The Computer is my Shepherd…

If this were a business concerned with bottom lines, cash flows and sustainability, this would be a good time to begin planning one of those posh executive retreats to evaluate current strategy. People would be feverishly working on pulling data for Power Point presentations, summarizing market research and deciding whether to select the vegetarian meal or not. If this were a better business, lots of little meetings would take place in preparation, and resolute department heads would be soliciting original thought from those not invited to the big executive retreat, but whose jobs are now on the line along with the department heads and maybe even the executive suite. But this is not a business and it is unclear who the executives are, or if there are any at all, so there will be no strategic retreat. There will be no retreat at all because we are witnessing the birth of a new religion, and the true faithful don’t ever retreat.

Once upon a time, two three decades ago, health care businesses attempted to utilize computers, just like everybody else, in their daily work. And just like everybody else, those green-eyed early computers were found to be pretty good for administrative health care tasks previously conducted by means of forms and ledgers. Those were just big (really big) calculators and typewriters rolled into one, with the added benefit of being capable of storing and recalling their work. With the advent of the Graphic User Interface and the Internet, computers were increasing their charm and capabilities by leaps and bounds, and almost every business sector found utility in transitioning administrative and drudge work to computers, and health care was no different. The bigger and more complex the business entity, and the more repeatable and uniform its processes were, the more returns on investment could be extracted from computerization. You would be hard pressed today to find any business of any size that is not using some sort of computer software for accounting, scheduling and inventory management purposes, and health care is no different. Mass production and mass consumption industries were able to extract returns from a much deeper integration of computers into their business, and sometimes even a competitive advantage from proprietary ways of utilizing their proprietary software.

Some industry sectors though seem to have been left behind, not because their administrative tasks are not computerized (they are), but because they were unable to make computers part of their core service or business. Most of these sectors are in business to provide local personal services, where the service itself is highly dependent on client preferences and circumstances and/or the service requires manual labor touching the client or his/her property. For example, there is no software for arguing in front of the Supreme Court (or even a night court) via standard vocabularies arranged in structured data fields and transmitted over standard Internet protocols. Legal services are just one example. Hair styling, fresh flower arrangements, restaurants, yard work, house cleaning, fitness coaching and medicine are other examples of businesses where standardization is difficult. In recent years, some of these industry sectors experimented with mass production of their offerings, some over the Internet, and others through computerized supply chains of human labor, and quite a few were successful in increasing market share by creating cheaper, limited in scope and quality, standardized service offerings.

Presumably based on these experiments and perhaps on other insights, medicine, which is the only not-yet-automated sector to come to national attention (for obvious reasons), is now being ordered to computerize and standardize itself. The belief is that computerized, standards-based medicine will be cheaper and better, not just good enough, but actually better. This is a bit strange, but it’s very difficult to argue with beliefs. For example, when CMS published its final Meaningful Use Stage 2 criteria, the document contained over 300 references to the authors beliefs (We believe = 219; we continue to believe = 29; our belief = 10; we do not believe = 60), and very little evidence to support the proposal. Fortunately, the evidence is beginning to hobble in from all sorts of conflicting sources.

The newest report comes from a JAMA study performed at Kaiser facilities in Colorado and it shows that patients with computerized access to their medical providers increased their utilization of in-person medical services by a little bit. One could and should argue that these patients were self-selecting for computerized access and obviously all hypochondriacs must have chosen such access. One could also argue that these patients are now actively engaged in their care and chances are that in the long-term their health will be better and their care will be cheaper. Previous studies at Kaiser found the exact opposite effect, but we can’t infer the opposite now without shooting the new theory in the foot. Perhaps in Colorado, Kaiser advises those who email with vague symptoms to come in or go to the ER, and in other locales Kaiser may be suggesting that the email sender takes two aspirins and email again next morning, or maybe some other mysterious factor is at play. Another experiment with posting medical records online showed that patients like it that way and doctors were fine with it too. So why not? There you go.

And then there is the shocking billing problem. As the New York Times reports, Medicare is wringing its hands in despair because we just figured out that computers itemize charges exceedingly well and thus allow Medicare’s contracted providers to bill more like lawyers than doctors. Since Medicare can only look back at two year old claims, I would venture a guess that they are in for another rude awakening in a year or two, when the full effect of the intentional herding of independent doctors into hospital employment hits Medicare’s slow like molasses accounting system. Why? Because Medicare agreed for some peculiar reason to pay hospital employed doctors twice or three times as much as they pay private doctors for the same exact service. So in order to cut costs, Medicare is upgrading to larger and more expensive contractors, in the belief that those can provide better care, and better care is believed to be cheaper care, for which we agreed to pay more. Don’t ask me….

