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J Ambulatory Care Manage Vol. 37, No. 2, pp. 106–119 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
What’s Inside a Medical Home? Providers and Staff Give Insight Allyson Hall, PhD; Fern Webb, PhD; Claudia Tamayo-Friedel, MPH
Abstract: This study describes how 4 primary care practices deliver components of the patientcentered medical home (PCMH) model. Interviews with administrators and clinicians were conducted and analyzed. All practices had achieved National Committee for Quality Assurance Level 3 Medical Home Accreditation. Yet, the manner in which some of the core PCMH components were delivered varied across sites. For example, information technology is used in different ways and to different degrees although the same electronic medical record is employed in all settings. Evaluations of the PCMH model must account for differences in approach to truly assess its effectiveness. Key words: medical homes, medical home transformation, patient-centered care, qualitative research
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HERE ARE CALLS for increased integration across the US health care delivery system to improve outcomes for patients, especially those living with chronic diseases (Bodenheimer, 2008; Bodenheimer et al., 2002; Grumbach & Bodenheimer, 2002). The patient-centered medical home (PCMH) model is one approach to care integration that has gained significant traction over the years. It has been described as “a model of care characterized by comprehensive primary care, quality improvement, care management, and enhanced access in a patient-centered environment” (Nocon et al.,
Author Affiliations: Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, Gainesville (Dr Hall and Ms Tamayo-Friedel); and Community Health and Family Medicine, College of Medicine, University of Florida, Jacksonville (Dr Webb). The Aetna Foundation provided financial support for this research. No conflicts of interest to report. Correspondence: Allyson Hall, PhD, Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, PO Box 100195, Gainesville, FL 32610 ([email protected]). DOI: 10.1097/JAC.0000000000000017
2012). Core elements of the PCMH model include the provision of continuous, coordinated, and integrated care across a range of clinical and community-based services. Practices provide these services by ensuring that care is accessible, patient-centered, and that there are significant information technology supports (Vest et al., 2010). Successful implementation of the PCMH is thought to be a key component of quality health care. Considerable technical and financial resources have been provided to assist practices in transforming health care facilities into medical homes (Agency for Healthcare Research and Quality, 2012; National Committee on Quality Assurance [NCQA], 2011; Patient-Centered Primary Care Collaborative, 2012; Coleman and Phillips, 2010). The Federal government, Veterans Administration, private insurers, state Medicaid agencies, and various nongovernmental collaboratives are testing versions of the model (Hsu et al., 2012; Kaye & Takach, 2009; PatientCentered Primary Care Collaborative, 2012; Takach, 2012; True et al., 2012). There is some emerging evidence that PCMH improves patient outcomes. Several studies and reviews of the literature have
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What’s Inside a Medical Home? noted that medical homes are associated with positive patient experiences with care; lower costs of care; and reductions in urgent care and emergency room utilization, hospital admissions, and readmissions (Nielsen et al., 2012; Nocon et al., 2012; Williams et al., 2012). Numerous studies have also described practice experiences with transforming to a PCMH. For many primary care sites, the transformation goal is to achieve PCMH recognition through the NCQA (Calman et al., 2013; Green et al., 2012; Reid et al., 2011; Rittenhouse et al., 2013). Physician practices demonstrating that they have met certain criteria in the following areas receive a certificate of recognition from NCQA: enhancing access and continuity; identifying and managing patient populations; planning and managing patient care; providing self-care and community support; tracking and coordinating care; and measuring and improving performance (Green et al., 2012; NCQA, 2011). To become recognized, practices must complete a survey and provide documentation. The personnel at NCQA assess the practices’ survey responses to determine a score for each criteria or standard. Patient-centered medical home recognition of level 1, 2, or 3 is based on whether specific performance elements have been achieved and reported to NCQA (Green et al., 2012; NCQA, 2011). In essence, the process of achieving NCQA PCMH recognition provides a roadmap for practices who wish to transition to models of care that are patient-centered with a strong primary care orientation. Achieving NCQA patient-centered medical home accreditation is viewed as a key milestone for practices in their primary care transformation. One concern, however, with the NCQA process is that information on the provision of PCMH care is largely dependent on clinic or physician practice reporting and documentation. As such, exactly how practices implement key components might not be captured. There could be huge variation in the manner and approaches to implementing key PCMH components, which could ultimately impact the health outcomes of patients.
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In this qualitative research study, we seek to describe how PCMH care is delivered among 4 practices that are part of a faculty group associated with an academic medical center in the southeastern United States. Three clinics serve a mostly inner-city, low-income population, while the fourth clinic is in a suburban location. Although the sites are part of the same academic medical system, they operate very much like individual entities and, at the time of the study, were not a formal practicebased research network. Almost 5 years ago, the practices began adopting components of the PCMH model, including the introduction of electronic medical records (EMRs) and the expansion of care management and disease management supports for patients. At the time the study was conceived, all 4 clinics had achieved NCQA level 1 accreditation. Although there was no formal process for communicating lessons learned during the accreditation process, the medical directors did attend and share information during periodic departmental meetings. By the time the research was conducted, all had been similarly recognized at a level 3, meaning that they had complied with all elements as required by NCQA.
METHODS The data reported in this article were collected as part of a larger study, which sought to understand the relationship between how medical homes are operationalized and the health care experiences and level of engagement or activation of patients with diabetes seen at these clinics. To understand how the PCMH was implemented at each of the 4 clinics, project investigators conducted in-depth interviews with medical and administrative staff (see Appendix). The interview guide was designed to ask about the domains associated with the NCQA PCMH framework. Questions asked about how a specific medical home domain was actually implemented in the practice. In addition, interview questions probed on understanding the specific uses and applications associated with health information
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technology, referral and coordination procedures, and care management supports. Project investigators conducted 18 interviews with clinic staff across the 4 sites. At each site, the medical director, the lead administrator, and nurse were interviewed. At 3 of the largest sites, at least 1 additional physician was interviewed. A diabetes educator who was associated with 3 of the sites, a senior practice manager who was responsible for all locations, and a front office manager from one location were also interviewed. All interviews were taped and then transcribed. Following standard qualitative methodology (Patton, 2002), project investigators developed an initial set of codes using the interview guide. These codes essentially corresponded to the key domains within the NCQA framework. Graduate students from the university assisted with coding transcripts. Teams of 2 students coded each transcript— essentially grouping narrative within the broad sets of initial codes. At team meetings, the research team, including students, identified and developed both new codes and subcodes based on the content of the data. Transcripts were coded separately and then compared. Teams that differed in their coding approach discussed their differences at team meetings, and codes were assigned on the basis of the consensus of the group. Once the narrative was grouped into codes and subcodes, team meetings were held to determine study themes and conclusions. RESULTS The interviews revealed that despite the fact that all 4 practices are part of the same academic health system and that they have all received NCQA level 3 PCMH designation, there are key differences in the manner and degree to which key components of the PCMH are implemented (see the Table). Health information technology Integration of systems Providers consistently reported using and integrating at least 4 information technology (IT) systems for billing, inpatient hospital
care, laboratory data, and referral processing. What was consistent was that providers spent a lot of time navigating between IT systems to extract information for entry into the patient’s EMR. In addition, laboratory information obtained from external sources must be scanned into the patient’s EMR. One practice has fully integrated all of the IT systems such that systems automatically communicate with one another. This was done during the planning and development phases of this practice (since this is a relatively new practice). Thus, all of this practice’s IT scheduling, appointment and insurance verification systems communicate with each other, which is not standard practice across all of the other PCMH sites. In the other locations, data can be brought into the EMR in a variety of ways including manual entry by a medical assistant or the clinician, scanned in as PDFs, cut and pasted from another electronic source, or automatically electronically populated. One provider expressed the complexity of the current IT system: NAME OF COMPANY is our main medical EMR, but then the hospital has a different system, billing system is a separate system, hospital has one billing system and practice has another billing system. I mean there are just a lot of systems out there . . . .
Provider alerts/tasks Another tool providers use within the EMR is “task” or “tasking.” Providers explained that tasks are generated from all entities, including the call center (where all patient calls go and appointments are made), and from medical assistants, and other providers. Similar across practices, all tasks appear on the provider’s EMR screen and remain on providers’ screen until they are dealt with, which can become a challenge when seeing patients. For example, having to respond to 15 tasks before being able to view a patient’s chart can significantly delay an office visit. Another similar finding across practices was that tasks are not grouped on the basis of level of urgency or emergency, which is more than likely a result of tasks being generated by a central location, the call center. Thus, providers reported that this also delays the process of seeing patients and providing medical care.
