The 8th Pillar of the Patient Centered Medical Home

The Patient Centered Medical Home (PCMH) model of care is built on seven principles. Seven is a lucky number in some cultures, but if you ever tried to stand something up on seven legs, you probably know that eight is better and sturdier. The medical home is missing a pillar, and strangely enough the missing pillar is the very reason why the concept was originally proposed. The seven principles of the PCMH were jointly formulated by the primary care medical societies in 2002 to describe the characteristics of a PCMH practice, and consist of a personal physician, physician directed medical practice, whole person orientation, coordinated and/or integrated care, quality and safety, enhanced access and appropriate payment. So what are we missing?

Back in 1967, the American Academy of Pediatrics (AAP) introduced the term “medical home” realizing that fragmented and incomplete medical records are an impediment to proper care for children with chronic conditions:

"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"

The pediatric medical home was a place where a longitudinal medical record would be compiled and aggregated from all care providers a sick child may encounter along the way, and the idea was that all those other providers of care would proactively inquire about a child’s medical home, and then promptly transmit their records to that central place, so that care can be adequately supervised by the child’s medical home. Not too bad for an idea that is almost half a century old, and little has changed since. Today’s medical records are increasingly electronic in format, but still scattered across various health care delivery locations. A primary care doctor may receive consult notes from specialists, but not always, and could in some cases download hospital notes from a physician portal or request that these be faxed over. The medical record available in a primary care practice whether PCMH designated or not, is never complete, which may not be a problem for generally healthy folks, but it certainly presents difficulties for people with chronic disease.

In the spirit of the first mention of the term “medical home”, an 8th principle should be added to the joint principles endorsed by the primary care associations, to establish the PCMH as the medical records aggregator. The 2002 joint principles of the PCMH have been operationalized by a variety of State and public organizations who certify primary care practices as PCMHs. Practices must meet an extensive set of requirements in several domains, and provide supporting documentation to that effect. For example, the current recognition program from NCQA, the leading PCMH certifying body, consists of 151 factors, some mandatory, some optional, and complicated methods for calculating the level of medical homeness a practice offers to its patients. As complex as the process may be, and as difficult as some measures are, the primary care practice has full control over all current PCMH defining factors (other than payment). This is not the case for our proposed 8th principle.  

To initiate the aggregation of medical records by the medical home, someone other than the primary care doctor, must ask the AAP question, “Where is the child’s medical home?”, and then proceed with information transmittal to that place. It is up to specialty clinics, hospitals, nursing homes and other facilities of care to initiate this aggregation. Obviously the PCMH must be able to receive, process and meaningfully aggregate the received information, and in return, make it available to all those other facilities as needed, and to patients at all times. Just like achieving current PCMH recognition does not require that you absolutely must have Electronic Health Records (EHR) software, meeting the 8th principle is entirely possible with nothing more than paper charts and a fax machine, although an EHR would make the process a lot easier for all involved.

So how would we go about adding a medical records home to the plain medical home? We could add half a dozen, or so, factors to be met to the existing NCQA standards and guidelines, while assuming that primary care practices have the necessary clout to force specialists and hospitals to push information back to the medical home on a consistent basis. Alternatively, we could just rely on the kindness of the “medical neighborhood” (a fairly new concept outlining how all providers should help PCMH practices) and hope for the best. Or, we could use the one giant lever at our disposal, which is being used for a variety of other purposes, and gradually add some measures to Meaningful Use.

Specialists have been complaining (and rightfully so) for almost two years that the Meaningful Use program was defined with primary care in mind. Here is an opportunity to add a specialty specific measure that will require all specialists to promptly transmit complete consult notes back to the referring primary care doctor. Hospitals should send ED summaries, admission notes, op-notes, discharge notes and instructions. And let’s make this achievable with large thresholds, by allowing fax, electronic fax, secure email (like Direct) or whatever the sender can use to send. We have plenty of time to insist on structured messages as the infrastructure for information exchange matures. The countermeasure for primary care docs would be the ability to incorporate the information into the electronic chart by scanning it in, receiving it electronically directly into the EHR and attaching it to the patient chart manually or automatically, or by any means necessary. Since most EHR products are capable of electronic faxing or secure email or both, the development effort for EHR vendors should be minimal. And I cannot imagine any doctor or hospital arguing that this measure imposes undue administrative burden, because this goes directly and unequivocally to better patient care.

