Medical Homes
Interview with Bruce Kleaveland of Kleaveland Consulting

Medical Homes - How will this up-and-coming concept of consolidating and directing individual medical care affect your patient care and the IT tools you need to make it work?

Can doctors find a home in the medical home?

Yes—if they have an EMR.

If you were looking for another reason to finally invest in an EMR—or trying to justify your current EMR investment, you should add the medical home to your list.

As most of you probably know, the medical home is a new paradigm for providing care that is a way for practices to step off of the visit-centric treadmill of back to back 15 minute visits and move to a more patient-centric approach with a greater focus on disease management and customer service.

Why the focus on IT and the EMR in particular?

Because it is virtually impossible to make a medical home work without these tools.

Let’s look at some of the core components of the medical home I and will show you what I mean.

Team care within the practice: one of the basic tenets of the medical home is that all members of the clinical staff—NPs, nurses, MAs, lab techs, even your reception staff, can play a role in care management. It is challenging to build an effective team approach with paper-based systems because clinical information is locked in the chart which is typically filed away. With an EMR, any approved member of the staff can instantly access information from any workstation. Efficiently coordinating care for everything from scheduling more time for diabetic patients to complete overdue tests to pro-active disease management become reasonable tasks if the members of the team have instantaneous access to patient information.

Quality of care and safety: Part of the reason insurers across the board are sponsoring medical home demonstration projects is the justified belief that preventative care and disease management will have a nice double whammy of healthier patients and lower costs. One model suggested that if all primary care practices embraced the medical home, it would yield savings of about $67BB, or about 5.6% of our health care spend.

So: for all you paper based practices out there—can you give me a list of all of your diabetics? And can you tell me which ones have HgBA1C’s greater than 9? You probably could, but it would a very labor intensive task.

EMRs by themselves or in conjunction with disease registries were made for these types of tasks, allowing a team member—presumably a nurse—to efficiently manage disease management or preventative care initiatives.

EMRs are also great at reminding providers at the point of care that tests or screenings are overdue. And they offer great potential for both clinical decision support (analyzing information within the chart to help clinicians make decisions) and evidence based medicine (providing electronic access to the latest evidence based finding, usually via a link from the EMR to specialized web sites).

Expanded access: A key concept behind the medical home is making it easier patients to see their physicians. Part of this is achieved through expanding hours and offering same day scheduling (called open access scheduling). Access is also improved by taking advantage of the internet and offering patients the option of secure email communication, e-visits, or on-line scheduling. While these add-ons may not directly impact the bottom line (reimbursement for e-visits is still variable among payers and e-mail communication with a patient is not a billable event), they improve customer service in an increasing competitive market.

Coordination of Care: In a medical home, the primary care practice takes a greater role in helping manage the patient through the maze of specialists, ancillaries, test facilities, and other services that exist outside the walls of the practice. In a perfect world, regional health care communities would all be connected in a seamless and secure fashion and complete patient information was wherever it was needed. We are clearly a long way from that IT utopia, but even in today’s fragmented world, relatively simple tools such as secure email linking provider to specialist or e-prescribing between provider and pharmacy offer a much more efficient way of communication than phone, fax, or paper.

Bottom line: you can’t efficiently implement the medical home without a pretty significant IT infrastructure.

But does it work in the real world?

To answer that question, I quizzed one of my physician friends, an avid EMR user in rural 8 provider primary care practice in a small town in the Pacific Northwest.

He is believer. So much so, that they are physically re-designing their practice to be compatible with medical home principles. They have been successful in establishing care teams and have a very active disease management program. Roughly 65% of their 25,000 visits are year are related to chronic care. Care plans for hypertension, diabetes, COPD, and cardiovascular conditions are built into their EMR and also available on their web site for patients. Patients with chronic conditions are proactively scheduled for follow-up visits—even if they are asymptomatic—helping the patient and provider stay ahead of disease. “It helps productivity. The visits are much more focused and less chaotic,” he noted.

Their participation in an EMR based research network (which functions as a type of disease management registry) helps them identify individual patients that are not meeting performance goals, as well as providing a macro picture of how they well there a managing their diabetics or hypertensive.

They are doing well financially (a designation as rural health clinic has helped with their Medicare patients) and are excited about making a difference with their patients. “We have been really surprised at how dramatically the hospitalization rates for our patients have dropped, since we started instituting these changes,” my friend observed proudly.

He was also quick to note, “You can’t do the new model with paper charts. You have to the right software tools to make it work.”

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Despite the fact that the hospitalization rates for their patients have dropped significantly, they are not receiving additional bonuses for disease management and are still relying on fee-for-service for income. A designation has a rural health clinic has help fees on the

But they are also immensely practical and are focusing their efforts on the components of the medical home that are supported by current health care financing. That means that items like e-visits and group visits, which

They believer One of my physician friends who’s practice has embraced the disease management portion of the model over the past three years is already seeing the hospitalization rates for his patients decline significantly. He is a believer. “Compare the cost of a diabetic seeing me four times a year at $70 a visit to help manage their disease vs, the cost of one hospitalization because their condition is out of control and you get the idea of the potential of this approach.” he notes.

But here is another bottom line: main stream health care financing has not caught up with it yet. So unless you are part of a pilot program, most insurers will not recognize your efforts with extra greenbacks.

One of my physician friends who’s practice has embraced the disease management portion of the model over the past three years is already seeing the hospitalization rates for his patients decline significantly. He is a believer. “Compare the cost of a diabetic seeing me four times a year at $70 a visit to help manage their disease vs, the cost of one hospitalization because their condition is out of control and you get the idea of the potential of this approach.” he notes.