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.