This proposal wouldn’t be complete without addressing the small, but very energetic, minority of self-described patient advocates, who due to life changing events of their own, or because of other interests, are demanding that the mighty Meaningful Use lever be used to extract data from all medical facilities and transmit it in computable format to commercial medical records aggregators. The assumption being that “adequate health supervision” is most adequately performed by the patient and a myriad of completely free and exquisitely sophisticated tools to be defined later. There is no contradiction here, folks. If the patient prefers to have a separate medical records home, for one reason or another, by all means, let everybody transmit information to wherever the patient desires. If the patient doesn’t want anything transmitted, that’s fine too, and these “opt-out” choices would be counted as exclusions to the measure by primary care medical homes or specialists, or both. My guess would be that with all the managed and accountable care models proliferating out there, patients will be assigned to a medical home, and opt-out choices will be rare. Either way, and with the possible exception of Boston or Silicon Valley, most folks would welcome and be better served by medical records supervision delivered by real doctors and their clinical teams.

Speaking of doctors, I know that many of you consider the PCMH construct as nothing more than a burdensome layer of bureaucracy designed to bankrupt primary care. However, if you look at the seven original joint principles and the additional principle proposed here, it is impossible to argue that the essence of a “medical home” is inconsistent with good primary care, even though the processes around it may very well be. This is not much different than sitting for your medical boards, which may seem unduly bureaucratic, but do not invalidate the essence of being a physician. Furthermore, and adapting freely from Michelangelo, I would submit that the medical home is already there inside your practice and we only need to hew away the rough walls that obscure it from view, and from proper reimbursement.

Is Meaningful Use Too Successful?

Approximately a quarter million clinicians and hospitals have signed up for Meaningful Use incentives to date. Of those, almost a hundred thousand have received over $5 billion in incentives. In addition to the registered providers, there are significant numbers of practicing physicians who do not qualify for incentives, due to payor mix or practice characteristics, and who are also buying and using EHRs. Perhaps this is a bit slower than the most optimistic projections, but the entire program seems to be forging ahead rather well, and EHR adoption is steadily increasing.

The EHR incentive program is funded by taxpayer dollars to the tune of $30 billion, in the midst of a harsh recession, and is supposed to motivate our health care providers to purchase EHRs because according to the White House, the Secretary of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) and obviously the Office of the National Coordinator for Health Information Technology (ONC), EHRs are the cornerstone on which the nation will build strategies to control health care costs while improving population health and quality of care for individuals. Since health care has urgent problems that need to be resolved now, health care providers are receiving incentives to purchase software now, use it in prescribed ways now, and the bar is continuously raised until the ultimate goals are achieved. In addition to direct cash incentives to health care providers, both CMS and ONC are funding, through grant making, all sorts of other health care innovation activities, including new technologies, new care delivery models and novel payment arrangements.

One of the ONC initiatives is the Strategic Health IT Advanced Research Projects (SHARP) program aimed at development of new health information technologies. The SHARP grants, of $15 million each, were awarded over 2 years ago to several universities, with the ultimate goal to accelerate health IT adoption. The SHARP grant for “Health Care Application and Network Design” was awarded to Harvard University to “facilitate information exchange while ensuring the accuracy, privacy, and security of electronic health information”. The grantees chose to focus on developing an iPhone-like SMART platform for assembling EHRs. Not sure how this ties into network design or the accuracy, privacy and security of health information, and admittedly I have often expressed many reservations regarding the entire iPhone paradigm, both here and elsewhere, but this was 2 years ago.

This month’s issue of NEJM contains an article written by the Harvard SHARP grantees which is essentially a blistering attack on the EHR products currently on the market and those who manufacture and sell them. According to the authors, it is only a myth “that medicine requires complex, highly specialized information-technology (IT) systems”.  Since both authors are physicians, let’s assume that they are correct and medicine is as simple as they contend, in which case it is rather unclear to me why after two years and with $15 million in funding, they have not solved the problem in its entirety.

The answer is of course based on the vilification of very successful EHR vendors, since the authors “believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants”. Although I don’t believe there is a dark EHR vendor conspiracy out there, and I don’t believe that health care has much in common with Twitter, Facebook and iTunes, I do agree that health care IT is similar to other “industrial” products, like say, banking, which maintains huge proprietary systems, based on Oracle and IBM software (very expensive) in private data centers (no Amazon clouds), and as funny as it may seem, one of the largest online brokerage firms is using the same MUMPS database as one of our largest EHR vendors, which by the way, is also used by the European project that is mapping the Milky Way galaxy. Just because something was first invented in the sixties (like the Internet), it doesn’t mean it has not changed since, and it doesn’t necessarily mean that it is now obsolete. Anyway, as it turns out, other industries cannot run multimillion dollar businesses with free iPhone apps either. Bummer.

