Tuesday, August 27, 2013

Researchers Create New 'Education-Centered Medical Home' Teaching Model

August 26, 2013 02:46 pm Sheri Porter – Researchers at the Northwestern University Feinberg School of Medicine in Chicago confronted two opposing truths back in 2011. The AAFP-supported patient-centered medical home (PCMH) model of care -- a team-based model that features easily accessible, high-quality health care coordinated by a primary care physician -- was gaining popularity nationwide as a means of improving patient care and lowering health care costs, but few medical schools were introducing PCMH concepts to students via curricular changes.
As a result, researchers set out to test the feasibility of a longitudinal clerkship based on PCMH principles and anchored by PCMH educational objectives. Researchers developed a model they dubbed the "education-centered medical home" and enlisted 56 student volunteers and four faculty preceptors from the medical school to participate in a study from June 2011 to April 2012.
The overall objective, according to study authors, was to "assess the feasibility and perceptions of an education-centered medical home clerkship on students and preceptors."
At the study's conclusion, program evaluations completed by participants revealed that students gained confidence in their understanding of PCMH principles and, in particular, appreciated experiencing early clinical exposure, continuity of care with patients and peer teaching. Faculty members also responded positively. In fact, all preceptors and 39 of 42 non-graduated students said they wanted to continue participation in the education-centered medical home clinics in the 2012-13 academic year.
  • Researchers at Northwestern University Feinberg School of Medicine tested the feasibility of a longitudinal clerkship based on patient-centered medical home (PCMH) concepts and anchored by PCMH educational objectives. 
  • They created an "education-centered medical home" model and enlisted 56 volunteer medical students and four physician preceptors to participate in a study from June 2011 to April 2012. 
  • Students liked the early clinical exposure, continuity of care and peer teaching experiences; all four preceptors and 39 of 42 non-graduated medical students wanted to continue participation in the model. 
The research is summarized in an article titled "The Patient-Centered Medical Home as Curricular Model: Perceived Impact of the 'Education-Centered Medical Home'(link.springer.com)" in the August 2013 issue of the Journal of General Internal Medicine.

Program Setup

For purposes of the study, education-centered medical homes were established at four existing faculty practices. Two of the clinic sites are federally qualified health center family medicine clinics, another is an academic general internal medicine clinic, and the fourth is an academic pediatric pulmonary clinic. Student teams were formed with first-, second-, third- and fourth-year medical students on each team. High-risk patients were recruited in each setting. Clinical education was achieved via a traditional physician preceptor model with the additional component of third- and fourth-year students directly observing first- and second-year students. All students attended monthly grand rounds conferences.
Curriculum was developed with three objectives in mind. Researchers aimed to
  • maximize student continuity experiences with patients, preceptors and peers;
  • demonstrate patient-centered care principles of the PCMH model; and
  • incorporate students in the delivery of PCMH care as health coaches and coordinators.
Researchers said the implementation of the education pilot at the Feinberg School of Medicine was a success and announced plans to expand the model in the 2012-13 academic year. They also acknowledged the study's limitations. For example, the authors said establishment of an education-centered medical home "would require significant financial resources and a substantial number of preceptors to incorporate all students at an institution."

