Introduction
In prior modules, we have now discussed many areas of improvement that currently plague the US healthcare system. In exploring these issues, we have also come to discuss some of the ways in which the current state of affairs may be improved to the extent of fully exploiting the potential benefits that could be provided by effective implementation of EHR/EMR systems and the variety of add-ons that can be found within those platforms. In a healthcare system that is operating with highly-functional EHR systems, the healthcare industry may be able to migrate from its current state towards a moderately different system called the patient-centered medical home (PCMH).
There is much speculation that a PCMH system could be a less expensive and more effective healthcare system that would be capable of providing higher-quality care in a way that is beneficial to both patients and providers. Some healthcare organizations have already begun working on implementing a PCMH system across their medical institutions while others are reluctant to the idea or still trying to acquire the necessary technology for a functional PCMH system. But what exactly is PCMH? What does this ideal model look like and how does it differ from our current situation? And, most importantly, if this is a system that the US is interested in adopting, what does the path towards PCMH look like? In the following sections, we will explore these questions.
There is much speculation that a PCMH system could be a less expensive and more effective healthcare system that would be capable of providing higher-quality care in a way that is beneficial to both patients and providers. Some healthcare organizations have already begun working on implementing a PCMH system across their medical institutions while others are reluctant to the idea or still trying to acquire the necessary technology for a functional PCMH system. But what exactly is PCMH? What does this ideal model look like and how does it differ from our current situation? And, most importantly, if this is a system that the US is interested in adopting, what does the path towards PCMH look like? In the following sections, we will explore these questions.
What is PCMH?
The following paragraph is taken directly from an article in the Journal of the American Medical Association as an introduction to the PCMH
"The patient-centered medical home (PCMH) model of primary care has become a recent focus for innovation in the US health care system, with endorsements by the major primary care physician (PCP) society and support in the Patient Protection and Affordable Care Act of 2010. As a holistic, patient-centered, team-based model of care, the PCMH promotes access, coordination, comprehensiveness, quality, and safety. This model emphasizes the core primary care function of providing clinical preventive services and a comprehensive approach to care over a patient’s lifetime rather than focusing on episodic treatment, a specific medical issue, or a particular body system. Increased clinical preventive service use is considered a key indicator for evaluating the success of the PCMH and early evaluations have shown consistent evidence of a positive association."
The patient-centered medical home (PCMH) is an innovative model for providing better care for the patients by improving connections between patients and providers and improving effective resource allocation by reducing extraneous specialist visits. The PCMH model focuses heavily on the core primary care function of providing regular preventative services. In order for a PCMH to function properly, each patient needs to have an ongoing relationship with a personal practitioner trained to provide first-contact preventative care. If and when a patient requires access to more specialized care, the personal provider must be able to have simple and passive access to the medical services provided such that they can continue to provide holistic care to the patient. For functional PCMH, it is critical that care be coordinated across all elements of the healthcare system including subspecialty care, hospitals, home health agencies, and nursing homes. To coordinate the efforts of a PCMH, however, effective registries, information technology, and electronic health record systems must all work seamlessly together in oder to provide an efficient and hassle-free experience for the patient.
Quality and safety are also hallmarks of an effective PCMH. Patient-centered care ought to be driven by a compassionate, robust partnership between physicians, patients, and patients' families. Physicians' decision making must be backed by evidence-based medicine and clinical decision-support tools and the payment system in place must prioritize patients' results over patient volume.[2] The idea of reorganizing the payment system within the healthcare system is an interesting one and very well may be the key to reorienting the entire healthcare industry towards patient interests. If this system sounds like a far-fetched idyllic vision of the future, take a moment to consider that we are actually closer than you may think. With a handful of major healthcare organizations around the country beginning to adopt PCMH models for healthcare delivery, the country is well on its way to this revolution in the system. However, the end goal is still quite a ways beyond our sight. What are the major considerations that still need to be made with regards to the PCMH system and what does the path forward look like for patients and providers alike?
"The patient-centered medical home (PCMH) model of primary care has become a recent focus for innovation in the US health care system, with endorsements by the major primary care physician (PCP) society and support in the Patient Protection and Affordable Care Act of 2010. As a holistic, patient-centered, team-based model of care, the PCMH promotes access, coordination, comprehensiveness, quality, and safety. This model emphasizes the core primary care function of providing clinical preventive services and a comprehensive approach to care over a patient’s lifetime rather than focusing on episodic treatment, a specific medical issue, or a particular body system. Increased clinical preventive service use is considered a key indicator for evaluating the success of the PCMH and early evaluations have shown consistent evidence of a positive association."