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No registries or manpower to begin diabetes registry Has 3 referral coordinators to generate and track referrals
Registry
The specialists should send/share results with patients (but may not) Uses guidelines developed by Family Practice department, using USPTF recommendations Internal monthly meetings to provide up-to-date information to all providers/staff
Receiving results from specialists
Provider ←→Provider communication
Evidence-based guidelines
Sends letters encouraging patients to follow up
Internal monthly meetings to provide up-to-date information to all providers/staff
Uses ADA guidelines (diabetes educator)
No definitive statement on this
Call patients with abnormal results
No definitive statement on this
Used Patient Quality Reporting Initiative
Create own internal process No clear method indicated; some to promote providers feel interaction is poor provider/team while others feel interaction is communication adequate (continues)
Use ADA guidelines
Will interpret specialists results and give to patients
Call patients with abnormal results
1 referral coordinator to generate and track referrals; able to track individual throughout the referral process
No registries
Too much additional work provided; maybe be good overall; not useful friendly Laboratory work faxed over
Primary Care Center D
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Sharing laboratory results
Laboratory work sent electronically and included in e-mails as a “task” Extensive diabetes registry used to monitor patients 1 referral coordinator who uses a specific referral software; able to track whether appointment was kept or not Calls patients with abnormal results; sends letters when results are normal No definitive statement on this
Laboratory work faxed over
No registries
Significantly useful
Primary Care Center C
Useful; best thing to happen
Primary Care Center B
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Other providers have received more training; old and antiquated Log into laboratory Web sites to get information
Primary Care Center A
Health Information Technology Laboratory results
Theme
Table. Medical Home Components by Clinic
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Yes, they are a medical home
Feelings About Medical Home Model
Yes, because they can No real need. Patients are provide materials in similar Spanish Yes, and no → Partially a Yes, and no → Partially a medical home medical home
Refers to diabetes educator or nutritionists
Yes, will refer to local gym
Abbreviations: ADA, American Diabetic Association; USPTF, United States Preventive Services Task Force.
No formal training but culturally competent
Cultural competence
Refer to community services Medical Support Services
Encourages patient communication via e-mail
Not accessible
Give ADA-approved handouts Provide a “report card”
Primary Care Center C
Yes, they have been a medical home all along
Yes, will refer to local food pantries, homeless shelters, or housing assistance Diabetes education; smoking cessation; pain clinics; pharmacists; psychiatrists Yes because have bilingual staff/medical assistants
Does not encourage patient communication via e-mail
Unaware if patients can access their own information
Provides newly diagnosed patients with educational CDs
Primary Care Center D
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Patient communication
Each provider does this differently → some give paper, some give Web sites, some just discuss; unclear if time spent on education is providing adequate return on investment Access but only information Access but unaware of that is accessible is what patients can demographics and making access or do in the an appointment system Does not encourage Some providers communication via e-mail communication with their patients via e-mail Yes, will share information Yes, will refer to about lectures or community community wellness programs programs None → refers to other sites Diabetes educator; having support pharmacist; podiatrist
Each provider in location does this differently
Primary Care Center B
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Patient access to their own information
Patient education
Primary Care Center A
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Theme
Table. Medical Home Components by Clinic (continued)
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What’s Inside a Medical Home? Tasks come primarily from the call center, when we get tasks from there, they mark it with a red star if it is highly important or a yellow triangle if it is just urgent. The downside of that is these are not medical people making these decisions, what they have said to me is if it is urgent to the patient, it is urgent.
Registries While all providers and primary care centers desired having health outcome or disease registries, only one center had a formal registry. This practice is relatively new and the registry was implemented from the beginning. Furthermore, the medical director and clinical staff are part of a master diabetes clinician program that shares their diabetes outcomes and metrics with other practicing clinicians. Having a registry is a key component of the master diabetes clinician program. For the 3 other practices, the majority of providers desired in-house registries and noted that they could generate lists if needed, but they reported a lack of resources, such as staff to enter information and monitor outputs and outcomes. Providers also reported that the institution has access to patient outcome data on an institutional basis because these outcome data are used to determine quality of care and physician bonuses, implying that separate, inhouse registries for each practice might not be necessary. However, providers seem to have similar desires to have a registry: We don’t have any registry. I think this is the future of medicine to target as our department kind of moves into the patient medical home. Using more registries, this is what is going to be expected of us and what we should be doing.
Referral process There was some consistency across practices/providers regarding the referral process. The general process is that the physician first generates a referral in the EMR note and then sends it to the medical assistant or referral specialist. The referral specialist then creates and tracks the referral in another IT system as well as documents the referral in the patient’s EMR. While the practices generally follow a simi-
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lar process, differences regarding personnel resources and tracking systems exist. For example, one center has 3 referral coordinators; another has 2 referral coordinators, while the other 2 sites have only 1 referral coordinator. This difference usually takes into account the varying number of health care providers and volume of patients in various clinics. Differences in making appointments with specialists also exist. In some instances, patients leave with a scheduled appointment to see a specialist by the end of their primary care visit. However, in other locations, it is the specialist’s office responsibility to schedule an appointment for the primary care patient. While referral tracking must be done by the medical assistants, there seemed to be no clear way to determine whether a patient actually completed an external referral or visit. Generally, providers are only able to tell whether a referral or external visit to a specialist occurred when the patient returned to the primary care office for a visit. It was easier to get information about referrals when specialists were within the same academic health system, using the same EMR. For patients completing a referral outside of the system, if the provider sent a follow-up report it would be scanned into the EMR. E-prescribing The availability of e-prescribing was also consistent across sites. The function in the current EMR system automatically checks for proper dose and drug interactions. Essentially, all the practices can transmit prescribing information to external national chain pharmacies in the area. For example, external pharmacies send e-mails informing the offices of patients’ requests for refills. Providers reported that the majority of patients (from all sites) seem comfortable with e-prescribing with only a small percentage of patients wanting or requiring a paper script. Oddly, there is no electronic relationship with the in-house medical system or the Navy system for e-prescribing. Patients having their medications filled at the pharmacy associated with the academic medical center or who are covered by the Navy need to have paper pre-
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scriptions. One center uses another system with patients’ consent, which allows for viewing all medications a patient filled from all participating pharmacies. Providers did report some inconsistencies with e-prescribing, however. For example, one center prefers to fax all prescriptions to external as well as in-house pharmacies rather than sending prescriptions electronically. Some providers also reported that prescriptions sometimes never “arrive” electronically to the pharmacy, requiring more research to verify that the prescriptions were sent, which then uses additional personnel, time, and efforts to track or verify prescriptions. Laboratory results The majority of clinics had a similar procedure for retrieving patients’ laboratory results. In general, laboratory work completed within the academic medical system is viewed in a separate system from the current EMR. These results are then copied and pasted, or scanned into the patient’s record. Some centers have an evolved process; for example, one center logs onto laboratory Web sites to retrieve results while other primary care centers received results through faxes directly from the laboratories. Another center is starting to receive patient results electronically in e-mails as a “task.” One consistent view is summarized in the following quote: Because the labs are available in the computer, there is no closed loop yet because information doesn’t feed into our system. The system in the lab is different from the electronic medical record, but they’re working on it.
Evidence-based guidelines Providers report using different evidencebased guidelines; one provider reported using the American Diabetic Association guidelines when providing information to patients (diabetes educator). Another provider reported using specific guidelines developed by the Family Practice department based on the US Preventive Task Force guidelines. Some providers stated that they used the health maintenance checklists in the EMR template
to assist in determining what care someone receives, while another provider stated that only 4 things must be done regarding diabetes patient care, according to the Physician Quality Reporting Initiative. Although practices reported varying processes for developing guidelines, one provider reported that the entire department, which would include all practices, developed evidence-based guidelines in a specific manner: The whole family practice department came up with specific guidelines of what general health maintenance should be and also what diabetic follow-up should be for that particular group of patients, we generally use the US preventive task force service guidelines plus the American academy of family physicians guidelines and some of those are different and we kind of come up with what we think is the best of both of those recommendations.
Decision support The majority of providers felt that the decision on how to deliver medical care is ultimately theirs and should not be entirely dependent on electronic decision supports, as evidenced in the following quote: I am the decision support, I make the decision, I see the lab come back abnormal and from that I make the decision.
Providers noted that the way their EMR is currently structured shows medication interactions but fails to suggest what medications might be more suitable for the patient. In essence, the EMR does not offer suggestions regarding what to prescribe to a particular patient. Cultural competency and patient-centered care While all practices/providers reported being patient-centered and culturally competent, no provider readily offered specific evidence of how patient-centered and/or culturally competent care was operationalized within their practices. Providers at one center reported that they had no formal training for staff in cultural competence although they often discussed this topic at meetings. Other
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What’s Inside a Medical Home? providers at another center had a Spanishspeaking medical assistant, which they felt made them culturally competent. Another center provided health materials in Spanish. All providers seemed to resonate with the following statement: The patient has always been the center of the practice, that’s the way we’ve always done things. I am the advocate for the patient, I don’t know any other way to be.
