Sunday, April 18, 2010

Patient Centered Medical Home for your PHR

In 1967 the American Academy of Pediatrics (AAP) published the Standards of Child Health Care suggesting the following:

"For children with chronic diseases or disabling conditions, the lack of a complete record and a ‘medical home’ is a major deterrent to adequate health supervision. Wherever the child is cared for, the question should be asked, ‘Where is the child’s medical home?’ and any pertinent information should be transmitted to that place"

This is the first known mention of the term Medical Home, and its meaning was a physical repository for a comprehensive and complete medical record for each child; a record continuously updated by all other agencies providing care for that particular child; a Personal Health Record (PHR).

By 1992, the AAP Medical Home concept evolved beyond its original medical records definition to include accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. Over the years the Medical Home model of care gained support from various agencies and medical associations and expanded beyond pediatrics and beyond chronic disease management. In 2007 the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP) and the American Osteopathic Association (AOA) joined the AAP in support of a Patient-Centered Medical Home (PCMH) approach for providing primary care to all patients based on seven principles: personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, enhanced access, payment reform.

In 2010 the Patient Protection and Affordable Care Act (PPACA), a.k.a. the health care reform bill, is authorizing Medicare to participate in the various privately led PCMH pilot projects and to initiate its own (delayed) demonstration projects.

The NCQA has defined criteria for a qualified PCMH and those criteria are pretty heavy on Healthcare IT. An interesting new study by Ferrante et all, just published in the Annals of Family Medicine is examining preventive care in PCMH settings, and concludes:

PCMH principles are associated with higher rates of preventive services delivery in community primary care practices, with the high-touch relationship-centered principles more highly correlated than information technology capabilities”.

This study should serve us all as a reminder that, at its heart, PCMH is very much like Cheers, the famed Boston establishment, a place where everybody knows your name. It is a place where you can always see your own physician, with whom you have a long and trusting relationship; a place where you are regarded as a whole person and an active and equal partner in health decisions; a place where continuity of care is not abbreviated to CCD and CCR and does not refer to a software standard, but instead it is the embodiment of a commitment from your doctor and his supporting team to always be there for you.

This is not to say that Healthcare IT is not necessary in a PCMH. In order for a PCMH to be competent and efficient in today’s complex and highly fragmented health care environment, it will need to utilize technology for care coordination, communications with patients and evidence based decision support. But most of all the Medical Home, as conceptualized from its inception, will use computer technologies to maintain complete medical records for all its members. The Patient Centered Medical Home is the most logical aggregator and steward of PHRs.

There are various software products and services in today’s market that allow people to either aggregate their medical records on their own, or view and interact with electronic medical records maintained by their physicians. The latter is usually a Patient Portal attached to an EHR, and the former, confusingly named PHR, is a service provided over the Internet by independent companies like Google or Microsoft, or by large employers like Walmart. A recent survey by CHCF suggests that there is a small, but increasing interest in using such software and its mere usage may have positive impact on wellness.

If you are one of the very few lucky Americans who have a Medical Home, the Patient Portal provided by the PCMH is as close as we are today to a true PHR. It probably lacks the ability for you to contribute your own content or connect your own input devices, and it most likely does not contain your entire record from birth to the present day. As more features are added, the portal should allow you to add your own content and connect home devices. The portal’s main function is to facilitate direct communications between you, your physician and your PCMH team. It should also display all information your PCMH receives from specialists, hospitals, pharmacies and any other care provider you interact with.

If on the other hand you are the proud user of a commercial PHR, or a patient controlled PHR, you most definitely can create your own content and connect devices and clinical advice feeds approved by the PHR provider. You will need to request every care provider you encounter along the way to upload data into your commercial PHR and you will be able to control what each provider sees, if anything at all. It’s not very likely that you will be able to pay your bills, or make an appointment or ask a doctor a question, but maybe as technology improves, that will be possible too. This PHR will not contain your entire record either, but you may enter data from memory as best you can.

As time goes by and America comes to the inevitable conclusion that strengthening and empowering the partnership between primary care physicians and their patients is the only equitable way to reduce health care costs and minimize disparities in care quality, Medical Homes will become the standard of care. By then the Patient Portal and the commercial PHR software will become very similar in functionality. At that time people will probably have to choose whether they want their Medical Home to aggregate and maintain their medical records as part of a trusted partnership, or they prefer to do the footwork and aggregation themselves, and store their life records with an unrelated third party corporation who is providing a PHR service for free to all comers, most likely out of the goodness of their heart or perhaps to fulfill a civic duty to society.

If given the choice, I think I would prefer to manage my medical records in the relative privacy of my Medical Home.


  1. The PCMH model will require a shift in thinking among both the medical community and patients. Technology can help facilitate the communication between patients and the medical community, but both parties must be willing and able to use it for a common goal. PHRs may be useful tools, but it will require patients to take some ownership and responsibility for monitoring/recording data for the PHR; it will require that physicians value the PHR and develop technology to help populate patient data into the PHR; and it will require technology to safely and securely integrate EHRs and PHRs. There is work to be done on many levels to advance the PCMH, and leveraging technology could truly assist in this effort. I found an interview that EHRtv did with IBM at HIMSS10. They discuss technology and the PCMH:

  2. Funny that you should mention IBM in this context. I am an avid fan of Websphere Portal and had the opportunity to introduce it and use it in a healthcare organization setting many years ago when it was brand new. I thought then and I still think now, that WPS is the perfect platform for building a modular EHR including the patient facing portion.
    With all the recent talks about healthcare platforms and EHR modules and grant money being spent to reinvent the wheel, it is not clear to me why IBM is not more significantly involved in this market.
    It is almost too simple and too straightforward to build a complete EHR/PHR with interchangeable modules (portlets) based on well established and open source standards, using the WPS platform. At least it was so in 2003-2004. I can't imagine it beeing anything but easier nowadays.