders and other communications to

individual and subpopulations of patients through

patient portal as well as phone, e-mail, and text

identification of automation Opportunities in the Manual Care Management process


Health risk assessment (HRA) is fundamental

because it serves as the basis for the

interventions to be applied to patient

populations. HRA stratification enables

practices to sort their patients into three

categories: healthy people, people in early

stages of chronic diseases, and people with

advanced chronic diseases. These groups

are always changing. Those who are well

today may be sick tomorrow, and those who

have an early stage of disease today may

be in a more advanced stage tomorrow. So

regular administration of HRAs can help keep

medical homes apprised of which patients

are likely to need additional care in the future.

To reinforce the lifestyle modification

messages delivered in the office visit, medical

homes should use tailored communications

and interventions to achieve and sustain

behavior change. These include online

educational materials that may be linked to

HRAs, along with automated reminders to

patients. Practices can also take advantage

of the new mobile technologies, such as

smart phones and texting, as well as patient

Web portals that may be attached to EHRs.

Medical homes can also use automation

tools to support the efficient functioning of

care teams. These include accurate and

usable patient data summaries to minimize

the need for chart reviews. The summaries,

generated by registries, will remind providers

of a patient’s care gaps and the need to

work with him or her on modifying health

behavior. Care teams can also streamline the

visit preparation process by identifying care

opportunities and having patients get tests

done before visits.

To support the work flow of care managers,

medical homes can deploy software

that automatically sets priorities for their

communications with patients, based on the

severity of their condition. Using data from

EHRs and registries, this type of application

can tell a care manager whether he or she

needs to call a patient directly or whether

electronic messaging will suffice.

Biometric home monitoring, which has been

around for more than a decade, is finally

starting to get some financial support from

health plans.40 As a result, it may be feasible

for medical homes to start using it to keep

tabs on their sickest patients with such

chronic conditions as heart failure, diabetes,

and high-risk pregnancy. Because doctors

don’t have time to monitor the continuous

stream of data, this would be a natural task

for care coordinators.

The benefits of using these health IT tools

include the ability to track, monitor, and

engage patients; to tailor interventions to

different segments of the population; to

measure performance for quality reporting;

to automate care coordination; to ensure

that care gaps are filled; and to do all of this

without increasing the workload of doctors or

staff members.

40. Ibid.

Medical homes can use automation tools to support the efficient functioning of care teams


Conclusion

The PCMH 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:

Successful medical homes will have to perform population health management; they will

need a variety of health IT tools to do that and to coordinate care effectively; and they

will 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 proper

use of information technology. In the end, practices must be reengineered to provide

effective, PCMHs—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.

scaling the pcmh delivery model with automation

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