Patient access to their own medical record Providers at one center fully realized that patients have and should have access to their own medical record. One provider reported that while patients have access to their information through a “patient portal,” appointment times and contact data are the only information currently available. No other providers reported being aware of the patient portal or having interaction with one. Importantly, one provider where patients did not have access to their own medical record felt the following: I know that laboratory sites are allowing patients to retrieve their own lab and I think that is phenomenal. Really it is but no we don’t have that just yet but I know it is coming.
Patient communication The general process for patients to contact providers seemed consistent across practices. A patient calls the call center, which creates a “task” in the patient’s EMR, alerting the provider to call back or act on the request. However, providers had slightly different methods in how they responded to patient requests. For example, some providers would contact the patient directly if they felt that the situation was urgent or emergent, or required the provider’s direct attention. Otherwise, the provider would have a medical assistant contact the patient to get more information or to assist the patient with the task or the message. There was some variation in how laboratory results were communicated to patients. What is consistent is that all practices/providers reported that someone telephoned patients having abnormal results to schedule a follow-up
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visit, while normal results would be mailed to the patient. Specifically, one provider telephoned patients having abnormal results to schedule a follow-up visit or to determine an action plan. Other providers had their medical assistants telephone patients with abnormal results. Some providers communicate with patients via e-mail as well as provide their e-mails to their patients while other providers did not feel that e-mail communication was appropriate. Following is one provider’s description of how they deal with abnormal results: If it is something that needs to be caught right then, like for a patient that had labs done it was all normal, we don’t call them, we take that letter, make a copy of it so we can scan it into the patient’s chart and then we mail it to the patient. But if it is an abnormal lab that needs attention or if they need to come back in and have more lab work as a result of this abnormal one, we are told to call the patient, or the doctor does this himself.
Patient alerts/reminder systems One consistent response from providers is that there are no automatic alerts in the EMR to remind providers of the need for preventive care, blood work, or to refer a patient to a specialist (ie, podiatrist, eye test). In fact, in some practices, medical assistants are responsible, for the most part, for alerting physicians of extremely elevated patient values. These extremely elevated patient values or any type of “alert” are then added manually to the note or a certain section in the EMR to notify the provider of the patient’s status/ condition. Some providers created their own alerts by generating delayed e-mail messages. For example, providers reported that one could generate a task, dated for the future, to remind oneself that the patient needs to get a mammogram at a future date; then, the task appears or comes due when the future date arrives. Specifically, some providers manually created self-tasks or reminders for what to check when a 50-year-old man has a visit, or a 45-year-old woman visits. These providers manually create these reminders and then send them to themselves regarding their pa-
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tient, so that in the future, the reminder will generate and alert them. Providers also reported creating folders and putting patient information into them to serve as a selfalert/reminder system; the providers would then look for patient information in these selfcreated folders when patients return for visits. What was clear is that providers varied in their creation of patient alert/reminder systems. For example, one provider reported that his/her center has the ability to check the system [a unique system to their center] to see if a patient completed an outside appointment or received medical care from an outside source. However, other providers reported that they created a cumbersome process of reminding themselves and medical assistants to get results of follow-up care or tests to patients. Another provider has created a similar process of tasking, by sending a task to oneself, set for a future date, as a reminder that he/she referred the patient or must follow up with the patient regarding a screening test, blood work, or a particular procedure. It is also important to note that these reminders or tasks are established by the individual providers for their own purposes and are not intended for other members of the clinical team to act on. EMR/Internet used to educate patients The way providers share information with patients also varied substantially although the majority of providers use the Internet as a primary source for education information. Some providers printed online resources for patients although they recognize that they must be cautious to avoid advertising other “institutions” or academic medical centers. Some providers give information (via Web or print) from other medical institutions while others adamantly avoid this. Some providers give patients the exact Web site in which to visit. Providers at all sites reported giving handouts approved by American Diabetes Association. One provider reported lending compact disks to newly diagnosed diabetic patients to assist them with learning more about diabetes. One provider provided patients with a “report card,” generated from their diabetes registry,
to educate patients about their current health status. Although there is a function in the current EMR to show patients their health indicators (ie, blood pressure, weight) and plot these values over time, no provider readily used this function to educate patients. Patient support services All centers used support services to some degree. For example, while some providers had onsite, in-house services, other providers referred patients to other centers within the academic health care system. The type of support services also varied between centers. Some centers have an onsite dietician, podiatrist, pharmacist, and psychiatrist, while others refer patients to support services such as a nutritionist or diabetes education. One center has various in-house disease management programs (ie, Be Lean program, smoking cessation, Coumadin clinic), while others have no onsite disease management programs. Another point was that programs at each center were primarily started by the medical director or providers at the center. “Our RN actually works with the indigent program, which works with patients who are high risk for no shows and then they have their own personal dynamic . . . to encourage them to keep their appointments, which has been very helpful.”
Referrals to community supports All practices have various approaches to connecting people to outside resources. There was a consistent message that referral to support services, specifically diabetic education, is insurance-based or driven. Sites, although not fully coordinated with external services, will refer patients to social services in the community. One center relies on referral coordinators to give patients additional information for support services, such as housing, nursing homes, or food pantries. However, one perception is that communitybased programs are not consistent or do not last (ie, programs offered at the library or through grants are temporary). Another potential difficulty, as reported by one provider is that there is no “established” relationship with community-based resources; thus refer-
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What’s Inside a Medical Home? ring patients to these sources (ie, exercise programs, food pantries) may not prove beneficial for the patient. Referrals depend a lot on their insurance, if they have one form of insurance, they have this program that is called Silver Sneaker, and so they have the choice of whether or not to go to the YMCA or go to other community wellness programs.
Diabetes education One center had a formal, organized diabetes education program while another center had a semistructured diabetes education program. The other 2 centers refer patients to the formal diabetes education program although the diabetes educator indicated that this does not routinely occur. Furthermore, the classes are not conveniently located for patients from these other 2 sites. Is the practice a PCMH and focused on patient centered care? Despite the fact that all practices had achieved NCQA level 3 accreditation, participants at 2 of the 4 sites were cautious in describing their locations as a medical home. These respondents tended to focus on perceived deficiencies such as the lack of a registry, or not having a referral process as well defined as they would have liked. In their answers, providers focused on the definitional aspects of the medical home and the extent to which they are being accomplished. At these locations, the medical directors noted that the process of transforming to a medical home is ongoing. For example, all noted that the health information technology system would be changed in the coming year with the expectation that the functionality of the new technology will provide greater support for medical homes. Participants at the 2 remaining sites were more definitive and clearly defined their practice as a medical home. For example one participant noted that their practice has always been a medical home even before the term was commonly used. We have been a medical home. The only alternation is just documenting. I don’t see any difference
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other than documenting what has been done for the last 20 years.
Participants did note that implementing the medical home model involved a complex set of tasks. Limited resources can hamper the implementation of the medical home as it is truly envisioned. These respondents focused on the patient-centered aspects of the model. One respondent noted that his practice was a medical home because they treated patients with respect. Specifically, that practice reported being a medical home because: they ensured that their patients with diabetes had required procedures performed and that they spent time with patients to answer their questions. So, for this location, the concept of the medical home had more to do with the quality of the patient-provider interactions than with other components of the model. Further probing on how respondents would define the practice culture revealed that all locations worked hard to provide care that focuses on patients’ needs. Individuals were very clear about the distinction between the formal requirements for recognition as a medical home compared with having a patient-centered focus as noted by the following response: So I think just to standardize that to have us all under the same rules in a medical home basically that is a good thing . . . it is really about who you are and how approachable you are to patients. I like that my patient loves me and I like that they are free to call me anytime. I can always see them even on short notice.
DISCUSSION All providers sought to provide the highest standard of care to patients, although having different ways in which they use available resources. While these differences may seem relatively benign, they have important implications for how easily providers can search and retrieve information. While there were many consistencies in how providers implemented procedures, such as using the EMR, providing results to patients, and providing some type of education
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to patients, there were also many differences. Some of the difference could be attributed to the fact that medical directors have varying opinions about medical homes. While generally there was recognition that a medical home is a place where a patient can go for all of their medical needs, there was the perception among all respondents that the theory is significantly different from the practical application of medical practice. One provider felt that in order for medical homes to be reality, government and the “powers that be” will need to appreciate the financial and practical implications of medical home implementation. What is also interesting is how these 4 sites, within the same academic health system, chose to operationalize the concept of medical homes. What is evident is that implementation is often driven by opinion and values. For example, the centers where providers felt it somewhat unnecessary for patients to access their own medical record did not have much patient access. On the contrary, providers communicated with patients via e-mail/electronic resources at centers where providers thought that this was an essential part of medical care. Our study raises questions and opportunities for further research in a number of areas. First, a better understanding from both a qualitative and quantitative standpoint regarding what process of care and components of the medical home contribute best to patient experiences and satisfaction is still desired.