The patient-centered medical home (PCMH) is an innovative model for providing better care for the patients by improving connections between patients and providers and improving effective resource allocation by reducing extraneous specialist visits. The PCMH model focuses heavily on the core primary care function of providing regular preventative services. In order for a PCMH to function properly, each patient needs to have an ongoing relationship with a personal practitioner trained to provide first-contact preventative care. If and when a patient requires access to more specialized care, the personal provider must be able to have simple and passive access to the medical services provided such that they can continue to provide holistic care to the patient. For functional PCMH, it is critical that care be coordinated across all elements of the healthcare system including subspecialty care, hospitals, home health agencies, and nursing homes. To coordinate the efforts of a PCMH, however, effective registries, information technology, and electronic health record systems must all work seamlessly together in oder to provide an efficient and hassle-free experience for the patient.
Quality and safety are also hallmarks of an effective PCMH. Patient-centered care ought to be driven by a compassionate, robust partnership between physicians, patients, and patients' families. Physicians' decision making must be backed by evidence-based medicine and clinical decision-support tools and the payment system in place must prioritize patients' results over patient volume.[2] The idea of reorganizing the payment system within the healthcare system is an interesting one and very well may be the key to reorienting the entire healthcare industry towards patient interests. If this system sounds like a far-fetched idyllic vision of the future, take a moment to consider that we are actually closer than you may think. With a handful of major healthcare organizations around the country beginning to adopt PCMH models for healthcare delivery, the country is well on its way to this revolution in the system. However, the end goal is still quite a ways beyond our sight. What are the major considerations that still need to be made with regards to the PCMH system and what does the path forward look like for patients and providers alike?
PCMH: What's next?
Providing excellent primary care is central to the delivery of high-quality medical care and, more broadly, to the health of greater populations. However, the primary care most US citizens are receiving is through the primary physicians who operate in an environment which severely lacks communication and teamwork with the rest of the healthcare delivery system. The gaps and discontinuity in the delivery of care has become one of the biggest challenges in this country to providing high-quality care. With the increased interest and popularity of patient empowerment - where patients have the tools and resources to acquire knowledge and access personal health data and thus play a more active role in healthcare delivery process - the notion of providing patient-centered, team-based, continual care with accentuation on care quality and patient safety has become an exciting development that is in high-demand. If we think about the attributes that PCMH features, it is not surprising to find that technologies, especially EHR, play an important role in these principles. A 2010 article in the Journal of Health Affairs[3] has categorized the challenges of implementing PCMH from an informatician’s point of view and presents seven informatics domains that EHRs need to improve in order to fully realize the medical home’s potential.
- Team care: Providing team care is one of the core principles of PCMH. Team care is delivered by a group of healthcare professionals composed of any combination of nurses, social workers, pharmacists, medical assistants, specialists and primary care physicians. Unsurprisingly, the main challenge for promoting team-based care is the communication between these actors and the accessibility of up-to-date patient information. Figuring out how to appropriately divide new tasks among the clinical workforce is another challenge faced by team-based care. Fortunately, these barriers can be overcome with a well-designed information system that can be seamlessly incorporated into providers' workflow and with the instant messaging and updates of information that is supported by EHRs. However, that being said, more research is needed to determine the best way to connect and involve patients and families as the team members in team-based care and how to best exchange patient data that lies within different EHR systems.
- Care transition: Care transition is concerning the continuity of care given by healthcare providers during the transition between various healthcare departments within or between organizations (e.g. from a rural hospital to an urban rehabilitation clinic). Most of the research and concern in this area, however, are focused almost exclusively on medication management. So far, there are controversial results as to whether or not these tools improve patient’s safety and outcome which require more studies to investigate the possible long-term improvements.
- Clinical decision support systems: As covered in a previous module, CDSS must provide the right information at the right time to support the decision-making process of healthcare providers in order to result in better patient outcomes. The main challenge in this domain is a distinct lack of clinical control trials to justify the positive effects of CDSS in improving a patient's care quality. Another are for future work mentioned is the demand of more research in how to integrate smartphone application technology and web-based tools to support patient-centered decision making (known as shared decision-making, or SDM).
- Personal health record: The Markle Foundation defines personal health records as “an electronic application through which individuals can access, manage, and share their health in-formation and that of others for whom they are authorized, in a private, secure, and confidential environment”. The challenge in this domain is the low adoption rates caused by a variety of different reasons including patient demographics, lack of motivation to adopt PHRs, issues revolving around health literacy and numeracy, and usability issues with tools and display information. Another challenge faced by PHR is the lack of strong connection between the use of PHR and improved clinical care outcomes, increased patient engagement, and better care coordination and access.
- Telehealth and telemedicine: Telehealth (or telemedicine) is the burgeoning use of electronic devices to support remote healthcare delivery in order to overcome geographical and time barriers. However, the main challenges lie with access and quality of remote internet connection, access to providers that are willing and able to engage in telehealth settings, and the fact that there are simply some medically relevant questions which cannot be answered remotely.
