The Patient-Centered Medical Home (PCMH) and Healthcare Information Technology (HIT)

Background
Originally developed as a rallying cry to promote primary care in the United States, the Patient-Centered Medical Home (PCMH, or “medical home”) has gained prominence not only among leading medical associations, but also with other stakeholders including payors, patients and legislators as a model for addressing the fragmented delivery of care in the United States through practice transformation and payment reform.

The American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics and the American Osteopathic Society have convened a national multi-stakeholder coalition-the Patient-Centered Primary Care Collaborative (PCPCC)-to advance the PCMH model. The Collaborative has formalized a set of principles [i] that focus on the trust relationship between a patient and his/her personal physician. Hallmarks of the PCMH include:

Identification of a personal physician for first contact, continuous and comprehensive care.
A practice-level care team that is physician-directed, where the personal physician maintains overall responsibility for managing the care provided to the patient.
Patient-care that is whole-person oriented where the personal physician is responsible for providing or arranging the care and services for each patient throughout his/her lifespan.
Integrated or coordinated care where the personal physician is the focal point for integrating the services and care for his/her patient across care settings. This level of coordination also takes into account the patient’s family and community resources.
Patient activation and self-management through joint goal-making with the personal physician and his/her team.
Use of technology including both clinical and practice management tools to assist in clinical decision-making (e.g., codification of evidence-based guidelines), workflow management (e.g., test tracking and referral management) and exchange of information among all those involved with the patient’s care.
Physician accountability through voluntary participation in quality improvement and reporting activities.
Enhanced access through open scheduling and advanced forms of communication between patients and their physicians.
Payment reform that appropriately reimburses personal physicians for the increased value provided through the PCMH.

Leveraging Health Information Technology (HIT) within the PCMH
The medical home model has begun to garner public attention; media stories emphasize not only the patient benefits of first contact, continual and comprehensive care with a personal physician, but also the benefits to the community of physicians-particularly in the decimated area of primary care– in terms of their ability to once again practice medicine in a way that rewards the quality of care rather than the quantity of care provided to one’s patients. Additionally, the aspects of improving the level of care coordination between generalists and sub-specialists-the entire “house of medicine”– and the potential to improve clinical outcomes appeal universally to all stakeholders.

The resulting change environment has led to current efforts to establish a voluntary program for certifying physician practices as a medical home. The National Committee for Quality Assurance (NCQA) has recently updated and extended the criteria for their Physician Practice Connection (PPC) program as a certification pathway for PCMH. Under the guidelines [ii] of this program, a physician practice is evaluated along the following nine areas:

1. Access and Communication
2. Patient Tracking and Registry Functions
3. Care Management
4. Patient Self-Management Support
5. Electronic Prescribing
6. Test Tracking
7. Referral Tracking
8. Performance Reporting and Improvement
9. Advanced Electronic Communications

Although an electronic health record (EHR) is not required to achieve Level I and II PCMH certification, only practices that use both an EHR and practice management systems (PMS) can achieve the highest level of certification, e.g., Level III. Advanced EHR functionality such as embedded e-prescribing, the use of clinical decision support and the ability to generate quality improvement reports based on national measures are typically available in a comprehensive EHR product. Similarly, workflow engines that automate tasks like lab and referral tracking and “close the loop” for services ordered and provided across care settings are features of advanced practice management systems. Several ambulatory EHR companies have begun to evaluate their capacities to support the medical home, using the NCQA standards as their guide.

The level of PCMH certification a practice can achieve is important because, as of this writing, the amount of reimbursement is tied to the level of certification. Several states, together with a variety of payors, vendors and professional medical associations, are in various stages of developing or implementing demonstration projects to test the medical home model and evaluate the process and financial impacts on the healthcare system. More importantly, the Center for Medicare and Medicaid Services (CMS) has begun its own medical home demonstration project that will include eight states across the country [iii] ; with an average Internal Medicine (IM) physician panel of 40% Medicare patients, the results of this demonstration will significantly shape the future of the medical home model. CMS has slightly revised the NCQA program and certification levels to address their institution’s goals. Physician participation in these demos is important to their success and many demos plan to offer some in-kind support to practices; interested practices should reach out to their state medical societies, major payors or professional medical associations to identify any opportunities in their practice area.

To Learn More
The following sites are provided as additional educational resources:

The Patient-Centered Primary Care Collaborative (www.pcpcc.net)
American Osteopathic Association Welcome Home (http://www.osteopathic.org/files/pub_do0308medhome.pdf)
American Academy of Family Physicians PCMH Q&A (http://www.aafp.org/online/en/home/membership/initiatives/pcmh/brief.html)
American College of Physicians - What is the Business Model for the PCMH? (http://www.acponline.org/advocacy/where_we_stand/medical_home/business_model.htm)
National Committee for Quality Assurance PPC-PCMH (http://www.ncqa.org/tabid/631/Default.aspx)
CMS Medicare Medical Home Demonstration (http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1199247)

[i] http://www.pcpcc.net/node/14. Accessed 08/22/2008.
[ii] Standards and Guidelines for Physician Practice Connections® ̶ Patient-Centered Medical Home (PPC-PCMHTM). Downloaded from www. ncqa.org.
[iii] http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1199247. See download of legislation.
Maria E. Rudolph - Vice President, Medical Informatics