Having patients’ viewpoints as to what they want from a medical home is also critical to assuring a patient-centered focus. In addition, our study revealed that clinicians themselves have varying views on what a medical home is and the benefits of organizing medical care in this way. Specifically, we were able to note that providers do distinguish between what a medical home is and the patient-centered aspect of their practice. For them, the 2 concepts could be mutually exclusive. Not having all of the medical home process components in place does not necessarily mean that a practice is not providing patient-centered care. Because providers are key to medical home implementation, we need further understanding of their opinions on how to deliver patientcentered care. While we believe this study adds to the existing body of knowledge on PCMH and implementation, our sample is limited to only 4 sites of care that are a part of the faculty practice of one academic medical center. This coupled with the qualitative nature of the inquiry limits the generalizability of our findings to other primary care locations. Regardless, we think our findings provide important insight into some of the ways primary care providers operationalize medical homes. These findings also suggest that more research and evaluation needs to occur to better understand how the medical home model in NCQA-accredited practices is fully operationalized and how this actually impacts overall quality of care and health outcomes.
REFERENCES Agency for Healthcare Research and Quality. (2012). Patient-centered medical home. Resource center. Retrieved December 10, 2012, from http:// www.pcmh.ahrq.gov/portal/server.pt/community/ pcmh_home/1483 Bodenheimer, T. (2008). Coordinating care—a perilous journey through the health care system. New England Journal of Medicine, 358(10), 1064–1071. Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. JAMA, 288(14), 1775–1779.
Calman, N. S., Hauser, D., Weiss, L., Waltermaurer, E., Molina-Ortiz, E., Chantarat, T., . . . Bozack, A. (2013). Becoming a patient-centered medical home: a 9year transition for a network of Federally Qualified Health Centers. Annals of Family Medicine, Suppl 1: S68–S73. Green, E. P., Wendland, J., Carver, M. C., Hughes Rinker, C., & Mun, S. K. (2012). Lessons learned from implementing the patient-centered medical home. International Journal of Telemedicine and Applications, Article ID 103685.
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What’s Inside a Medical Home? Grumbach, K., & Bodenheimer, T. (2002). A primary care home for Americans: putting the house in order. JAMA, 288(7), 889–893. Hsu, C., Coleman, K., Ross, T. R., Johnson, E., Fishman, P. A., Larson, E. B., . . . Reid, R. J. (2012). Spreading a patient-centered medical home redesign: a case study. [Research Support, N.I.H., Extramural ov’t]. The Journal of Ambulatory Care Management, 35(2), 99– 108. Kaye, N., & Takach, M. (June 2009). Building medical homes in state medicaid and CHIP programs. Washington, DC: National Academy for State Health Policy. National Committee on Quality Assurance (NCQA). (2011). Patient-centered medical home. Retrieved April 12, 2011, from http://www.ncqa.org/tabid/631/ Default.aspx Nielsen, M., Langner, B., Zema, C.,, Hacker, J., & Grundy, P. (2012). Benefits of implementing the primary care patient-centered medical home: a review of cost and quality results, 2012. Washington, DC: PatientCentered Primary Care Collaborative. Nocon, R. S., Sharma, R., Birnberg, J. M., Ngo-Metzger, Q., Lee, S. M., & Chin, M. H. (2012). Association between patient-centered medical home rating and operating cost at federally funded health centers. JAMA, 308(1), 60–66. Patient-Centered Primary Care Collaborative. (2012). Retrieved December 10, 2012, from http://www.pcpcc. net/ Patton, M. Q. (2002). Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA/London, UK/New Delhi, India: Sage Publication.
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Reid, A., Baxley, E., Stanek, M., & Newton, W. (2011). Practice transformation in teaching settings: lessons from the I3 PCMH collaborative. Family Medicine, 43(7), 487–494. Rittenhouse, D. R., Schmidt, L. A., Wu, K. J., & Wiley, J. (2013). Incentivizing primary care providers to innovate: building medical homes in the Post-Katrina New Orleans Safety Net. Health Services Research. Advance online publication. doi:10.1111/1475–6773.12080. Takach, M. (2012). About half of the States are implementing patient-centered medical homes for their medicaid populations. Health Affairs (Millwood), 31(11), 2432–2440. doi:10.1377/hlthaff.2012.0447. Coleman, K., & Phillips, K. (May 2010). Providing underserved patients with medical homes: assessing the readiness of safety-net health centers. Washington DC: The Commonwealth Fund. True, G., Butler, A. E., Lamparska, B. G., Lempa, M. L., Shea, J. A., Asch, D. A., . . . Werner, R. M. (2012). Open access in the patient-centered medical home: lessons from the Veterans Health Administration. Journal of General Internal Medicine, 28(4), 539–545. Vest, J. R., Bolin, J. N., Miller, T. R., Gamm, L. D., Siegrist, T. E., & Martinez, L. E. (2010). Medical homes: “where you stand on definitions depends on where you sit.” Medical Care Research and Review, 67(4), 393–411. Williams, J. W., Jackson, G. L., Powers, B. J., Chatterjee, R., Bettger, P., Kemper, A. R., . . . Gray, R. (July 2012). Closing the quality gap: revisiting the state of the science. Vol 2: Patient-centered medical home [Evidence Reports/Technology Assessments]. Rockville, MD: Agency for Healthcare Research and Quality.
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Use of additional care management supports
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Use of health educators and counselors
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Use of information technology
We are interested in learning about how you manage your patients, especially patients who are living with type 2 diabetes. What HIT applications are currently in use? “In use” means that the applications are used routinely by clinic personnel to enhance patient care and clinic administrative • Decision support systems, electronic prescribing; electronic medical records; billing; registries; reminder systems; referrals, patient portals, etc. Describe step by step how these systems are used (eg, how is an electronic prescription initiated? How is patient scheduling done using HIT? Discuss the application of clinical management systems to clinical practices? What kinds of e-mail communication occur? How do you track referrals? Laboratory results?) • Who uses them? How often? Do you maintain paper versions of data or processes? Do all people involved use the systems? Are there reluctant users? When it is determined that a patient needs to be referred to another provider, how is this done? • How are providers identified? How are providers contacted for an appointment? Does the primary care provider communicate in any way with the specialist either prior or after the referral visit? What kinds of information are sent to the referring physician? After the referral occurs how do the practice and the primary care provider obtain the results of the consultation? • Does the primary care provider receive information from the referring physician? How? How do patients find out the results of the consultation? How is the referral information maintained? How are health educators used in the practice? • One on one consultation with a patient? Group classes? Describe the specific health education programs. • Are these community-based programs or are they developed specifically for the practice? • Are the patient supplied with written material? • Curriculum What kind of feedback have you had from patients about these programs Describe the disease management programs • How does the practice identify patients to participate in the programs • Provide an in-depth description of the programs—what’s involved • Do you think the programs are successful? Why or why not? What would you change • What are patients telling you about the programs? Do the DM programs provide patients with more ability to manage their care? (Continues)
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Introduction
PCMH Attribute
Appendix: In-Depth Interview Protocol With Medical Directors and Other Clinical Staff
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Abbreviations: DM, disease management; HIT, health information technology; PCMH, patient-centered medical home.
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Practice culture and characteristics
Performance measurement and quality improvement
Are patients linked to community resources outside of the practice? • How do you identify these programs? Are you able to assess the quality of these programs? • How does the practice link patients to specific community-based programs? What guidelines do you use? • Do you follow all of the guidelines? Strictly? How are clinicians monitored in terms of their use of the guidelines? Describe the quality improvement activities • What kinds of performance measures are collected? How routinely? By whom? How easy/difficult to collect? • How are these measures used in performance improvement activities? • Describe the feedback process to clinicians and other practice staff • Are you able to chart change over time? Do you consider your practice to be a medical home? In what ways? • Accessibility to care? Coordination (Referrals, test tracking)? Registry functions? Cultural competency? • What does a medical home mean to you? • What is the mission, vision, or goal of your practice? • Does everyone in the practice (clinical and non clinical embrace the concept of medical home) • Has the process of transformation been a deliberate one? • Has performance changed over the past 5 years When I say the word practice culture—what comes to mind? • Emphasis on team work, cohesiveness, participation • Emphasis on innovation and risk-taking; entrepreneurial • Emphasis on achievement and meeting objectives • Emphasis on stability, rules, policies and regulations What does patient-centered care mean to you or the practice? How is this concept operationalized? Cultural competency? Other than the programs we have discussed above, what else does the practice do for patients to ensure that care is patient-centered? Customer service programs?