- Measurement: It is important to identify success factors to guide and evaluate the implementation of PCMH. Many studies have been devoted to identifying foundations and frameworks to assess patient-centered care measures. One thing that is highlighted in the literature is the concern of using the one-size-fits-all framework to guide patient-centered care. The complexity and uniqueness of patient demographics, genetics, and environment are extremely diverse and as such, one may imagine that there certainly may be situations where PCMH is simply not the best option for care delivery.
- Registries: Registries are applications that classify and track patients with specific conditions while also tabulating disease status which can be used to facilitate community-wide disease management and useful data aggregation. Currently, there is not a standardized method of managing a registry as they are often maintained by third-party organizations. However, with gradual shifts to PCMH, this shift of data entry has gradually begun to migrate to nurses and health administrators which seems like a logical change to the workflow.
Want to Learn more?
Here are some resources we used to write this article!
[1] Markovitz, Amanda R et al. “Patient-centered medical home implementation and use of preventive services: the role of practice socioeconomic context.” JAMA internal medicine vol. 175,4 (2015): 598-606. doi:10.1001/jamainternmed.2014.8263.
[2] “Joint Principles of the Patient-Centered Medical Home.” American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA), March 2007.
[3] David W. Bates and Asaf Bitton. "The Future Of Health Information Technology In The Patient-Centered Medical Home." Journal of Health Affairs 29:4, (2010). 614-621.
[2] “Joint Principles of the Patient-Centered Medical Home.” American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA), March 2007.
[3] David W. Bates and Asaf Bitton. "The Future Of Health Information Technology In The Patient-Centered Medical Home." Journal of Health Affairs 29:4, (2010). 614-621.
Personal Reflections
Oliver |
In module two and three, we learned about the status quo for the implementation of EHRs and CDSS, what problems they have solved and also discussed the current challenges and future design and modification. I think the concept of a patient-centered medical home treats these two domains as its important components and dreams about what the healthcare system looks like if EHRs and CDSS meet their initiatives and reach their potential. For me, this module is like a summary of previous modules but think about their application and improvement from a different perspective. When we learn about the challenge of EHRs and CDSS, we place more weight on their effect on healthcare givers and how to overcome the challenges faced by providers. However, this module thinks about the improvement of EHRs and CDSS for realizing patient-centered care which makes me recall the patient-centered recommendation from the AMIA report we learned in EHR’s module. Another thing I recall when reading the articles for this module is that if we perceive PCMH as a new care delivery model, the two articles I read focus mainly on the improvement of the functionalities of EHRs but did not mention how the healthcare organization along with the providers in the team can manage this change. Furthermore, the articles also did not discuss much about human factors in implementing PCMH.
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Weipeng |
While writing this primer, I thought of the community health center I had in my hometown. It wasn't new but it was not until recently that it was largely implemented. Previously, people like to go to a large hospital. In large hospitals, people can very little money and see famous doctors. So people like to go there. However, the problem is that most patients just do not need that many medical resources. Large hospitals should be for people who have more serious diseases because they are most equipped. To address this issue, the government pushed a new policy called a multi-level medicare system. That is, people are encouraged to first go to the community clinics and if they could not handle, the patients will be transferred to large hospitals. At the time I went back, I did a blood test for examining my body. I got part of the report today and I was told the rest of the tests were sent to large hospitals. After a few days, I got the rest of the tests back. It was an interesting experience.
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Dakota |
I find the concept of a patient-centered medical home very interesting for many reasons. There's a variety of research related to this topic to show definitively that giving people regular access to healthcare would reduce the overall annual costs that are associated with treating illnesses that could have been prevented or at least reduced in severity if they were caught sooner by a primary care provider. I am very much a fan of the idea of PCMH however I have some very serious questions regarding how feasible it is to successfully implement. While this certainly seems that it could reduce the number of annual specialist visits (both necessary and unnecessary), and while it does seem appealing to have such a patient-centered healthcare system, I think there is one critical shortcoming of the US healthcare system in general that is not accounted for in the considerations outlined above. This is the simple question of cost. We did elaborate, in minimal details, that PCMH would be most effective by overhauling the compensation mechanisms for healthcare providers to migrate away from quantity and towards quality. While there are certainly some things that can be helped by this adjustment in payment distribution, I think that fundamentally, the US healthcare infrastructure as it is, will only be able to accommodate the PCMH model for the select Americans that can afford it. I think that reworking the payment system within the healthcare system definitely has the potential to increase care quality, however, one of the primary goals of PCMH is to improve patient care quality by providing frequent and continuous checkups. This is something that I would estimate is only readily available to a simple minority of Americans as it is currently quite expensive for many Americans to just have a simple physical. Many of my friends that are at a relatively similar stage of their career as me pay between $20 and $200 for routine doctor checkups which is an unsustainable amount of money to be required to pay for the regular preventative care visits that would theoretically yield an overall higher quality of care.
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