Back in March, Health Affairs published a study showing that computerized medical offices tended to order more expensive tests. But that study too was resting on shaky grounds and was loudly disputed and contrasted to other equally rickety studies showing more inconclusive results. Surveys of medical professionals stating that computers take them away from patient care are routinely dismissed as growing pains of an older generation, or anecdotal evidence at best. One such anecdotal evidence is an ER doc who took the trouble of doing a time-motion study on his shift and found that during a 420 minutes shift, he spent 156 minutes interacting with patients and 237 minutes interacting with the computer. But that’s just one doctor and he was using one of those terrible legacy software products. No doubt newer programs, yet to be developed, will be much more efficient. For right now though, if this physician is salaried, the cost of his services just doubled.

Speaking of new and improved computerization, Meaningful Use will increasingly emphasize clinical decision support in an attempt to make sure that medicine is practiced the right way. To that end, Meaningful Use is proposing to remind both doctors and patients of a multitude of preventive care screenings that should be done for asymptomatic patients. Screening for breast cancer, colorectal cancer, cervical cancer, elevated blood pressure, high cholesterol, just plain being fat, chlamydia, unhealthy alcohol use, tobacco use…. you name it. And sanctioned preventive care is now pretty much “free”. This must be a good thing for people’s long term health, right? Well, at least regarding breast cancer, a brand new NEJM paper (reiterated by the New York Times) contends that around 1.3 million women were actually harmed by treatments for cancers they didn’t have, over the last 30 years of breast cancer screening religion. And how do people think utilization of medical services will be affected by computerized reminders for every (insured) person to present at the nearest clinic to be screened for fatness, hypertension, high cholesterol or drinking too much beer? You’d think people will probably ignore these reminders, but now that the Secretary of Health and Human Services is officially empowering your insurer and your employer to levy financial penalties if you, or your children, don’t get screened and don’t get “necessary” treatments for your “condition”, chances are that we are all going to become engaged patients, or a nation of medicated hypochondriacs, depending on your point of view. And this is the true power of standardized computerization of medicine.

Computers as their name indicates are best at computing, and in order for computing to commence, enough computable data needs to be supplied to the Computer. If we could tag every person, living or dead, with a unique identifier, and if we could model every person in terms of a finite set of elements, and if we could define a finite set of possible actions to be taken on each modeled element by external and internal forces, we could then unleash the infinite power of the Computer. The Finite Element Method (my first and true love), or its stochastic cousin, has been successfully applied to many previously incomputable phenomena, and conceptually it could be applied to biological organisms. Computers then, would tell us what works and what doesn’t, what costs more than it’s worth and what is a great bargain, where every modeled person is and what every external actor does at any given point in time. Better yet, the Computer could tell us what every modeled person, and what every externally applied intervention, should do in every modeled circumstance to elicit predefined outcomes.

The crude modeling of current clinical decision support rules is irrelevant. How people react to having email access to their medical providers is irrelevant, and whether a doctor orders a couple more MRIs, bills a couple more dollars per visit, or spends a couple more hours wrestling with primitive software, is also irrelevant. The only relevant thing in this quest for imposing order on the seemingly chaotic human condition is the collection of computable data. The rest will follow in good time, or we’ll run out of money, whichever comes first.

Meaningful Use – A Pinch of 3 and a Dash of 4

While most folks are busy trying to keep up with Meaningful Use Stage 1, and Meaningful Use Stage 2 only recently emerged from the customary rulemaking process, those who plan for distant futures are providing us a glimpse of what is being considered for Meaningful Use Stage 3 and here and there a hint at the possibility of a never before mentioned Stage 4 and beyond. Since Stage 2 is still somewhat theoretical, there is little value to enumerating the proposed measures of Stage 3, which is not due to take effect until 2016, but it may prove instructive to take a general look at the overall direction that seems to be favored by policy makers for future design and use of EHR technologies. To that end, several new proposed measures seem most enlightening.