Corresponding Author Answers Questions

AAFP News Now asked corresponding author Daniel Evens, M.D., an assistant professor of medicine-general internal medicine and geriatrics at Northwestern University Feinberg School of Medicine to answer a few questions about the project.
Q. What drove your interest in giving medical students training in a PCMH setting?
A. My career path as a "hybrid" ambulatory/hospitalist physician has placed me three months per year on our inpatient teaching service and the rest of the year in the clinic as a primary care physician. As a result, I recruited a large number of medically complex patients to my panel, and I have learned the hard way how difficult it is to coordinate care for these patients with chronic illness.
I've come to appreciate that there is no way that I can do it alone, and that I need a team to help me manage these patients. I also learned that medical students are eager to have continuity with complex patients and are willing to help with service learning projects.
During our recent curriculum renewal at Feinberg, we floated the idea of merging the needs of our primary care docs (e.g., the need for care coordinators and health coaches for our complex patients) with the desires of our students (e.g., the desire to have continuity with a panel of patients and learn how to manage chronic illness) into a new educational model called the education-centered medical home.
Q. What do you make of the highly positive evaluations from participating students and preceptors?
A. The positive student reaction to our education-centered medical home was not a surprise to our steering group. We knew that the average medical student was graduating after four years having never seen a single patient back for a continuity visit, so we knew that any program focused on continuity would be well received. The major question before our steering group was whether or not we could we create a program that was feasible from the viewpoint of the preceptors, and our retention of 13 out of 13 preceptors from last year's program gives us tremendous confidence that we are on the right track.
Q. Did the findings hold any surprises for you and your colleagues?
A. We started with the model of 16 students per preceptor mainly out of convenience (it was a multiple of four, easy for organizing four classes of students) and out of necessity (our limited funding required a large student-to-preceptor ratio). However, we were delighted to learn just how impactful it was for our preclinical students to pair up and have third- and fourth-year students directly observing patient encounters as peer teachers. The peer teaching aspect of the education-centered medical home ended up being rated just as highly as the continuity aspect of the program, and this was a wonderful unintended consequence of our 16:1 preceptor formula.
Q. Can immersing students in the PCMH model via the education-centered medical home help drive students to primary care specialties?
A. It will take several years to find out if our education-centered medical home program impacts the career choice of our graduates. We certainly hope that placing students into high-functioning primary care clinics that are committed to practice transformation will inspire some students to become medical home leaders themselves. Just as important, we hope that our graduates who still choose (sub)specialty practice will have a better understanding of the scope of primary care medicine and will be better prepared to be collaborative medical neighbors in the future.
Q. What's the most important take-away message from this project?
A. There is a large appetite among our students for continuity experience and the opportunity to learn about the medical home model. Our trainees are excited to work in the PCMH environment, and medical educators need to advocate on their behalf to create opportunities to involve them in practice transformation activities. For our part, we are happy to collaborate and share teaching materials with other institutions who are considering similar programs.

OIG Advisory Opinion supports remote health monitoring arrangements

In an Advisory Opinion posted on Aug. 16, 2013, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) assessed an arrangement under which a vendor of technology platforms (the “Vendor”) proposed to contract with hospitals to provide services to certain patients following hospital discharge in an effort to reduce preventable hospital admissions (the “Arrangement”). The OIG concluded that it would not impose penalties under the Anti-Kickback Statute even though the Arrangement could potentially generate prohibited remuneration if the requisite intent was present. The OIG further concluded the Arrangement would not constitute grounds for the imposition of civil monetary penalties under a provision prohibiting inducements to beneficiaries.
The Proposed Arrangement
The Vendor, a wholly-owned subsidiary of a pharmaceutical manufacturer, has developed technology platforms and services that are designed to help hospitals avoid payment reductions associated with excess readmissions by coordinating care and facilitating patient adherence to discharge plans. The Vendor will offer the Arrangement to hospitals either directly or indirectly through a group purchasing organization (GPO), patient-centered medical home (PCMH) or managed care organization (MCO). Agreements for the Arrangement would be in writing, for a term of at least one year, fees would be set at fair-market value and discounts would be structured in compliance with the discount exception to the Anti-Kickback Statute. Fees for the Arrangement will include (1) an initial flat fee; (2) an annual fee, based on patient volume, which can only be adjusted and increased if the actual use exceeds the baseline use already paid for by the annual fee; and (3) additional fees for additional services requested by a hospital.
Services provided by the Arrangement (the “Services”) include the availability of patient liaisons to monitor a participating patient’s adherence to the hospital discharge plan and his or her current health status. The Services would also include scheduling follow-up appointments, the provision of refill reminders, transportation support and the generation of reports to help the hospitals monitor the use of the Services and readmission rates. Finally, the Vendor certified that neither the Vendor nor nurses contracted by the Vendor would promote the pharmaceutical manufacturer’s products. In addition, regardless of the patient’s question or symptom, the nurses contracted by the Vendor would not refer the patient to any provider or supplier other than the patient’s established providers and suppliers.
Minimal Risk Under the Anti-Kickback Statute
Although the parties to the Arrangement are potential referral sources (i.e., the hospital’s staff is in a position to order drugs manufactured by the Vendor’s parent company and the Vendor’s employees could refer patients to the hospital), the OIG concluded the Arrangement posed a low risk of fraud and abuse under the Anti-Kickback Statute for the following reasons:
  1. The Arrangement is unlikely to lead to increased costs or overutilization. In contrast, the Services could actually save federal healthcare programs money if the Arrangement is successful in furthering its goal of decreasing hospital readmissions.
  2. The Arrangement is unlikely to interfere with clinical decision-making. The Services would be rendered after a participating patient is diagnosed and discharged from the hospital.
  3. The purpose of the Arrangement is to promote compliance with a participating patient’s discharge plan and all prescribed therapies, regardless of which drugs are prescribed to the patient. The Vendor certified that it would implement a number of safeguards to prevent the Arrangement from being used to increase drug sales by the pharmaceutical manufacturer. Further, the Vendor certified that the fees charged would be consistent with fair market value in an arm’s length transaction.
  4. The Arrangement is unlikely to result in inappropriate patient steering. Individuals contracted by the Vendor to interact with participating patients would be prohibited from referring the patients to any provider, practitioner or supplier other than a patient’s established provider, practitioner or supplier.
Beneficiary Inducement Concerns Do Not Exist
The OIG may assess civil monetary penalties against an individual if the individual offered or transferred remuneration to Medicare or Medicaid beneficiaries and the individual knows, or should have known, that the remuneration is likely to influence a beneficiary to order or receive a federally payable item or service from a particular provider, practitioner or supplier. The OIG found that although the participating patients would receive a valuable service without cost under the Arrangement, the Arrangement is a low-risk method of guiding patients through the post-discharge period without influencing a participating patient to order or receive a federally payable item or service or limiting a participating patient’s choice of provider, practitioner or supplier.