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Community-based programs
PCMH Attribute
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J Ambulatory Care Manage Vol. 37, No. 2, pp. 106–119 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
What’s Inside a Medical Home? Providers and Staff Give Insight Allyson Hall, PhD; Fern Webb, PhD; Claudia Tamayo-Friedel, MPH
Abstract: This study describes how 4 primary care practices deliver components of the patientcentered medical home (PCMH) model. Interviews with administrators and clinicians were conducted and analyzed. All practices had achieved National Committee for Quality Assurance Level 3 Medical Home Accreditation. Yet, the manner in which some of the core PCMH components were delivered varied across sites. For example, information technology is used in different ways and to different degrees although the same electronic medical record is employed in all settings. Evaluations of the PCMH model must account for differences in approach to truly assess its effectiveness. Key words: medical homes, medical home transformation, patient-centered care, qualitative research
T
HERE ARE CALLS for increased integration across the US health care delivery system to improve outcomes for patients, especially those living with chronic diseases (Bodenheimer, 2008; Bodenheimer et al., 2002; Grumbach & Bodenheimer, 2002). The patient-centered medical home (PCMH) model is one approach to care integration that has gained significant traction over the years. It has been described as “a model of care characterized by comprehensive primary care, quality improvement, care management, and enhanced access in a patient-centered environment” (Nocon et al.,
Author Affiliations: Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, Gainesville (Dr Hall and Ms Tamayo-Friedel); and Community Health and Family Medicine, College of Medicine, University of Florida, Jacksonville (Dr Webb). The Aetna Foundation provided financial support for this research. No conflicts of interest to report. Correspondence: Allyson Hall, PhD, Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, PO Box 100195, Gainesville, FL 32610 ([email protected]). DOI: 10.1097/JAC.0000000000000017
2012). Core elements of the PCMH model include the provision of continuous, coordinated, and integrated care across a range of clinical and community-based services. Practices provide these services by ensuring that care is accessible, patient-centered, and that there are significant information technology supports (Vest et al., 2010). Successful implementation of the PCMH is thought to be a key component of quality health care. Considerable technical and financial resources have been provided to assist practices in transforming health care facilities into medical homes (Agency for Healthcare Research and Quality, 2012; National Committee on Quality Assurance [NCQA], 2011; Patient-Centered Primary Care Collaborative, 2012; Coleman and Phillips, 2010). The Federal government, Veterans Administration, private insurers, state Medicaid agencies, and various nongovernmental collaboratives are testing versions of the model (Hsu et al., 2012; Kaye & Takach, 2009; PatientCentered Primary Care Collaborative, 2012; Takach, 2012; True et al., 2012). There is some emerging evidence that PCMH improves patient outcomes. Several studies and reviews of the literature have
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What’s Inside a Medical Home? noted that medical homes are associated with positive patient experiences with care; lower costs of care; and reductions in urgent care and emergency room utilization, hospital admissions, and readmissions (Nielsen et al., 2012; Nocon et al., 2012; Williams et al., 2012). Numerous studies have also described practice experiences with transforming to a PCMH. For many primary care sites, the transformation goal is to achieve PCMH recognition through the NCQA (Calman et al., 2013; Green et al., 2012; Reid et al., 2011; Rittenhouse et al., 2013). Physician practices demonstrating that they have met certain criteria in the following areas receive a certificate of recognition from NCQA: enhancing access and continuity; identifying and managing patient populations; planning and managing patient care; providing self-care and community support; tracking and coordinating care; and measuring and improving performance (Green et al., 2012; NCQA, 2011). To become recognized, practices must complete a survey and provide documentation. The personnel at NCQA assess the practices’ survey responses to determine a score for each criteria or standard. Patient-centered medical home recognition of level 1, 2, or 3 is based on whether specific performance elements have been achieved and reported to NCQA (Green et al., 2012; NCQA, 2011). In essence, the process of achieving NCQA PCMH recognition provides a roadmap for practices who wish to transition to models of care that are patient-centered with a strong primary care orientation. Achieving NCQA patient-centered medical home accreditation is viewed as a key milestone for practices in their primary care transformation. One concern, however, with the NCQA process is that information on the provision of PCMH care is largely dependent on clinic or physician practice reporting and documentation. As such, exactly how practices implement key components might not be captured. There could be huge variation in the manner and approaches to implementing key PCMH components, which could ultimately impact the health outcomes of patients.
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In this qualitative research study, we seek to describe how PCMH care is delivered among 4 practices that are part of a faculty group associated with an academic medical center in the southeastern United States. Three clinics serve a mostly inner-city, low-income population, while the fourth clinic is in a suburban location. Although the sites are part of the same academic medical system, they operate very much like individual entities and, at the time of the study, were not a formal practicebased research network. Almost 5 years ago, the practices began adopting components of the PCMH model, including the introduction of electronic medical records (EMRs) and the expansion of care management and disease management supports for patients. At the time the study was conceived, all 4 clinics had achieved NCQA level 1 accreditation. Although there was no formal process for communicating lessons learned during the accreditation process, the medical directors did attend and share information during periodic departmental meetings. By the time the research was conducted, all had been similarly recognized at a level 3, meaning that they had complied with all elements as required by NCQA.
METHODS The data reported in this article were collected as part of a larger study, which sought to understand the relationship between how medical homes are operationalized and the health care experiences and level of engagement or activation of patients with diabetes seen at these clinics. To understand how the PCMH was implemented at each of the 4 clinics, project investigators conducted in-depth interviews with medical and administrative staff (see Appendix). The interview guide was designed to ask about the domains associated with the NCQA PCMH framework. Questions asked about how a specific medical home domain was actually implemented in the practice. In addition, interview questions probed on understanding the specific uses and applications associated with health information
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technology, referral and coordination procedures, and care management supports. Project investigators conducted 18 interviews with clinic staff across the 4 sites. At each site, the medical director, the lead administrator, and nurse were interviewed. At 3 of the largest sites, at least 1 additional physician was interviewed. A diabetes educator who was associated with 3 of the sites, a senior practice manager who was responsible for all locations, and a front office manager from one location were also interviewed. All interviews were taped and then transcribed. Following standard qualitative methodology (Patton, 2002), project investigators developed an initial set of codes using the interview guide. These codes essentially corresponded to the key domains within the NCQA framework. Graduate students from the university assisted with coding transcripts. Teams of 2 students coded each transcript— essentially grouping narrative within the broad sets of initial codes. At team meetings, the research team, including students, identified and developed both new codes and subcodes based on the content of the data. Transcripts were coded separately and then compared. Teams that differed in their coding approach discussed their differences at team meetings, and codes were assigned on the basis of the consensus of the group. Once the narrative was grouped into codes and subcodes, team meetings were held to determine study themes and conclusions. RESULTS The interviews revealed that despite the fact that all 4 practices are part of the same academic health system and that they have all received NCQA level 3 PCMH designation, there are key differences in the manner and degree to which key components of the PCMH are implemented (see the Table). Health information technology Integration of systems Providers consistently reported using and integrating at least 4 information technology (IT) systems for billing, inpatient hospital
care, laboratory data, and referral processing. What was consistent was that providers spent a lot of time navigating between IT systems to extract information for entry into the patient’s EMR. In addition, laboratory information obtained from external sources must be scanned into the patient’s EMR. One practice has fully integrated all of the IT systems such that systems automatically communicate with one another. This was done during the planning and development phases of this practice (since this is a relatively new practice). Thus, all of this practice’s IT scheduling, appointment and insurance verification systems communicate with each other, which is not standard practice across all of the other PCMH sites. In the other locations, data can be brought into the EMR in a variety of ways including manual entry by a medical assistant or the clinician, scanned in as PDFs, cut and pasted from another electronic source, or automatically electronically populated. One provider expressed the complexity of the current IT system: NAME OF COMPANY is our main medical EMR, but then the hospital has a different system, billing system is a separate system, hospital has one billing system and practice has another billing system. I mean there are just a lot of systems out there . . . .
Provider alerts/tasks Another tool providers use within the EMR is “task” or “tasking.” Providers explained that tasks are generated from all entities, including the call center (where all patient calls go and appointments are made), and from medical assistants, and other providers. Similar across practices, all tasks appear on the provider’s EMR screen and remain on providers’ screen until they are dealt with, which can become a challenge when seeing patients. For example, having to respond to 15 tasks before being able to view a patient’s chart can significantly delay an office visit. Another similar finding across practices was that tasks are not grouped on the basis of level of urgency or emergency, which is more than likely a result of tasks being generated by a central location, the call center. Thus, providers reported that this also delays the process of seeing patients and providing medical care.
