Selecting an EHR for the Patient Centered Medical Home

The conceptual definition of a Patient Centered Medical Home (PCMH) speaks of a physician directed medical practice, oriented to the whole person, where patients have enhanced access to a personal physician and care is coordinated and integrated focusing on quality and safety, nothing more and nothing less, other than appropriate payment to physicians for all activities.

Since concepts are rarely enough, the National Committee for Quality Assurance (NCQA) took it upon itself to provide concrete requirements and formal certification for medical practices desirous of being recognized as Patient Centered Medical Homes. The NCQA PCMH definition consists of nine Standards used to score the practice. This is NCQA’s attempt at translating the original PCMH concept into measurable activities and here is where Health Information Technologies (HIT) and EHR in particular, are formally associated with the PCMH concept. Conspicuously absent from the NCQA standard are the “personal physician” and unless you consider the assessment of language barriers sufficient, so is the “whole person orientation". Most NCQA PCMH elements are geared towards data collection, data analysis, tracking and reporting. Theoretically, you could earn NCQA PCMH designation without an EHR, but the amount of typing, writing, filing and calculating would easily consume your entire day. If you are serious about PCMH designation, you will need an EHR. But which one should you get? Are some technologies better than others for PCMH purposes?

Unfortunately, no one is trying to answer these questions and perhaps this is one of the reasons for the initial mixed results observed in PCMH implementations. The HITECH Act put in motion a monumental rush towards Meaningful Use and associated financial incentives. The Patient Protection and Affordable Care Act (ACA) is initiating another rush, this time towards new payment models and PCMH seems to be at the heart of all innovations. So what should we do first, buy HIT and become Meaningful Users, or transform our practices into an NCQA PCMH? Some would say, let’s do both and others, mostly primary care physicians in small private practice, would say, let’s do neither. In reality, Meaningful Use trumps PCMH right now, since it has hard due-dates and specific dollar amounts associated with it. Moreover, the pervasive opinion amongst PCMH consultants (yes, they have those already) is to get the HIT part over with, before engaging in the complex PCMH "culture transformation". And this is yet another recipe for failure, driven by tactical instant gratification needs and inability to take the time necessary for formulating long term strategies.

Suppose you decide to build a tree-house for your kids. Since you’re a doctor, not a carpenter, what do you do next? You could go on the Internet and figure out what tools and materials you need, measure the big old oak tree in the backyard, talk to the neighbor that just built one and make a list of stuff you would need to buy for the project. Or you could just get in the car and rush to Home Depot because they have a holiday sale on hammers & nails and buy a truckload of random tools and lumber. If you pick the latter route, chances are most of what you bought will be rotting in your garage and the kids will be playing in the neighbor’s tree-house. Similarly, if you want to build a PCMH and randomly purchase some EHR tool just because the Government is giving out rebates and vendors have fire sales, chances are your PCMH will never take off successfully. Below is a list of NCQA PCMH standards and things you need to consider when shopping for an EHR with the goal of eventually obtaining NCQA PCMH recognition (items marked with ** are mandatory).

Standard 1: Access and Communication

1. Has written standards for patient access and patient communication** - An EHR won’t help you write the standards, but it will help you implement them. You should have a scheduler that enables you to easily set aside times for open schedule, allows creation of global scheduling templates and gives you the ability to define your own appointment types, including web visits and email encounters. The EHR should also have the ability to create encounter notes without an appointment and/or a physical office visit.
2. Uses data to show it meets its standards for patient access and communication** - The EHR should have built-in capabilities to report on aggregate schedules and be able to account for email communications and web visits in one comprehensive report.

Standard 2: Patient Tracking and Registry Functions

1. Uses data system for basic patient information (mostly non-clinical data) – Any good Practice Management System will do here.
2. Has clinical data system with clinical data in searchable data fields – This is your Registry. Querying the Registry should be flexible and allow multiple parameters (e.g. all diabetics taking drug A, but not drug B, with A1c in a certain range, who also have a Dx of HTN and have not been seen in 6 months), but should not require that you have a degree in applied mathematics to use it. The quality of registries in EHRs varies wildly. Make sure the reports look clear, that all columns are sortable and that the reports are actionable (i.e. clicking on a data element will allow you to do something about it right then and there, instead of having to print the report out and search for each patient).
3. Uses the clinical data system – If you have that nice Registry, you would probably use it. For this element and the next two, the Registry should be able to report on itself (i.e. how many queries were run in a certain time period – an audit log is not sufficient).
4. Uses paper or electronic-based charting tools to organize clinical information** - Same as above.
5. Uses data to identify important diagnoses and conditions in practice** - Same as above.
6. Generates lists of patients and reminds patients and clinicians of services needed (population management) – With a good and actionable Registry, sending reminders out to patients should be easy, but you need to verify that the functionality to send bulk reminders (by email, phone or mail merge) is there and it defaults to recorded patient preferences for communications.

