Health Information Technology: Turning the Patient-Centered Medical Home from Concept to Reality
By David Meyers, M.D., Matt Quinn, M.B.A., and Carolyn M. Clancy, M.D.
This commentary first appeared in the March/April 2010 issue of Patient Safety and Quality Healthcare.
Primary care should stand as the foundation on which our entire health care system rests, but the Nation's primary care infrastructure is under great strain. Millions of Americans lack access to a regular primary care provider, and primary care clinicians are overburdened and, compared with their specialist counterparts, modestly paid. Primary care in the United States can and must do better, and America needs to do better for primary care.
The patient-centered medical home (PCMH) has emerged as a model of care that would restore order to the Nation's primary care system. It reasserts the role of primary care by taking a team approach to health care and placing the patient at the center of that team. Initially conceived in the 1960s, the PCMH model emphasizes the role of primary care practitioners to coordinate their patients' care across multiple locations and settings and over time; creates cost savings by delegating less complex aspects of care (e.g., so that specialists do not spend their time following up on routine chronic diseases); and uses measure-driven incentives to reward the quality of outcomes rather than simply volume of services provided.1
Now, decades after the concept was first proposed, the PCMH is no longer a theoretical concept. With Federal encouragement2,3 and heavy private sector interest, the PCMH is poised to revitalize primary care.4 This is a promising development, with even greater potential when we are able to combine it with the harnessing of the power of health information technology (IT) to enable rapid quality improvement.
The PCMH is not necessarily a physical place, but rather an organizational model that delivers the core functions of primary health care. AHRQ supports the PCMH by advancing its evidence base and by convening and working with government and private stakeholders to ensure that the best ideas are shared broadly. As AHRQ defines it, the PCMH encompasses five principles:
- A patient-centered orientation toward the whole person that requires understanding the patient's and the family's preferences and providing the patient's entire range of care needs.
- Comprehensive, team-based care, which relies on a (not necessarily physically co-located) team of providers that might include physicians, nurses, pharmacists, nutritionists, social workers, information technology specialists, and practice managers, in order to meet the patient's care needs.
- Care coordinated and/or integrated across all elements of the complex system (both medical and behavioral health care), including specialists, hospitals, and skilled nursing facilities; home health workers; community services and supports; and the panoply of other providers who see the patient.
- Continuous access to care, with shorter waits to get appointments, enhanced hours, and alternative methods of communication such as E-mail and telephone.
- A systems-based approach to quality and safety, some important aspects of which are: (a) the practice uses evidence-based medicine and clinical decision-support tools to guide decisionmaking; (b) the practice and patients and families participate in performance measurement and improvement; (c) patient experience and feedback are measured, with data from these measurements acted upon; and (d) the practice participates in population health and management.5-7
Health IT, the PCMH, and AHRQ
In the decades since the PCMH was initially proposed, much about the U.S. health care system has changed. Yet the PCMH is more necessary now than ever because of these changes, which include skyrocketing medical costs, an aging and growing population, advancements in the science of diagnostic and treatment procedures, and the rapid expansion of chronic care needs.
The development of health IT, such as electronic health records (EHRs), was unforeseen when the PCMH was proposed. While a PCMH could be established without health IT, health IT will facilitate their development and implementation. Capabilities include IT's ability to:
- Collect, store, manage, and exchange relevant personal health information, including patient-generated data.
- Enhance or facilitate communication among providers, patients, and the patients' care teams for care delivery and care management.
- Collect, store, measure, and report on the processes and outcomes of individual and population performance and quality of care.
- Support providers' decisionmaking on tests and treatments.
- Inform patients about their health and medical conditions and facilitate their self-management with input from providers.8,9
AHRQ research is supporting the effort to apply the best features of health IT to create a PCMH that will improve health care for all Americans.
To support AHRQ's efforts for the PCMH, a new Web site, http://www.pcmh.ahrq.gov, was developed for health care decisionmakers and researchers. The site provides searchable access to a rich database of publications and other resources on the medical home, including access to AHRQ-funded white papers on critical medical home issues. The Agency has awarded grants that will study primary care practices' experiences in transforming into medical homes; commissioned retrospective evaluations of long-standing efforts to re-engineer primary care; and cosponsored a conference to define a shared policy-relevant research agenda for the PCMH. (The results of the latter meeting and commissioned background pieces were recently published in the Journal of General Internal Medicine.)
AHRQ also has invested more than $300 million in contracts and grants to more than 200 communities, hospitals, providers, and health care systems in 48 States to expand our understanding of how health IT can improve health care quality. In a related project, AHRQ has established the National Resource Center for Health IT (NRC) to collect, analyze, and disseminate best practices and lessons learned from our portfolio of health IT projects.10 Please visit the NRC's Web site, http://www.healthIT.ahrq.gov, for more information.