The New US Census Bureau
Stage 1 of Meaningful Use added language, race and ethnicity to the customary demographic information collected from patients, such as name, address, date of birth, gender, etc. Stage 2 proposes to add language, race and ethnicity to clinical summaries provided to patients or sent to other providers of care. So the patient header of a Stage 2 clinical summary might look something like this:

Stage 3 proposes to require the collection of Occupation, Sexual Orientation, Gender Identity and Disability Status in structured, codified format. A futuristic clinical summary header may look a bit more substantial:

It’s anybody’s guess how long Ms. Doe will be able to keep her minimum wage janitorial job at the little church preschool, once her clinical summary gets circulated among neighborhood providers. The good news of course is that the IOM suggested research agenda on LGBT issues will be significantly advanced, which should eventually benefit Ms. Doe by shading light on disparities she is experiencing a bit more frequently than she expected. With a few more additions to the demographics recording section, perhaps in Stage 5 or 6, we could also save serious federal expenditures on the National Census which should become obsolete following full harmonization with a person’s EHR.

Clinical Decision Surveillance
Meaningful Use Stage 1 began the process of introducing evidence-based advice into clinicians’ workflow and Stage 2 is proposing to broaden availability of helpful alerts and notifications regarding disease management, preventive care and potentially harmful errors. Meaningful Use Stage 3 is contemplating a surge in such activities and is aiming to triple the number of EHR enabled clinical decision “interventions” to 15. To ensure a uniform approach, there seems to be a trend towards externally supplied “interventions”. For example, Stage 4 is mentioning externally maintained drug-drug-interaction (DDI) lists, which is a bit strange since EHRs currently do receive DDI from external sources, such as First Data Bank or Wolters Kluwer anyway, but considering the new ONC sponsored Health eDecisions workgroup and similar other activities, it seems that a centralized approach may be in the works. Thus, Stage 3 is making the initial foray into prescribing clinical decision interventions to include renal dosing checks and “appropriateness” checks for lab and radiology orders. Beginning with Stage 3, it is envisioned that EHRs are able to record and track clinicians’ response to prescribed interventions and in some cases mandates that clinicians view certain information “before” administering immunizations, for example. I think we could save boatloads of money if we required clinicians to install keyloggers on all devices where they might use an EHR from.

On a slightly different note, I find ONCs tortuous grappling with bringing formulary advice from the Pharmacy Benefits Management (PBM) industry into the EHR workflow, somewhat perplexing, since every Surescripts certified electronic prescribing module is already ensuring that PBMs formularies are clearly marked and physicians cannot prescribe anything off formulary without first staring at a screen detailing the PBM’s formulary alternatives (retail, mail-order, copays, etc.), and moreover, the PBMs (who own Surescripts) reserve the right (and exercise it religiously) to approve the actual screen designs for the entire prescribing flow. There is no need to pretend that the Surescripts monopoly doesn’t exist. If ONC needs to make the PBMs happy, Meaningful Use EHR certification should require Surescripts certification, just like CCHIT did in the past.

Bad EHR Design
Meaningful Use Stage 1 logically started with a requirement for EHRs to maintain problems and medications lists. These basic data points have been rolled up into a Clinical Summary requirement in Stage 2, but Stage 3 is proposing advanced ways to improve the accuracy of these lists which are at the heart of a medical record. In Stage 3 EHRs are supposed to be reviewing test results and prescription lists and suggest to physicians additions/edits to the problem list, and in parallel check the current problem list and come up with advice regarding changes to the medication list. The examples given in the Stage 3 document are for the EHR to suggest a diabetes diagnosis if it finds hypoglycemic meds, or to express concerns if it finds an antibiotic lingering around without some appropriate diagnosis. This sounds like the beginnings of magical artificial intelligence, IBM Watson style, because you can only imagine how many diagnoses the EHR could suggest for a particular med or lab test. But then, one question comes to mind: what are these meds and tests without a diagnosis doing there in the first place?