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No registries or manpower to begin diabetes registry Has 3 referral coordinators to generate and track referrals
Registry
The specialists should send/share results with patients (but may not) Uses guidelines developed by Family Practice department, using USPTF recommendations Internal monthly meetings to provide up-to-date information to all providers/staff
Receiving results from specialists
Provider ←→Provider communication
Evidence-based guidelines
Sends letters encouraging patients to follow up
Internal monthly meetings to provide up-to-date information to all providers/staff
Uses ADA guidelines (diabetes educator)
No definitive statement on this
Call patients with abnormal results
No definitive statement on this
Used Patient Quality Reporting Initiative
Create own internal process No clear method indicated; some to promote providers feel interaction is poor provider/team while others feel interaction is communication adequate (continues)
Use ADA guidelines
Will interpret specialists results and give to patients
Call patients with abnormal results
1 referral coordinator to generate and track referrals; able to track individual throughout the referral process
No registries
Too much additional work provided; maybe be good overall; not useful friendly Laboratory work faxed over
Primary Care Center D
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Sharing laboratory results
Laboratory work sent electronically and included in e-mails as a “task” Extensive diabetes registry used to monitor patients 1 referral coordinator who uses a specific referral software; able to track whether appointment was kept or not Calls patients with abnormal results; sends letters when results are normal No definitive statement on this
Laboratory work faxed over
No registries
Significantly useful
Primary Care Center C
Useful; best thing to happen
Primary Care Center B
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Other providers have received more training; old and antiquated Log into laboratory Web sites to get information
Primary Care Center A
Health Information Technology Laboratory results
Theme
Table. Medical Home Components by Clinic
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Yes, they are a medical home
Feelings About Medical Home Model
Yes, because they can No real need. Patients are provide materials in similar Spanish Yes, and no → Partially a Yes, and no → Partially a medical home medical home
Refers to diabetes educator or nutritionists
Yes, will refer to local gym
Abbreviations: ADA, American Diabetic Association; USPTF, United States Preventive Services Task Force.
No formal training but culturally competent
Cultural competence
Refer to community services Medical Support Services
Encourages patient communication via e-mail
Not accessible
Give ADA-approved handouts Provide a “report card”
Primary Care Center C
Yes, they have been a medical home all along
Yes, will refer to local food pantries, homeless shelters, or housing assistance Diabetes education; smoking cessation; pain clinics; pharmacists; psychiatrists Yes because have bilingual staff/medical assistants
Does not encourage patient communication via e-mail
Unaware if patients can access their own information
Provides newly diagnosed patients with educational CDs
Primary Care Center D
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Patient communication
Each provider does this differently → some give paper, some give Web sites, some just discuss; unclear if time spent on education is providing adequate return on investment Access but only information Access but unaware of that is accessible is what patients can demographics and making access or do in the an appointment system Does not encourage Some providers communication via e-mail communication with their patients via e-mail Yes, will share information Yes, will refer to about lectures or community community wellness programs programs None → refers to other sites Diabetes educator; having support pharmacist; podiatrist
Each provider in location does this differently
Primary Care Center B
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Patient education
Primary Care Center A
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What’s Inside a Medical Home? Tasks come primarily from the call center, when we get tasks from there, they mark it with a red star if it is highly important or a yellow triangle if it is just urgent. The downside of that is these are not medical people making these decisions, what they have said to me is if it is urgent to the patient, it is urgent.
Registries While all providers and primary care centers desired having health outcome or disease registries, only one center had a formal registry. This practice is relatively new and the registry was implemented from the beginning. Furthermore, the medical director and clinical staff are part of a master diabetes clinician program that shares their diabetes outcomes and metrics with other practicing clinicians. Having a registry is a key component of the master diabetes clinician program. For the 3 other practices, the majority of providers desired in-house registries and noted that they could generate lists if needed, but they reported a lack of resources, such as staff to enter information and monitor outputs and outcomes. Providers also reported that the institution has access to patient outcome data on an institutional basis because these outcome data are used to determine quality of care and physician bonuses, implying that separate, inhouse registries for each practice might not be necessary. However, providers seem to have similar desires to have a registry: We don’t have any registry. I think this is the future of medicine to target as our department kind of moves into the patient medical home. Using more registries, this is what is going to be expected of us and what we should be doing.
Referral process There was some consistency across practices/providers regarding the referral process. The general process is that the physician first generates a referral in the EMR note and then sends it to the medical assistant or referral specialist. The referral specialist then creates and tracks the referral in another IT system as well as documents the referral in the patient’s EMR. While the practices generally follow a simi-
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lar process, differences regarding personnel resources and tracking systems exist. For example, one center has 3 referral coordinators; another has 2 referral coordinators, while the other 2 sites have only 1 referral coordinator. This difference usually takes into account the varying number of health care providers and volume of patients in various clinics. Differences in making appointments with specialists also exist. In some instances, patients leave with a scheduled appointment to see a specialist by the end of their primary care visit. However, in other locations, it is the specialist’s office responsibility to schedule an appointment for the primary care patient. While referral tracking must be done by the medical assistants, there seemed to be no clear way to determine whether a patient actually completed an external referral or visit. Generally, providers are only able to tell whether a referral or external visit to a specialist occurred when the patient returned to the primary care office for a visit. It was easier to get information about referrals when specialists were within the same academic health system, using the same EMR. For patients completing a referral outside of the system, if the provider sent a follow-up report it would be scanned into the EMR. E-prescribing The availability of e-prescribing was also consistent across sites. The function in the current EMR system automatically checks for proper dose and drug interactions. Essentially, all the practices can transmit prescribing information to external national chain pharmacies in the area. For example, external pharmacies send e-mails informing the offices of patients’ requests for refills. Providers reported that the majority of patients (from all sites) seem comfortable with e-prescribing with only a small percentage of patients wanting or requiring a paper script. Oddly, there is no electronic relationship with the in-house medical system or the Navy system for e-prescribing. Patients having their medications filled at the pharmacy associated with the academic medical center or who are covered by the Navy need to have paper pre-
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scriptions. One center uses another system with patients’ consent, which allows for viewing all medications a patient filled from all participating pharmacies. Providers did report some inconsistencies with e-prescribing, however. For example, one center prefers to fax all prescriptions to external as well as in-house pharmacies rather than sending prescriptions electronically. Some providers also reported that prescriptions sometimes never “arrive” electronically to the pharmacy, requiring more research to verify that the prescriptions were sent, which then uses additional personnel, time, and efforts to track or verify prescriptions. Laboratory results The majority of clinics had a similar procedure for retrieving patients’ laboratory results. In general, laboratory work completed within the academic medical system is viewed in a separate system from the current EMR. These results are then copied and pasted, or scanned into the patient’s record. Some centers have an evolved process; for example, one center logs onto laboratory Web sites to retrieve results while other primary care centers received results through faxes directly from the laboratories. Another center is starting to receive patient results electronically in e-mails as a “task.” One consistent view is summarized in the following quote: Because the labs are available in the computer, there is no closed loop yet because information doesn’t feed into our system. The system in the lab is different from the electronic medical record, but they’re working on it.
Evidence-based guidelines Providers report using different evidencebased guidelines; one provider reported using the American Diabetic Association guidelines when providing information to patients (diabetes educator). Another provider reported using specific guidelines developed by the Family Practice department based on the US Preventive Task Force guidelines. Some providers stated that they used the health maintenance checklists in the EMR template
to assist in determining what care someone receives, while another provider stated that only 4 things must be done regarding diabetes patient care, according to the Physician Quality Reporting Initiative. Although practices reported varying processes for developing guidelines, one provider reported that the entire department, which would include all practices, developed evidence-based guidelines in a specific manner: The whole family practice department came up with specific guidelines of what general health maintenance should be and also what diabetic follow-up should be for that particular group of patients, we generally use the US preventive task force service guidelines plus the American academy of family physicians guidelines and some of those are different and we kind of come up with what we think is the best of both of those recommendations.
Decision support The majority of providers felt that the decision on how to deliver medical care is ultimately theirs and should not be entirely dependent on electronic decision supports, as evidenced in the following quote: I am the decision support, I make the decision, I see the lab come back abnormal and from that I make the decision.
Providers noted that the way their EMR is currently structured shows medication interactions but fails to suggest what medications might be more suitable for the patient. In essence, the EMR does not offer suggestions regarding what to prescribe to a particular patient. Cultural competency and patient-centered care While all practices/providers reported being patient-centered and culturally competent, no provider readily offered specific evidence of how patient-centered and/or culturally competent care was operationalized within their practices. Providers at one center reported that they had no formal training for staff in cultural competence although they often discussed this topic at meetings. Other
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What’s Inside a Medical Home? providers at another center had a Spanishspeaking medical assistant, which they felt made them culturally competent. Another center provided health materials in Spanish. All providers seemed to resonate with the following statement: The patient has always been the center of the practice, that’s the way we’ve always done things. I am the advocate for the patient, I don’t know any other way to be.