AHRQ's work on the PCMH and on health IT likely will overlap and, in some instances, even merge as we strive to make health IT an "agent of change" for the PCMH. AHRQ is eager to support research to align EHRs with PCMH implementation and operations. We anticipate a strong role for health IT to help operationalize and implement the key features of the PCMH, including supporting quality improvement, patient education, and enhanced communication.
We should not harbor illusions that health IT alone will automatically create fully functional PCMHs. EHR adoption, while increasing, still is relatively low—only 24.9 percent of physicians responding to a 2010 Federal survey reported having a basic system, and just 10.1 percent of physicians had a "fully functional" system. 11 And medical homes are not explicitly mentioned in the requirements for "meaningful use" of health IT in the EHR Incentive Program under the American Recovery and Reinvestment Act of 2009—although guidelines for qualification for the incentive program implicitly encourage the PCMH by targeting key domains such as coordinating care, engaging patients and families, and improving population management.8; Existing Federal legislation has laid important groundwork and is necessary, but not sufficient, to support the PCMH model; technical assistance to primary care practices to adopt IT is needed to ensure that the opportunity to support the transformation of these practices is not missed.12
Nevertheless, there can be little doubt that widespread adoption and use of EHR systems and other patient-centric health IT tools will support PCMHs in reaching their full potential. Thus, a PCMH "information model"—a map of the various interactions a patient has within the medical home, so that technology-enabled information flows properly through the various segments of the health care system and back to the patient—is being developed.13 This project seeks to define the medical home and the interactions among its stakeholders, both in narrative and technical terms, in order to understand where gaps exist and where development or harmonization of standards is needed to support the PCMH.
The widespread adoption of health IT to transform our Nation's health system is being accomplished in tandem with the extension of accessible, affordable health care to more Americans. The PCMH offers a tantalizing opportunity to accomplish both goals at once, to the ultimate benefit of American patients. These symbiotic efforts require a great deal of energy, focus, collaboration, resources, and commitment. When this effort succeeds, the quality of care for all Americans will be vastly improved.
1. Hollingsworth JM, Saint S, Hayward RA, et al. Specialty care and the patient-centered medical home. Med Care 2011 Jan;49(1):4-9.
2. Patient Protection and Affordable Care Act of 2010. P.L. 111-148.
3. Health Care and Education Reconciliation Act of 2010. P.L. 111-152.
4. Patient-Centered Primary Care Collaborative. Health care reform and the patient centered medical home. Available at: http://www.pcpcc.net/content/health-care-reform-and-patient-centered-medical-home. Accessed November 2010.
5. Clancy CM. Coordinating your care with a medical home. Director's Corner. Agency for Healthcare Research and Quality (AHRQ). May 19, 2009. Available at: http://healthcare411.ahrq.gov/%5C/column.aspx?id=518. Accessed November 2010.
6. Patient-Centered Primary Care Collaborative. Joint principles of the patient-centered medical home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. February 2007. Accessed August 2010.
7. Agency for Healthcare Research and Quality. What is the PCMH? AHRQ's definition of the medical home. Available at: http://pcmh.ahrq.gov/portal/server.pt/community/ pcmh__home/1483/what_is_pcmh. Accessed August 2010.
8. Moreno L, Peikes D, Krilla A. Necessary but not sufficient: the HITECH act and health information technology's potential to build medical homes. (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2.) AHRQ Publication No. 10-0080-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2010.
9. Patient-Centered Primary Care Collaborative. Meaningful connections: A resource guide for using health IT to support the patient centered medical home. Washington, DC: Patient-Centered Primary Care Collaborative; 2009. Available at http://www.pcpcc.net/files/CeHIA_Meaningful-Connections-Guide_2009_1.pdf. Accessed November 2010.
10. AHRQ Health IT brochure. Available at: http://healthit.ahrq.gov/portal/server.pt/community/health_it_brochure/670. Last accessed November 2010.
11. Hsiao CJ, Hing E, Socey TC, et al. NCHS Health E-Stat: electronic medical record/electronic health record systems of office-based physicians: United States, 2009 and Preliminary 2010 State Estimates. Available at: http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.htm. Last accessed December 2010.
12. Agency for Healthcare Research and Quality. Patient-centered medical home decisionmaker brief: strategies to ensure HITECH supports the patient-centered medical home. AHRQ Publication No. 11-0013. Rockville, MD: Agency for Healthcare Research and Quality. November 2010.
13. Porter S. AAFP named subcontractor on Westat contract from AHRQ. 8 Sept. 2010. Available at: http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20100908ahrqcontract.html. Accessed December 2010.