A good EHR should not allow anyone to order a test or prescribe a medication without associating it with a diagnosis even if it’s just differential, rule-out, etc. Besides, you need this association if you, or the lab, or the patient, want to get paid for the effort. If we enforce this clinically sound, basic design rule, there should be no need for Watson to weed through garbage data and fix it, and the government should not force such sloppy convoluted design on software products, many of which are already designed correctly. As to finding antibiotics floating around the medication list for no good reason, I wonder if the government is aware that good electronic prescribing systems are either asking for a stop date or are calculating it based on the prescribed quantity (including refills), after which the medication is removed from the active med list. So why should a conscientious EHR designer be forced to implement extremely expensive and fraught with ambiguity algorithms to clean up something that should be clean and buttoned up from the get go? Wouldn’t it be much simpler, more logical and infinitely cheaper to require that all CPOE orders have a diagnosis associated with them when originally entered into the system? And either way, wouldn’t it be wiser to let software builders and their clients make these micro-design decisions on their own?

The Road to Hell
One of the most wasteful and aggravating activities in a medical practice is obtaining prior authorizations for various orders. In a valiant effort to come to the rescue, Meaningful Use Stage 4 and beyond is proposing to automate the process, by having physicians enter the necessary information in the EHR and through “web services” automatically receive “real time” authorization (or denial) from payers. Sounds pretty straightforward, but someone should notify the payers. Prior authorization requirements are put in place by insurers to discourage ordering of expensive items, and to that end the process is made so onerous as to make physicians think multiple times before attempting to order something that is not automatically covered. If you look at something as simple as Medicaid drug formularies, there are 50 different sets of rules, one for each State, and then as many more as there are managed care plans in each State, and the rules are different for various medications. Some require stepping through a complex phone triage protocol and are dependent on covered diagnoses (Oregon), some have a special form for each drug, and others have generic forms for all brand names, except a subset of specific brand names. Some specify exactly what supporting documentation is required, while others have nebulous “medical records” requirements.  Some have requirements that patients actually suffered an adverse event from stepping through cheap drugs, and in an extremely patient-centered manner are specifying that “client said” or “client reports” is unacceptable (Utah). So much for patient engagement….

To incorporate automated prior authorization into a nationally marketed EHR in a meaningful way, the software would have to computerize thousands of perpetually changing perverse decision trees, with no assurance that the payers will reciprocate the effort. You can make an educated guess regarding the increase in EHR complexity, brittleness and consequently price tags. Wouldn’t it be better for CMS to first standardize the rules for prior authorization across payers, or at least across itself (Medicare/Medicaid and all commercial derivatives thereof)?

Suggestion
The notion that EHRs and health information technology can be used as a “lever” to alter the business of health care delivery is basically flawed. To date, the only business changes occurring in the health care delivery system are the demise of small private practice and the transformation of health systems into increasingly monopolistic entities, and while the Meaningful Use complexity and expense is not the main driver, it is certainly playing a non-negligible part in this development. Besides, health care delivery is largely dictated by health care financing models, and while I appreciate the difficulty of imposing anything on an industry that spends billions of dollars on lobbying, perhaps CMS can lead by example.

Would CMS consider making its databases available to EHRs through “web services” to obtain demographic and clinical information in “real time” on all Medicare and Medicaid patients? Maybe we won’t be able to get the patient’s BMI or Sexual Orientation, but we should be able to get a pretty accurate (and medical necessity validated) list of problems, medications, procedures, hospitalizations and whatever else CMS paid for, along with the most accurate demographic data (inaccurate claims are denied). Wouldn’t that be a perfect first step in “information exchange”, for the sickest and most expensive patients? And if technology is then shown to cut costs for CMS, wouldn’t private payers follow suit at short notice? Every EHR vendor I know will be fighting to be the first to connect its clients to this data. Perhaps it’s time to impose some meaningful technology and openness rules on the payer side of the house. All the query-response standards for exchanging a minimal, yet extremely valuable, dataset are in place, and all Meaningful Use certified EHRs should be able to process this dataset. How about downsizing and elevating Meaningful Use Stage 3 out of the weeds and branching out to Meaningful Access Stage 1 in 2016?

Electronic Parking Lot

I was headed to a meeting downtown yesterday, and finding a place to park in the city is always a challenge. Luckily, there is a little old lot right next to the office building, which is a bit more expensive and does not accept any ticket validation, but it’s very clean, well lit and convenient. Up until last year the lot was owned and operated by a “mom and pop” type of business. You pulled in, found a good spot and by the time you grabbed your stuff and stepped out of the car, an elderly gentleman was standing there writing your receipt. You gave him some cash, took the little pink receipt and went about your business. When you were done, you came back, got in your car and drove away. No automated barriers, no buttons, no credit cards and no hassles. Yesterday, my little parking lot was different.

