Patient-centric medical homes are touted to fix the healthcare cost crisis, but the deep pockets and extensive IT resources they require aren't available to every healthcare provider.
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Debacle is certainly the right word to describe U.S. healthcare costs. Americans spend about $7,300 per year per person on healthcare, according to the April 2010 Harvard Business Review. And with an average U.S. lifespan of 78, that translates into about $570,000 per person over a lifetime. If we stay on this course, nearly half of the U.S. economy will be spent on medical care by 2080, the Congressional Budget Office says, which is essentially the road to bankruptcy.
The National Committee for Quality Assurance is one of healthcare's many stakeholders who suggest a patient-centric medical home is part of the solution to this mess. NCQA describes this medical home as "a healthcare setting that facilitates partnerships between individual patients and their personal physicians." Registries, IT, health information exchanges, and other tools facilitate care, assuring "that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner," NCQA says.
Wait a minute. I thought patients and physicians already are partners. Isn't that what's supposed to be happening in primary care practices?
But of course, we all know there are far too many Americans that don't have anything remotely approaching a real relationship with their caregivers, and more than a few people only see doctors in ERs for problems that are less than emergencies.
So how might a medical home address these issues and what role should IT play in this solution?
Two of the biggest problems in medical practice today, especially in smaller offices, are the difficulty of coordinating care with other providers and getting patients fully engaged in their own care.
Good care coordination can take many forms: Getting all the data needed from a discharge nurse when a patient is released from the hospital; tracking an elderly patient as he moves between home and a rehab facility; and keeping the lines of communication open with specialists once a patient is referred--these are only a few of the challenges.
Similarly, patient engagement can include post-visit reminders that encourage patients to follow dietary advice; a structured preventive care program that tracks which patients have received mammograms and colonoscopy screenings; and care for patients who can't get to the office as often as they should--think telemedicine.
In a health delivery organization with deep pockets, these tasks are all doable. University of Pittsburgh Medical Center, for instance, has put in place several tools and strategies as the basis upon which to build robust medical homes. Those building blocks include integration among many data sets; natural language processing; an intelligent, centralized document and medical image repository; and deep clinical analytics.
Starting with these building blocks, UPMC set out to create medical homes that connect all the resources that a patient is likely to use within a primary care physician practice. Those resources include pharmacy, long-term care, preventative, specialty care, home health, telehealth, and lifestyle coaching services. And they're all built on top of an IT infrastructure that includes data warehousing, patient and physician portals, data registries, and electronic health record (EHR) connectivity and interoperability.
In practical terms, that means patients assigned to a specific medical home are tracked so that their primary care physicians can find out where there are gaps in care and quickly plug them. Equally important, such an integrated system gives clinicians a much fuller picture of a patient's meds and diagnostic tests, which in turn lets the doctor catch unanticipated drug-drug interactions and avoid the cost of duplicate testing.
At UPMC, they take the medical home model even further, adding in insurance claims data. "Claims data offers additional value because it provides details on episodes of care that take place outside your world" i.e., outside the UPMC medical home, said Anne Boland Docimo, MD, UPMC Health Plan's chief medical officer, at the recent HIMSS conference.
So, for example, if Ms. Jones wound up in an ER while vacationing in Miami, that information would be available to her primary care physician in Pittsburgh because it would be part of her claims data.
The problem, of course, is how do you scale down this model so that small practices, not part of a large integrated healthcare provider group, would see the benefits. Unfortunately even a cursory look at the statistics indicates we're light years from making the medical home system work in smaller medical groups.
In a survey of primary care, specialty, and multispecialty practices by the Medical Group Management Association only 51% of practices with three or more physicians are using some kind of EHR. Even more disconcerting, the poll found that around half of the EHRs used by their members lacked key functions. For example, only 56% of respondents with EHRs said their systems could generate problem lists, and just 49% had EHRs that provided drug interaction warnings. And these EHRs only let clinicians see data within the practice itself, so they lack the ability to see patient data from other provider organizations.
Also bear in mind that the survey didn't look at solo and two-doctor offices, which no doubt are even less likely to have an adequate EHR.
A recent survey by the Centers for Disease Control and Prevention found that last year 57% of office-based physicians had an EHR. But 34% of the respondents had only what the researchers described as a "basic EHR." A basic EHR includes only a patient's medical history, demographics, diagnoses, medications, and allergies, as well as the ability to prescribe and view lab and imaging results electronically.
Put another way, about half of U.S. medical practices have yet to install an EHR and many of the systems that are in place are of the kindergarten variety, incapable of handling many of functions of a medical home.
Clearly the journey toward patient-centric medical homes, with its promise of care coordination and patient engagement, is going to be a long one.
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