Speaking of mythology, the article goes on to regurgitate the most common myth, asserting without citation that “[c]ommercial EHRs evolved from practice-management (i.e., billing) systems, and in response to the patient-safety movement, vendors tacked on documentation modules and order entry for physicians”. Really? Did Cerner start out as a billing system? Did Epic? What about the many smaller ambulatory EHRs, like Amazing Charts, that don’t even have a practice management module? And how about the shiny new entrants who seem to not be as blocked out as the authors imply? How about Practice Fusion and athenahealth? No, they are not built on a bits and pieces apps model, but they are new and doing rather well, I believe. One with no billing at all and the other ironically, exactly evolved from a billing system, and both regarded as great innovations.

The frustration expressed in this article is pretty common fare from folks trying to enter the EHR market only to discover that the simplicity they envisioned from the outside is nothing more than a mirage. Health IT is a cruel temptress in that way, and many have succumbed to her lures of quick riches. However, this particular article was written by people who are funded by ONC as part of a national effort to get doctors and hospitals to buy and use EHRs, and this article is titled “Escaping the EHR Trap — The Future of Health IT”. Are the authors arguing that the EHRs that ONC wants people to purchase today are a trap? Should doctors and hospitals stop their Meaningful Use efforts and wait until Harvard, if “properly nurtured” (with more taxpayer dollars, I presume), comes up with their version of EHR? Does ONC support this position?

On the ONC website, the description of the Harvard SHARP grant opens with this sentence: “Today's HIT environment is largely populated by outdated one-size-fits-most systems”. This is the same website that was purpose built to encourage health care providers to buy EHRs. Is ONC knowingly paying hospitals and doctors billions of dollars to buy “outdated” systems? I don’t think so, but I do believe that ONC should come up with some sort of response to this article, and perhaps be more careful with the contents of their website and with their grant making processes.

The Other Side of the EHR Mirror

For almost three years now, since the advent of the HITECH Act, and prompted by the exorbitant prices of health care, an animated electronic medical records debate has been unfolding on a national stage. It seems that every possible or impossible solution to our health care woes is in some shape or form dependent on widespread use of computerized medical records. Computers have been utilized to change almost every industry, making products and services cheaper, more accessible and in some instances better, so the hope is that computers can do the same for health care services. There are three fundamental ways in which computerization of an industry is advantageous: process automation, improved information processing and better communications. Arguably, we can use all three in health care.

Process automation need not be construed as referring to the processing of people, although it often is. Health care has plenty of processes that can and should be automated. The most ubiquitous automation is in the form of electronic claim submission and the respective electronic remittance advice (ERA) from payers. The vast majority of physicians are using computers for this process, but even the most advanced practices still have billers in the back office eyeballing most outgoing claims and overseeing the electronic posting of payments. Not to mention the ever increasing burden of patient collections, or the sometimes automated process of checking eligibility for services, or the rarely automated process of verifying status of deductibles. Referrals and pre-authorizations are another labor intensive and time consuming set of processes that can and should be automated. Transitioning these largely administrative chores to the computer requires that rules and regulations are standardized in deference to physicians’ and patients’ judgment (nowhere on the horizon) and that computer software becomes much more reliable and “intelligent” than it currently is (slowly taking place). I’m sure you can think of other business processes than can, or may even already be automated with assistance from computers.

When it comes to automating clinical processes, current day computerized systems have precious little to offer, and perhaps that’s how it should be. Sure, many software products come with clinical decision support, order sets, template based protocols, algorithms and pathways, but none of these qualify as automation of processes, even in instances when a health system mandates adherence to protocols, because manual labor is always required and by definition, variability is certain to occur. However, bits and pieces of the larger clinical process can be and are automated, e.g. orders processing, calculations of numerical values and tracking of events. Other processes, such as transitions of care, could benefit from some automation as well (e.g. automatically sending admission/discharge information to a known primary care physician). When judiciously utilized, computer software can provide some measure of efficiency and quality assurance to the overall clinical process.