Patient access to their own medical record Providers at one center fully realized that patients have and should have access to their own medical record. One provider reported that while patients have access to their information through a “patient portal,” appointment times and contact data are the only information currently available. No other providers reported being aware of the patient portal or having interaction with one. Importantly, one provider where patients did not have access to their own medical record felt the following: I know that laboratory sites are allowing patients to retrieve their own lab and I think that is phenomenal. Really it is but no we don’t have that just yet but I know it is coming.
Patient communication The general process for patients to contact providers seemed consistent across practices. A patient calls the call center, which creates a “task” in the patient’s EMR, alerting the provider to call back or act on the request. However, providers had slightly different methods in how they responded to patient requests. For example, some providers would contact the patient directly if they felt that the situation was urgent or emergent, or required the provider’s direct attention. Otherwise, the provider would have a medical assistant contact the patient to get more information or to assist the patient with the task or the message. There was some variation in how laboratory results were communicated to patients. What is consistent is that all practices/providers reported that someone telephoned patients having abnormal results to schedule a follow-up
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visit, while normal results would be mailed to the patient. Specifically, one provider telephoned patients having abnormal results to schedule a follow-up visit or to determine an action plan. Other providers had their medical assistants telephone patients with abnormal results. Some providers communicate with patients via e-mail as well as provide their e-mails to their patients while other providers did not feel that e-mail communication was appropriate. Following is one provider’s description of how they deal with abnormal results: If it is something that needs to be caught right then, like for a patient that had labs done it was all normal, we don’t call them, we take that letter, make a copy of it so we can scan it into the patient’s chart and then we mail it to the patient. But if it is an abnormal lab that needs attention or if they need to come back in and have more lab work as a result of this abnormal one, we are told to call the patient, or the doctor does this himself.
Patient alerts/reminder systems One consistent response from providers is that there are no automatic alerts in the EMR to remind providers of the need for preventive care, blood work, or to refer a patient to a specialist (ie, podiatrist, eye test). In fact, in some practices, medical assistants are responsible, for the most part, for alerting physicians of extremely elevated patient values. These extremely elevated patient values or any type of “alert” are then added manually to the note or a certain section in the EMR to notify the provider of the patient’s status/ condition. Some providers created their own alerts by generating delayed e-mail messages. For example, providers reported that one could generate a task, dated for the future, to remind oneself that the patient needs to get a mammogram at a future date; then, the task appears or comes due when the future date arrives. Specifically, some providers manually created self-tasks or reminders for what to check when a 50-year-old man has a visit, or a 45-year-old woman visits. These providers manually create these reminders and then send them to themselves regarding their pa-
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tient, so that in the future, the reminder will generate and alert them. Providers also reported creating folders and putting patient information into them to serve as a selfalert/reminder system; the providers would then look for patient information in these selfcreated folders when patients return for visits. What was clear is that providers varied in their creation of patient alert/reminder systems. For example, one provider reported that his/her center has the ability to check the system [a unique system to their center] to see if a patient completed an outside appointment or received medical care from an outside source. However, other providers reported that they created a cumbersome process of reminding themselves and medical assistants to get results of follow-up care or tests to patients. Another provider has created a similar process of tasking, by sending a task to oneself, set for a future date, as a reminder that he/she referred the patient or must follow up with the patient regarding a screening test, blood work, or a particular procedure. It is also important to note that these reminders or tasks are established by the individual providers for their own purposes and are not intended for other members of the clinical team to act on. EMR/Internet used to educate patients The way providers share information with patients also varied substantially although the majority of providers use the Internet as a primary source for education information. Some providers printed online resources for patients although they recognize that they must be cautious to avoid advertising other “institutions” or academic medical centers. Some providers give information (via Web or print) from other medical institutions while others adamantly avoid this. Some providers give patients the exact Web site in which to visit. Providers at all sites reported giving handouts approved by American Diabetes Association. One provider reported lending compact disks to newly diagnosed diabetic patients to assist them with learning more about diabetes. One provider provided patients with a “report card,” generated from their diabetes registry,
to educate patients about their current health status. Although there is a function in the current EMR to show patients their health indicators (ie, blood pressure, weight) and plot these values over time, no provider readily used this function to educate patients. Patient support services All centers used support services to some degree. For example, while some providers had onsite, in-house services, other providers referred patients to other centers within the academic health care system. The type of support services also varied between centers. Some centers have an onsite dietician, podiatrist, pharmacist, and psychiatrist, while others refer patients to support services such as a nutritionist or diabetes education. One center has various in-house disease management programs (ie, Be Lean program, smoking cessation, Coumadin clinic), while others have no onsite disease management programs. Another point was that programs at each center were primarily started by the medical director or providers at the center. “Our RN actually works with the indigent program, which works with patients who are high risk for no shows and then they have their own personal dynamic . . . to encourage them to keep their appointments, which has been very helpful.”
Referrals to community supports All practices have various approaches to connecting people to outside resources. There was a consistent message that referral to support services, specifically diabetic education, is insurance-based or driven. Sites, although not fully coordinated with external services, will refer patients to social services in the community. One center relies on referral coordinators to give patients additional information for support services, such as housing, nursing homes, or food pantries. However, one perception is that communitybased programs are not consistent or do not last (ie, programs offered at the library or through grants are temporary). Another potential difficulty, as reported by one provider is that there is no “established” relationship with community-based resources; thus refer-
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What’s Inside a Medical Home? ring patients to these sources (ie, exercise programs, food pantries) may not prove beneficial for the patient. Referrals depend a lot on their insurance, if they have one form of insurance, they have this program that is called Silver Sneaker, and so they have the choice of whether or not to go to the YMCA or go to other community wellness programs.
Diabetes education One center had a formal, organized diabetes education program while another center had a semistructured diabetes education program. The other 2 centers refer patients to the formal diabetes education program although the diabetes educator indicated that this does not routinely occur. Furthermore, the classes are not conveniently located for patients from these other 2 sites. Is the practice a PCMH and focused on patient centered care? Despite the fact that all practices had achieved NCQA level 3 accreditation, participants at 2 of the 4 sites were cautious in describing their locations as a medical home. These respondents tended to focus on perceived deficiencies such as the lack of a registry, or not having a referral process as well defined as they would have liked. In their answers, providers focused on the definitional aspects of the medical home and the extent to which they are being accomplished. At these locations, the medical directors noted that the process of transforming to a medical home is ongoing. For example, all noted that the health information technology system would be changed in the coming year with the expectation that the functionality of the new technology will provide greater support for medical homes. Participants at the 2 remaining sites were more definitive and clearly defined their practice as a medical home. For example one participant noted that their practice has always been a medical home even before the term was commonly used. We have been a medical home. The only alternation is just documenting. I don’t see any difference
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other than documenting what has been done for the last 20 years.
Participants did note that implementing the medical home model involved a complex set of tasks. Limited resources can hamper the implementation of the medical home as it is truly envisioned. These respondents focused on the patient-centered aspects of the model. One respondent noted that his practice was a medical home because they treated patients with respect. Specifically, that practice reported being a medical home because: they ensured that their patients with diabetes had required procedures performed and that they spent time with patients to answer their questions. So, for this location, the concept of the medical home had more to do with the quality of the patient-provider interactions than with other components of the model. Further probing on how respondents would define the practice culture revealed that all locations worked hard to provide care that focuses on patients’ needs. Individuals were very clear about the distinction between the formal requirements for recognition as a medical home compared with having a patient-centered focus as noted by the following response: So I think just to standardize that to have us all under the same rules in a medical home basically that is a good thing . . . it is really about who you are and how approachable you are to patients. I like that my patient loves me and I like that they are free to call me anytime. I can always see them even on short notice.
DISCUSSION All providers sought to provide the highest standard of care to patients, although having different ways in which they use available resources. While these differences may seem relatively benign, they have important implications for how easily providers can search and retrieve information. While there were many consistencies in how providers implemented procedures, such as using the EMR, providing results to patients, and providing some type of education
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to patients, there were also many differences. Some of the difference could be attributed to the fact that medical directors have varying opinions about medical homes. While generally there was recognition that a medical home is a place where a patient can go for all of their medical needs, there was the perception among all respondents that the theory is significantly different from the practical application of medical practice. One provider felt that in order for medical homes to be reality, government and the “powers that be” will need to appreciate the financial and practical implications of medical home implementation. What is also interesting is how these 4 sites, within the same academic health system, chose to operationalize the concept of medical homes. What is evident is that implementation is often driven by opinion and values. For example, the centers where providers felt it somewhat unnecessary for patients to access their own medical record did not have much patient access. On the contrary, providers communicated with patients via e-mail/electronic resources at centers where providers thought that this was an essential part of medical care. Our study raises questions and opportunities for further research in a number of areas. First, a better understanding from both a qualitative and quantitative standpoint regarding what process of care and components of the medical home contribute best to patient experiences and satisfaction is still desired.
