Sunday, April 11, 2010

IT and the Medical Home

The April 2010 issue of Health Affairs devotes the entire issue to the impact and use of health IT on care quality and costs. One of the articles “The Future of Health Information Technology in the Patient-Centered Medical Home” looks at what is needed in terms of electronic records to further enable medical homes to really improve efficiency, quality, and safety.

In order to achieve the goals for medical homes, the authors David W. Bates, Chief of the Division of General Internal Medicine at Brigham and Women’s Hospital in Boston and Asaf Bitton a Fellow in General Internal Medicine at Brigham and Women’s Hospital and in the Department of Health Care Policy at Harvard Medical School, think that developing electronic health records is critical in seven major areas.

The seven major areas include telehealth, measurement of quality and efficiency, care transitions, personal health records, registries to use for team care, along with clinical decision support for chronic diseases. The authors also suggest that in order to encourage development, policy leaders need to look at the issues related to medical homes in the emerging electronic health record regulations.

Using telehealth technologies can help practitioners check on patients but it also can be used to monitor patients remotely. According to the authors, medical homes could use this technology to collect vital signs and report on symptoms for patients with chronic illnesses and do this not only in urban areas but in rural areas as well.

The authors concluded that EHRs are important in establishing medical homes but in order for this to happen, EHRs and other systems will have to evolve substantially. The key areas needing development include registry functions, clinical decision support, and development of the tools needed to deliver care. Also, an external payment reform is absolutely essential for medical homes to take hold and become financially sustainable.

The medical home concept is not only being developed in the civilian sector but the concept is under development in the military setting. However, there are differences between the civilian and military sector in the ability to develop and test the concept. However, both the civilian and military medical home concepts require and are dependent on the use of technology.

The military has more financial and personnel resources and is able to reassign staff to what is needed, has an easier job selecting systems, has the resources to invest in team building, and is able to operate on a larger scale. It is easier for the military to set up and operate a medical home at one facility and then test and develop the concept at many other facilities doing this all at the same time.

In 2007, Navy doctors and researchers at the Naval Medical Center’s Department of Internal Medicine serving 35,000 patients on an outpatient basis began investigating how to restructure their primary care delivery system so that they would be able to use a patient-centered approach emphasizing primary and preventive care.

The Navy researched and borrowed from medical home models developed by the Patient Centered Primary Care Collaborative (PCPCC). The Collaborative is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians, and others working to develop the patient-centered medical home.

The Naval Medical Center then created integrated medical home teams within the internal medicine outpatient clinics. The goal was to provide personalized, proactive, coordinated care, and care management services to patients.

The system put in place provides scheduling for same day appointments for acute care, allows emails to go to providers, and enables patients to submit requests for prescription refills. Patients are also encouraged to schedule visits virtually rather than schedule face-to-face visits with providers when it is appropriate.

Web-based personal health records and systems support this form of care management. The medical team, working with IT specialists created the portal and personal health record system. At the same time, they designed a medical home management system for clinicians that includes population management functions and in-depth data search capabilities.

The Navy’s pilot program with 1,200 patients then presented training sessions to tell the patients how the new medical home model would work. Also, patients registered at the web site, provided information and answered questions about their health. Patients were encouraged to enter clinical information such as recent blood glucose or blood pressure readings that may be helpful to providers. Eventually, the team members hope the online concept grows and they will be able to enroll about 70 percent of the patients in the system.

The providers benefit by being able to obtain data on patients especially patients with chronic conditions. The providers find it especially valuable to detect when patients are not being seen or screened as recommended. The system uses benchmarks, such as blood glucose and mammography screening rates to measure quality of care for each provider. In addition, disease management tools are provided to help provide better care for patients with chronic illnesses. The technology is in place to alert the medical team when a patient has been treated in the emergency department or enters the hospital in the past 24 hours.

At present six teams are working and there are plans underway to create additional medical home clinics to serve children, adolescents, wounded soldiers, and geriatric patients. Periodically, it is necessary to re-examine the model’s strengths and weaknesses, making changes as needed.

The Navy hopes to create a comprehensive information management system to enable teams to access disparate medical and patient health records through the portal. The ultimate goal is to provide evidence-based resources at the point-of-care, a patient-centered education portal, and assistance with check in procedures for patients.