There is of course a certain overlap between those bits and pieces of clinical automation and the overarching information processing afforded by computerization. In most other industries held up as examples for what electronic health care should be, there is one basic entity that is being measured, calculated, analyzed, tabulated and displayed: dollars. Dollars across time, dollars across populations, dollars across products and services, dollars in and dollars out. The business of medicine, a.k.a. payers, is as good and as advanced in its electronic dollar information processing as any other industry, if not much better. Unfortunately, clinical information processing lacks a universal unit of measure for all things, and therefore requires much more sophisticated software, and larger efforts to collect the information to be processed. Meaningful Use and the various Quality Reporting programs are meant to facilitate and accelerate the collection of information, with the hope that sometime in the future the collected information will be of sufficient quality to enable meaningful information processing beyond what the insurance sector already does.

Industrial computer enabled communications can take two basic forms, ad-hoc and process driven, triggered by and directed to one of the following actors: customers, or personnel and machines, both of which can be internal or external to the business entity. Process driven communications, which are initiated by machines, are obviously part and parcel of process automation as discussed above. It is interesting to note that even in industries that are heavily computerized, communications to and from external entities, where a buyer/seller relationship does not exist, are either mostly manual and paper based, or very simplistic (e.g. ATM networks). And these are exactly the types of communications we are attempting to computerize in health care by means of health information exchange organizations and the Nationwide Health Information Network (NwHIN). We must realize that this is unprecedented in all those supposedly more computer savvy industries, particularly since the health information to be exchanged is very complex and to some extent “mission critical”.

Interactions of personnel with machines, i.e. use of Electronic Health Records (EHRs) by physicians and other clinical staff, has been the source of much angst and passionate debates on feasibility, merit, timing and approach, and having written thousands upon thousands of words on the subject, I will just say that when you compare health care enterprise software to other industries, ours is no worse, may very well be much better and most definitely includes many more choices than, say, banking software or supply chain software. The only difference is that the President of your bank is rarely in need of using the software, while the “president” of a medical practice must use the software all day, every day. This is where the problem is, and this where a solution is needed. Rearranging boxes and buttons on computer screens will not provide much relief.

Last, but not least, are the budding electronic communication channels between health care customers (patients) and health care industry machines. Here we take the fateful step to the other side of the EHR looking glass to see what patients see. Health care was never too terribly concerned with patients’ interactions with their medical records. Health care, although usually paid for when possible, was considered mostly an act of kindness, hence the “care” in health care. People did not “deliver” or “provide” care. Instead they “attended”, “administered”, “nursed” and generally cared for the sick, the wounded and the dying. The result was a rather unique relationship based on gratitude, fear, hope, trust, deference, commitment and all sorts of other human emotions. Examining the books was not in the realm of considerations and most patients lacked the basic abilities to do so. Over the years, health care, or rather medicine, has transformed into a profession and now it is morphing into a service business with providers and consumers. Like a bank. And everybody knows that you must keep an eye on the bookkeepers. As the preferred solution to our health care crisis is beginning to emerge, in the form of transferring more costs to consumers, so they can control expenditures by only purchasing what they can afford, it is becoming imperative to have smooth and comprehensive communications between patients and health care’s newfangled computers. Like a bank.

When EHRs started out, no special provisions were made for patients (or communications in general). Financial software started out much the same way, but since banking was always a consumer business, the advent of the Internet and now the mobile Internet, brought us very slick, very useful and very consumer friendly Portals. And health care was left behind. First very slowly, and more recently at an accelerated Meaningful Use pace, EHR vendors began providing Patient Portals, and providers began buying them and deploying them. The online services in Patient Portals range from pathetic to pretty darn good, but there is a long way to be traveled before we reach the functionality and usefulness available in the financial or retail sector. It will happen though, because just like nobody would open an account at a bank without online services, pretty soon nobody will be willing to purchase health services from a provider without a useful online presence. It will become a differentiating factor first and then it will become a given that you can get most of your health services online. Just like a bank.

The time when patient needs were overlooked by EHR vendors has long since passed, and I am expecting to see significant advances in consumer facing software in the next couple of years. Your customer should not need to go to Walmart for a telemedicine quickie, and shouldn’t need to “transfer” information to Microsoft for figuring out his health status, and shouldn’t have to download “free” apps to manage whatever ails them. You as a provider, and your now computerized health business, should be able to provide everything your customer needs (and more) on your own customer Portal, for the web, the iPhone and Android devices. And you will, because this is quickly becoming a cost of doing business. Just like a bank.