Having patients’ viewpoints as to what they want from a medical home is also critical to assuring a patient-centered focus. In addition, our study revealed that clinicians themselves have varying views on what a medical home is and the benefits of organizing medical care in this way. Specifically, we were able to note that providers do distinguish between what a medical home is and the patient-centered aspect of their practice. For them, the 2 concepts could be mutually exclusive. Not having all of the medical home process components in place does not necessarily mean that a practice is not providing patient-centered care. Because providers are key to medical home implementation, we need further understanding of their opinions on how to deliver patientcentered care. While we believe this study adds to the existing body of knowledge on PCMH and implementation, our sample is limited to only 4 sites of care that are a part of the faculty practice of one academic medical center. This coupled with the qualitative nature of the inquiry limits the generalizability of our findings to other primary care locations. Regardless, we think our findings provide important insight into some of the ways primary care providers operationalize medical homes. These findings also suggest that more research and evaluation needs to occur to better understand how the medical home model in NCQA-accredited practices is fully operationalized and how this actually impacts overall quality of care and health outcomes.
REFERENCES Agency for Healthcare Research and Quality. (2012). Patient-centered medical home. Resource center. Retrieved December 10, 2012, from http:// www.pcmh.ahrq.gov/portal/server.pt/community/ pcmh_home/1483 Bodenheimer, T. (2008). Coordinating care—a perilous journey through the health care system. New England Journal of Medicine, 358(10), 1064–1071. Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. JAMA, 288(14), 1775–1779.
Calman, N. S., Hauser, D., Weiss, L., Waltermaurer, E., Molina-Ortiz, E., Chantarat, T., . . . Bozack, A. (2013). Becoming a patient-centered medical home: a 9year transition for a network of Federally Qualified Health Centers. Annals of Family Medicine, Suppl 1: S68–S73. Green, E. P., Wendland, J., Carver, M. C., Hughes Rinker, C., & Mun, S. K. (2012). Lessons learned from implementing the patient-centered medical home. International Journal of Telemedicine and Applications, Article ID 103685.
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What’s Inside a Medical Home? Grumbach, K., & Bodenheimer, T. (2002). A primary care home for Americans: putting the house in order. JAMA, 288(7), 889–893. Hsu, C., Coleman, K., Ross, T. R., Johnson, E., Fishman, P. A., Larson, E. B., . . . Reid, R. J. (2012). Spreading a patient-centered medical home redesign: a case study. [Research Support, N.I.H., Extramural ov’t]. The Journal of Ambulatory Care Management, 35(2), 99– 108. Kaye, N., & Takach, M. (June 2009). Building medical homes in state medicaid and CHIP programs. Washington, DC: National Academy for State Health Policy. National Committee on Quality Assurance (NCQA). (2011). Patient-centered medical home. Retrieved April 12, 2011, from http://www.ncqa.org/tabid/631/ Default.aspx Nielsen, M., Langner, B., Zema, C.,, Hacker, J., & Grundy, P. (2012). Benefits of implementing the primary care patient-centered medical home: a review of cost and quality results, 2012. Washington, DC: PatientCentered Primary Care Collaborative. Nocon, R. S., Sharma, R., Birnberg, J. M., Ngo-Metzger, Q., Lee, S. M., & Chin, M. H. (2012). Association between patient-centered medical home rating and operating cost at federally funded health centers. JAMA, 308(1), 60–66. Patient-Centered Primary Care Collaborative. (2012). Retrieved December 10, 2012, from http://www.pcpcc. net/ Patton, M. Q. (2002). Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA/London, UK/New Delhi, India: Sage Publication.
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Reid, A., Baxley, E., Stanek, M., & Newton, W. (2011). Practice transformation in teaching settings: lessons from the I3 PCMH collaborative. Family Medicine, 43(7), 487–494. Rittenhouse, D. R., Schmidt, L. A., Wu, K. J., & Wiley, J. (2013). Incentivizing primary care providers to innovate: building medical homes in the Post-Katrina New Orleans Safety Net. Health Services Research. Advance online publication. doi:10.1111/1475–6773.12080. Takach, M. (2012). About half of the States are implementing patient-centered medical homes for their medicaid populations. Health Affairs (Millwood), 31(11), 2432–2440. doi:10.1377/hlthaff.2012.0447. Coleman, K., & Phillips, K. (May 2010). Providing underserved patients with medical homes: assessing the readiness of safety-net health centers. Washington DC: The Commonwealth Fund. True, G., Butler, A. E., Lamparska, B. G., Lempa, M. L., Shea, J. A., Asch, D. A., . . . Werner, R. M. (2012). Open access in the patient-centered medical home: lessons from the Veterans Health Administration. Journal of General Internal Medicine, 28(4), 539–545. Vest, J. R., Bolin, J. N., Miller, T. R., Gamm, L. D., Siegrist, T. E., & Martinez, L. E. (2010). Medical homes: “where you stand on definitions depends on where you sit.” Medical Care Research and Review, 67(4), 393–411. Williams, J. W., Jackson, G. L., Powers, B. J., Chatterjee, R., Bettger, P., Kemper, A. R., . . . Gray, R. (July 2012). Closing the quality gap: revisiting the state of the science. Vol 2: Patient-centered medical home [Evidence Reports/Technology Assessments]. Rockville, MD: Agency for Healthcare Research and Quality.
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Use of additional care management supports
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Use of information technology
We are interested in learning about how you manage your patients, especially patients who are living with type 2 diabetes. What HIT applications are currently in use? “In use” means that the applications are used routinely by clinic personnel to enhance patient care and clinic administrative • Decision support systems, electronic prescribing; electronic medical records; billing; registries; reminder systems; referrals, patient portals, etc. Describe step by step how these systems are used (eg, how is an electronic prescription initiated? How is patient scheduling done using HIT? Discuss the application of clinical management systems to clinical practices? What kinds of e-mail communication occur? How do you track referrals? Laboratory results?) • Who uses them? How often? Do you maintain paper versions of data or processes? Do all people involved use the systems? Are there reluctant users? When it is determined that a patient needs to be referred to another provider, how is this done? • How are providers identified? How are providers contacted for an appointment? Does the primary care provider communicate in any way with the specialist either prior or after the referral visit? What kinds of information are sent to the referring physician? After the referral occurs how do the practice and the primary care provider obtain the results of the consultation? • Does the primary care provider receive information from the referring physician? How? How do patients find out the results of the consultation? How is the referral information maintained? How are health educators used in the practice? • One on one consultation with a patient? Group classes? Describe the specific health education programs. • Are these community-based programs or are they developed specifically for the practice? • Are the patient supplied with written material? • Curriculum What kind of feedback have you had from patients about these programs Describe the disease management programs • How does the practice identify patients to participate in the programs • Provide an in-depth description of the programs—what’s involved • Do you think the programs are successful? Why or why not? What would you change • What are patients telling you about the programs? Do the DM programs provide patients with more ability to manage their care? (Continues)
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Introduction
PCMH Attribute
Appendix: In-Depth Interview Protocol With Medical Directors and Other Clinical Staff
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Abbreviations: DM, disease management; HIT, health information technology; PCMH, patient-centered medical home.
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Practice culture and characteristics
Performance measurement and quality improvement
Are patients linked to community resources outside of the practice? • How do you identify these programs? Are you able to assess the quality of these programs? • How does the practice link patients to specific community-based programs? What guidelines do you use? • Do you follow all of the guidelines? Strictly? How are clinicians monitored in terms of their use of the guidelines? Describe the quality improvement activities • What kinds of performance measures are collected? How routinely? By whom? How easy/difficult to collect? • How are these measures used in performance improvement activities? • Describe the feedback process to clinicians and other practice staff • Are you able to chart change over time? Do you consider your practice to be a medical home? In what ways? • Accessibility to care? Coordination (Referrals, test tracking)? Registry functions? Cultural competency? • What does a medical home mean to you? • What is the mission, vision, or goal of your practice? • Does everyone in the practice (clinical and non clinical embrace the concept of medical home) • Has the process of transformation been a deliberate one? • Has performance changed over the past 5 years When I say the word practice culture—what comes to mind? • Emphasis on team work, cohesiveness, participation • Emphasis on innovation and risk-taking; entrepreneurial • Emphasis on achievement and meeting objectives • Emphasis on stability, rules, policies and regulations What does patient-centered care mean to you or the practice? How is this concept operationalized? Cultural competency? Other than the programs we have discussed above, what else does the practice do for patients to ensure that care is patient-centered? Customer service programs?
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Appendix: In-Depth Interview Protocol With Medical Directors and Other Clinical Staff
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