The first thing I noticed was that the parking spots were numbered, with big white digits imprinted on the freshly resurfaced asphalt. The second thing I noticed was that it was a bit harder to park because the spaces seemed to have shrunk a few inches on each side, and the third noticeable difference was the absence of the always cheery old attendant with his perennial pink book. Looking up and down the small lot, I saw a big sign at the entrance sporting the logo of some “Parking Lots R Us” company, and at the far end I saw a group of men wearing suits engaged in animated conversation. Maybe the attendant is now wearing a suit too. I headed over to the group and asked to pay for my parking. They were business men from another town trying to figure out the same thing, and right behind them was a brand new machine, looking very much like an ATM, about 4 feet tall, with lots of buttons and stickers on it explaining the process. Piece of cake.

I’m a technology geek, I travel quite a bit and I’ve seen similar machines before. I walked through the befuddled small crowd of what must have been potato farmers with no access to computers (or so I decided), which parted reverently like the Red Sea did for Moses, and approached the machine. It had a credit card slot, so I pulled out a random card and inserted it in the slot. Nothing. Pulled it out, and put it back in. Still nothing. Circled the machine slowly, and saw a picture of the exact card I inserted on the colorful sticker on the back of the machine. It should accept it, and there was no place to insert cash. I decided to try another card and this time, the machine came alive with a “Processing….” message on the huge screen on its front. I guess it has preferences the manufacturers didn’t know about. My potato farmers were happy with the progress, and digging through their wallets for a similar credit card. Then the machine requested that I use its buttons to enter my number. It was a credit card, so I had no idea what number it was asking for. Engineers don’t ever read instructions, but at this point, I felt a departure from customary behavior was acceptable. The big sticker with small fonts said that I needed the parking spot number. Aha. I looked back to my car, but the big white digits on the asphalt were hardly visible now, so I started walking towards my parking space. Luckily some spaces on the near side of my car were empty, and using advanced mathematics, I figured out that my number was 23. I yelled it out and the youngest potato farmer punched it into the machine. Of course he didn’t hit the “Enter” button, so nothing happened until I went back and completed the transaction. The machine printed out a big ticket, and flashed some advice on its screen saying that the ticket must be visible through the windshield, or a $50 fine will be assessed, which is twice what I had to pay today and 5 times what I used to pay the old attendant with the pink book. Then it said “Thank You” for parking with “Parking Lots R Us”. The potato farmers were cheering loudly, and emboldened by my success, proceeded to pay for their parking amongst much excitement and running back and forth to their cars to find their “numbers”. Technology can be so satisfying.

Good thing I had to go back and place the ticket in a visible spot on my dashboard, because I found that I had forgotten to roll my window all the way up, and you never know when it will start raining on a bright and sunny day. On my way out of the parking lot, I almost stumbled on a potato farmer, bending down to catch a better glimpse of his parking space number, and sticking out of his shoulder bag was a spiffy MacBook Air shining in the sun. Maybe they weren’t potato farmers after all. Oh well, I was 20 minutes late for my meeting and for some reason had trouble concentrating on “The Barriers and Benefits of CPOE Adoption in Community Hospitals”. So I wrote this blog instead. I'll write about Meaningful Use Stage 3 later.

Who’s Afraid of the Medical Home?

Obamacare is here to stay, and with it a host of initiatives small and large, some intended and some not so much so, targeting massive transformation of the health care delivery system. One of those initiatives involves the adoption of the principles of a Patient Centered Medical Home (PCMH) for primary care as formulated by the primary care medical associations, and to a large extent, as translated into operational processes by the National Committee for Quality Assurance (NCQA). There are other implementations of the PCMH put forward by public and private organizations, but NCQA’s Medical Home recognition program is considered the gold standard for PCMH. The PCMH concept is also here to stay, and as is the case with Obamacare, the Medical Home model has its supporters, its detractors and all sorts of misconceptions and implementation missteps.