Standard 3: Care Management

1. Adopts and implements evidence-based guidelines for three conditions ** - The EHR should come with built in clinical decision support from a reputable source, such as USPSTF and this should be updated by the vendor on a regular basis. It should also come with clinical documentation templates, care plans and order sets preconfigured based on equally reputable guidelines. Be sure to ask about it and verify that it is actually as the vendor claims it to be.
2. Generates reminders about preventive services for clinicians – The Registry should be able to be queried automatically in scheduled batch mode for all patients and it should also allow customized configuration to display overdue services when a chart is accessed (you don’t want pop-ups here – a gentle, but bold, reminder on the page itself should suffice).
3. Uses non-physician staff to manage patient care – Every decent EHR will allow you to do this, but it would be nice if the EHR recorded the user who enters data into the various portions of the chart (not just an audit log, but visible indication that nurse A took the vitals).
4. Conducts care management, including care plans, assessing progress, addressing barriers – The EHR should come with preconfigured, evidence-based and fully customizable care plans. It should also have a place to enter goals and subsequently calculate adherence to those goals. This is where you want the longitudinal display, particularly useful for chronic disease management.
5. Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities – This will probably be done by phone & fax for a while longer, but your EHR should have capabilities to interface with hospitals and other providers. Some of the larger vendors have the ability to exchange information within networks of their own customers, and all vendors will eventually have to play nice. I know this is not a popular view, but for interoperability with multiple complex sources, the bigger the vendor, the more capabilities it has.

Standard 4: Patient Self-Management Support

1. Assesses language preference and other communication barriers – All the EHR has to have is a place for you to document language, translator and health literacy status. It would be best if these were structured data fields, because sooner or later, they will require you to report on these things.
2. Actively supports patient self-management** - In addition to your goal oriented care plans and registries, you should have a quality Patient Portal where you can make all this information, along with education materials, available to the patient and his/her family. While most EHRs have Patient Portals now, you need to make sure that they are not just a web page for patients to pay bills and request refills. Whether your patients will use the Portal, or not, is a completely different question.

Standard 5: Electronic Prescribing

1. Uses electronic system to write prescriptions – An EHR certified to work with Surescripts is necessary for Meaningful Use. Here you just need to make sure that the EHR is not just certified by ONC, but also appears on Surescripts’ website and this feature is operational (not all are).
2. Has electronic prescription writer with safety checks – This is also a Meaningful Use requirement, but it won’t hurt to find out if the EHR uses a reputable source for drug and allergy alerts, such as First Data Bank, Medispan or Multum.
3. Has electronic prescription writer with cost checks – Again, check the Surescripts website to make sure that the EHR is certified for Formulary checks (not just sending prescriptions electronically).

Standard 6: Test Tracking

1. Tracks tests and identifies abnormal results systematically** - A nice dashboard, with sortable columns and color coded abnormal indicators should be standard in any EHR you are considering. This should also be actionable with respect to being able to sign-off and inform patients and staff on further actions right from the dashboard.
2. Uses electronic systems to order and retrieve tests and flag duplicate tests – This is the dreaded CPOE. Note that it requires additional intelligence in checking to see if the tests you are about to order are duplicative. This is not a simple task and very few ambulatory EHRs have this feature. Choose with care and beware the endless stream of possible alerts.

Standard 7: Referral Tracking

1. Tracks referrals using paper-based or electronic system** - Many EHRs will allow you to fax referrals from the application. Some will allow electronic transmission to providers using the same EHR or will have interfaces to hospital systems for transition of care. The upcoming Direct Project standards may facilitate this functionality. You should inquire about the EHR vendor’s plans, and capabilities to support implementation of emerging standards at short notice.

Standard 8: Performance Reporting and Improvement

1. Measures clinical and/or service performance by physician or across the practice** - If you have that nice Registry discussed above, you should be able to run any reports you want by physician, by date, by patient group, by practice, by specialty, by insurer, etc.
2. Survey of patients’ care experience – Although, you could do this on paper at check-out, this should be an option on your Patient Portal, which will allow you to measure and report results.
3. Reports performance across the practice or by physician ** - Same as element A above, only now you have to share those reports with others.
4. Sets goals and takes action to improve performance – Not much an EHR can do here, but the Registry should be able to provide reports substantiating improved performance.
5. Produces reports using standardized measures – Not sure why the repetition on reporting, but Meaningful Use has a host of required measures as well. Make sure your EHR can actually deliver on all 44 measures, plus whatever else you may want to measure. Some certified EHRs only have capability to deliver the minimum 6 NQF measures allowing you no freedom to choose what you want to measure, or report on. This too is part of the Registry.
6. Transmits reports with standardized measures electronically to external entities – Several EHRs have Registries that are certified by CMS to submit quality measures electronically. The standard for reporting will be changing soon, and as with interoperability in general, you need to be convinced that your EHR vendor has the resources and ability to roll with the punches.

Standard 9: Advanced Electronic Communications

1. Availability of Interactive Website – This is your Patient Portal, which needs to allow patients to input requests, data and generally communicate with the practice.
2. Electronic Patient Identification – This could mean a user name and password (or something more exotic, if you choose) for your patients to access the portal or it could refer to a unique patient identifier in the EHR. Either way, this is not an issue.
3. Electronic Care Management Support – Everything you do every day will satisfy this element, if it is done in an EHR.

To summarize this litany of standards, if you have any interest in NCQA PCMH recognition, the main functionalities to look for in an EHR, in addition to ease of use and affordable pricing, are a comprehensive Registry with excellent reporting abilities, a flexible Patient Portal, quality clinical content from reputable sources and vendor ability to sustain new standards and regulations, particularly those related to health information exchange. If you want to provide your patients with a compassionate and caring medical home, where they feel safe and well cared for, you will need a different set of “tools”, but perhaps technology can help a little.