Sept. 23 deadline looms for business compliance with HITECH Act on patient privacy

Organizations handling healthcare data have a month to comply with new security and privacy requirements under the Health Information Technology for Economic and Clinical Health (HITECH) Act.
After Sept. 23, all covered entities, including online storage vendors and cloud service providers, will be subject to new breach notification standards and limitations on how they can use and disclose PHI. They will also be required to ensure that their business associates and subcontractors are compliant with the privacy and security requirements of the Health Insurance Portability and Accountability Act (HIPAA). The HITECH Act amended portions of HIPAA by adding new security and privacy provisions on patient information.
In addition, covered entities will be required to have updated patient privacy notices in place that state the patient's rights over the data and how the data can be used and shared.
Unlike the original HIPAA privacy and security rules, which primarily applied to healthcare organizations and insurance companies, the new HIPAA Omnibus rules apply to business associates and their subcontractors. Under the omnibus rules, a business associate of a healthcare provider, such as a cloud service provider, is directly liable for protecting any patient data it handles, even if the vendor is just storing the data.
Business associates are also liable for ensuring that any subcontractor it hires, such as a document-shredding company, is similarly protecting PHI.
The new rules for safeguarding PHI create a complex liability chain, said Peter MacKoul, president of consulting firm HIPAA Solutions LC. A covered entity or a business associate could face stiff civil penalties for a breach by a subcontractor, regardless of how far down the chain the subcontractor might be, he said.
Under Omnibus HIPAA rules, covered entities and business associates are directly responsible for protecting against the use of PHI by employees, contract workers, trainees and even unpaid volunteers and interns, MacKoul noted.
The rules also give healthcare organizations and business associates less latitude to determine when to make a breach notification, he said.
Previously, a healthcare organization needed to notify individuals of a data breach only if there was a serious risk of financial or reputational harm. Under the new requirements, covered entities and business associates will be required to issue a breach notification in most cases, unless they can specifically show there is a "low probability" of the breached data being misused, MacKoul said.
Healthcare companies will be required to consider four specific factors, including the nature of the data that was breached and whether PHI was acquired or viewed only, to determine the seriousness of a breach. Importantly, breach notification requirements can be triggered even if an employee, contractor or unpaid volunteer uses PHI in an impermissible manner, he said.
Healthcare entities need to identify all their business associates, especially newly covered entities such as data storage companies, and ensure they have proper business associate agreements with them by Sept. 23, said William Maruca, a partner with Fox Rothschild LLP.
Healthcare companies also must have updated patient privacy notices in place by the deadline, Maruca said. The notice must specifically state that the covered entity is required to obtain the patient's authorization to use or sell his or her information for marketing or other purposes and to use or disclose psychotherapy notes, Maruca said. Privacy notices will also need to include a description of how an individual can revoke an authorization and explain their right to receive a notification in the event of a data breach, Maruca said.
"I think the readiness level varies considerably," Maruca noted. "Larger health systems and similar organizations with dedicated health privacy officers may be ahead of the curve, and some savvy smaller entities have been very proactive," he said. But "others are dragging their feet. I think it may take a high-profile enforcement ... to get the attention of the smaller players."
Deborah Peel, founder and chairman of the advocacy group Patient Privacy Rights , noted that while the changes are designed to improve patient privacy, several loopholes remain.
Despite the changes, most health data can still be sold, she said. There is also no chain of custody for health data despite the generally strong security and contract requirements for business associates and subcontractors, Peel said.
As a result there is no way for patients "to obtain a complete map or picture of who used your health information or why. Without a complete data map that tracks all flows of data, we have no idea about the harms and misuses, making it impossible to weigh the risks vs. benefits of using," health information technology systems, she noted.