If you randomly ask a primary care physician about his/her opinion on the Patient Centered Medical Home model of primary care, you will most likely get one of the answers listed below in order of increasing prevalence:

1. Absolutely fantastic way to practice medicine. We’ve been doing this for a while and are a Level III recognized Medical Home.
2. The idea is good and we are currently making the transition and working on obtaining NCQA recognition. It’s not easy, but we are hopeful.
3. We are part of a PCMH pilot in our state. It’s a lot of work and I am not convinced that it will have any benefits for my practice.
4. I read about it, but I can’t afford to hire dieticians and social workers and spend time on all the paper work.
5. I don’t have time for this.  Just a bunch of government regulations that do nothing for patient care.
6. This is the final nail in the coffin of primary care. It’s going to drive all remaining independent physicians out of practice, which is what the government wants anyway.
7. My mother-in-law is in an assisted living facility, but other than that I don’t have any patients in nursing homes….. I don’t take Medicaid.
8. Say that again….?

Just like Obamacare is not something invented by overzealous socialists, but the brainchild of extremely conservative thinking, the PCMH is not a government invention, but instead it is based on a statement made by physician associations attempting to define good primary care and the need for insurers to pay more for such excellence. The devil of course is in the details. It’s been said that the “official” NCQA PCMH requirements consist of too many details, and that some of those details are bureaucratic in nature, burdensome, expensive and contribute little to patient care. It’s been said that true quality of care and practice transformation, whatever that may be, is largely independent of counting points, formal testing, certifications and recognitions.  Granted, all these contentions seem reasonable, but before deciding to walk away, how about a quick bird’s eye tour of what NCQA PCMH recognition really is?

The six parts of formal NCQA 2011 PCMH recognition are called Standards. Let’s take a critical look at each one and note the order in which they are arranged.

Standard #1 - Enhance Access and Continuity – Continuity here refers to people having a personal physician instead of seeing whoever happens to have time that day. I don’t know many practices where this is not the case anyway, but it’s hard to argue against the need to build a long term relationship between patients and their doctors, and it’s even harder to argue against this being the #1 foundational requirement of delivering high quality longitudinal patient care. Note that by definition solo practices are automatically set up to care for patients this way (just saying…). The second part of this Standard is a bit more problematic from a physician’s point of view, because it does require availability after hours and seeing patients the same day as much as possible. It is not an easy task to start tinkering with your schedule, if you are not currently offering same-day appointments, and done haphazardly, it may have serious financial implications to your practice. How about being available after hours, particularly for a solo or very small practice? How about your family and personal life? If you are one of the new concierge docs with a tiny panel of well-behaved patients, this is obviously not an issue. If you have 2500 patients, or so, on your panel, some creative thinking may be required. How would your patients react if, say, every Tuesday you’d start seeing patients from 12 pm to 8 pm? Or if you closed early on Wednesdays and twice a month you saw patients on Saturday mornings? Or if you had an arrangement with a couple of other practices to provide urgent care at odd hours on a rotating basis?

A recent study in the Annals of Family Medicine found that total health care expenditures were 10.4% lower for patients who had access to extended hours of care. This is great news for the “system”, but how about benefits to you and your practice? Whether you like it or not, you are now competing against business models with extremely low overhead, such as grocery store clinics and virtual tele-medicine clinics, offering pseudo-primary-care to your rushed and hurried patients for simple needs, leaving you to deal with complex visits that cost you a lot to deliver, but pay as much (or as little) as the simple ones. Unless you start thinking outside the box, your model of business is destined to become obsolete. Offering some electronic visits, providing hours for urgent care needs and collaborating with others on extended coverage may very well be a matter of survival. Interestingly enough, another recent JAMA study, although limited to community health centers, finds measurable correlation between access and continuity and lower operational costs per unit of service. There should be very little doubt at this point that Standard #1 is the place to start work on the viability of any practice, or ignored at significant peril.

Standard #2 - Identify and Manage Patient Populations – This one sounds onerous and a departure from individualized patient care, but is it really so? The “populations” term notwithstanding, all this Standard requires is that you document patient demographics and clinical information in the chart (seriously?), that you take good histories and that you send reminders to your patients to mind their chronic and/or preventive care needs. There is really nothing here that a good primary care physician doesn’t already do, and probably to a much greater extent than the NCQA standards specify. The one thing that may be different is that this Standard talks about proactive reminders to patients that don’t come in to see you on their own. Good for business and definitely good for patient care on an individual level.

Standard #3 - Plan and Manage Care – Another statement of the obvious, but this standard uses terminology that may raise some eyebrows. For example, it asks that your care is evidence-based. Is your care not evidence-based? Surely you decide how to treat patients based on your education, what you learned along the years, books, articles and latest research, instead of throwing darts at a random treatments list hanging in your office. And this is really all there is to this Standard, other than practicing medicine, i.e. seeing patients, evaluating conditions, planning care, talking to patients, and generally speaking, being their doctor. 

Standard #4 - Provide Self-Care Support and Community Resources – This may sound like the new age fluff of patients taking care of themselves, and granted, there is some of that here, but the details are again pretty straightforward in their intent to have patients understand their conditions and do something about it. Primary care docs don’t usually fit the much publicized portrait of aloof and paternalistic doctors who won’t give you the time of day. It is the time constraints in fully loaded practices that may prevent some from fully engaging with their patients, and no certification process will change that without proper shift in reimbursement, or a change to a more direct practice model with smaller patient panels. This Standard’s feasibility is also highly dependent on patients themselves, but there are simple things you and your staff can do to better enable patients to take some responsibility for their own health (most of which you are probably doing already), and this is all this Standard is about.

Standard #5 - Track and Coordinate Care – Do you send patients to specialists and then forget all about them? Do you order lab tests and don’t care if the results come in or not or if they are normal or not? Do you get calls from the hospital notifying you that one of your patients was admitted, and you hang up thinking that this is not your problem? No? Then you are tracking and coordinating care. Can you do more? Probably, but here you are largely at the mercy of specialists and hospitals in particular. You most likely already have tickler lists to help remind your staff about getting specialists notes and test results, but it is extremely difficult to have the hospital contact you if you are not admitting your own patients (and sometimes even if you do). There is effort (and costs) involved in better tracking and better coordination and payers are starting to take notice as evidenced by the latest care coordination CPTs added to the Medicare physician fee schedule.

Standard #6 - Measure and Improve Performance – Here it is. This is the measuring, reporting and all administrating bag of requirements, complete with patient satisfaction surveys, sending data to payers and using electronic medical records. While most items here are optional, a medical home is required to set some improvement goals for clinical measures (just goal setting, not necessarily outcomes). So after doing everything outlined in previous Standards, this is where the assumption is implicitly made that a medical home should be able to continuously improve the care it provides. Perhaps you believe that you are already providing excellent care, and no doubt most of you do, but is there anything more you can do? This Standard is asking you to consider this question, and if you have an answer, begin acting on it. And yes, this too may take more time and more effort on your part, and thus be dependent on payments to support these efforts.

Did I leave anything out? If your opinion of the PCMH was something along the lines of #6 above, you are probably wondering about some “strategic” omissions. How about all that “team care” and nurse practitioners? How about those case managers and dieticians? What of the need to buy, implement and use an expensive EMR? Well, for starters these things are optional in nature. Unless you are a team of one, you already have people helping you out with patient care and administration, and you are not required to use or augment your staff more than you are comfortable with. A good EMR should help, but it is not mandatory either. And yes, NCQA will recognize nurse practitioner led practices as medical homes, but this is reflective of legislation at State levels, and it should be appropriately addressed at a policy and legislative level as well. As to the infamous amounts of paperwork involved, yes, there is plenty of that, but there is also plenty of help out there and you just need to find it.

On the surface the NCQA PCMH recognition process is an administrative test for primary care, but if you look at it carefully, you can see that it is also a logically ordered roadmap for quality primary care and a tool for you to take a fresh look at your practice and position it to change with the times without having to sacrifice your ethics and your principles. Some things in this roadmap are at the heart of what you do every day, others are things that you may want to do if time and finances allowed, and few are in the realm of “forget it”. Unlike Meaningful Use, the NCQA PCMH “test” is not an all-or-nothing proposition and there is reasonable freedom for you to discard those “forget it” items, or postpone the wishful thinking for a better day. There should be financial benefits accruing from just doing some of the things on this roadmap (such as Standard #1), and there are financial incentives from payers for doing other things or from just “passing the test”.

The medical home is a timeless model of care, repackaged for these troubled and technology driven times, and as such, it is also a business model for the future of primary care. You could approach the entire exercise as yet another payer and government mandated intrusion, or you could make this roadmap your own, and look at it as a means by which to refine and sustain an already excellent practice. It is ultimately all up to you.

[Disclosure: I am the founder of BizMed, a company whose mission is to support the viability of independent medical practice, and to that end it offers free software tools to reduce administrative complexity in private practice in general, and PCMH recognition in particular]