Five essentials for building the patient-centered medical home

Author Name Jennifer Bresnick   |   Date July 28, 2014 

The patient-centered medical home (PCMH) is becoming one of the most coveted recognitions for healthcare providers in urgent need of better ways to manage population health, close care gaps, and reduce wasteful spending.  As evidence of the model’s effectiveness mounts in conjunction with the shift towards accountable care reimbursement models, what are some of the most critical building blocks for the medical home, and how can providers begin their journey towards developing a system of data-driven, patient-centered care?

Roadmap to success

Providers can operate under the PCMH model without being officially recognized as such, but organizations such as NCQA and the American Academy of Family Physicians (AAFP) offer roadmaps and planning tools to guide providers towards the principles of PCMH operations.  Providers may also wish to bring in consultants that will examine their operations, workflows, and clinical health IT infrastructure maturity while making suggestions about the next steps towards developing strong relationships with patients and partner organizations.

Providers should be aware, however, that moving to the PCMH model does require significant investment in both time and resources, warns Michael Meucci, Director of Transformation and Improvement at Arcadia Healthcare Solutions.  “The medical home is a really resource-intensive model,” he says.  “You go from having a physician who has a one-on-one relationship to a patient to a team-based model where a team has a relationship with the patient.”

Strong leadership and staff commitment

The most important key for success is a strong commitment to that overall transformation, a clear leadership structure that engages all levels of staff, and effective communication within the organization as changes are being made.  “When we look at some of our most successful transformations, we see strong leadership buy-in,” Meucci says.  “[One client] built a steering committee that was made up of representation from the executive leadership team, practice leadership, medical leadership, and technology leadership.  It was really every functional area of that organization that was represented on this team.”

“One of the comments that we heard from [our client organization’s staff] was that they were excited to be asked questions about their patients and their care, because historically they had just been given edicts in terms of what they needed to do, and then they were expected to go do it without question,” adds LuAnn Kimker, RN MSN, CPHIMS, PCMH CCE, Director of Clinical Quality Improvement at Arcadia Healthcare Solutions.

In health systems with multiple locations, the PCMH model can help to standardize workflow and clinical tasks throughout the organization, leading to a reduction in potentially harmful variations and an increase in overall quality, communication, and adherence to the organization’s goals.

“The PCMH model really standardizes things across health centers,” said Carol Mensch, MSN RN-BC, Performance Improvement Coordinator at ChesPenn Health Services. “As a community health center, it really changes things to emphasize the patient-centered aspect of care.  If we hadn’t gone the PCMH direction, the Healthy People goals we follow might have pushed us towards those population health features, as well.  But having [the PCMH structure] helps us focus and channel some of our areas of need.”

An underlying technical infrastructure

While EHR adopters can succeed with many of the PCMH principles without an additional outlay in technological infrastructure, clinical analytics and population health management tools can expand a provider’s capabilities to conduct risk assessments, stratify patients, preempt non-adherence, and prevent 30-day readmissions that often come with a hefty financial penalty.  Many of the most technologically savvy organizations in the nation have invested heavily in predictive analytics and data warehousing.

“We are using real-time algorithms within and outside of the EHR to look at risk, and predict and inform clinical and operational pathways,” says Steve Hess, CIO, University of Colorado Health, one of this year’s “Most Wired” hospitals. “While still early, we are starting to see patterns related to how our patients are interacting with our system and the reimbursement impact of those changes. It is important that our systems are set up to provide the complete patient picture and to ensure that the patient is getting the appropriate care in the appropriate setting at the right time.”

Effective patient engagement tools

In addition to in-house analytics, providers must invest in patient engagement if the PCMH is to be successful.  Helping patients manage their chronic diseases, show up for screenings and other primary care services, and access their health information to improve literacy and encourage healthy choices are key features of the PCMH, and health IT tools are available to help.  The patient portal is a pillar of Stage 2 meaningful use, and is a wildly popular feature with patients.

“We recently started a system-wide patient engagement education that includes media, TV, and print, encouraging patients to talk to their providers about using our portal,” explains Catholic Health Partners CMIO Stephen Beck, MD, FACP, FHIMSS. “The intent is to educate patients and continue to educate our providers as we realize there is some economy in the use of our patient portal.”

“Collaboration across the community is going to be a very positive outcome from this work,” he added. “Some communities are well connected right now with HIEs and other interaction at the community level, but most are still very competitive. By nature of making it easier to share information about patient care and improving continuity, I hope the patient will be the winner relative to meaningful use and HIE integration.”

Community stakeholder buy-in

Those community connections provide the foundation for a truly effective PCMH.  Primary care providers can no longer work in isolation, sending patients out to specialists but rarely receiving feedback on the results.  By working together as a “medical neighborhood” instead of individual organizations spending money and man-hours faxing documents back and forth, both providers and patients can reap significant benefits.  Patients may not always understand their responsibilities when it comes to coordinating their care, and hospitals waste millions every year on inefficient communications, lengthy transitions, and waiting for information from colleagues.

“It is important for all health care professionals involved in patient care to have a solid understanding of the role of the patient and family in articulating needs and developing a care plan,” says AAFP. “PCMH integration enables warm handoffs at the moment the patient or family is ready and, thus reduces stigma, improves adherence and augments access to support groups, parenting programs and other medical neighborhood services.”

http://healthitanalytics.com/2014/07/28/five-essentials-for-building-the-patient-centered-medical-home/

The Next Generation of Healthcare: Games and E-Learning – high value, low cost!

Games drive engagement through consumer activation. We know this! They are a fantastic way to challenge learners and keep them engaged and interacting with the content at hand.

So, how do we improve on something that is already awesome? We embed it in a learning ecosystem that drives improvement through partnerships with all stakeholders. This new learning environment sets the stage for providers, patients and caregivers to connect and communicate - anytime, anywhere, any place and on any device.

As we move towards a healthcare system that reimburses for value instead of volume we will need tools that can capture this next generation of care.  We will need to automate the processes of education and learning much like the electronic claims we send today. All of this data will then need to be interpreted to understand and truly visualize the path to wellness. That feedback will allow us to refine the process and continually work to improve the delivery of care.

But what if we can already do this through fun, engaging, and cost effective e-learning games? I believe we can! With the help of new technology, such as the xAPI, we can now track and measure all those things that were so hard to track before.

These short games below can capture up to 32 data points vs. the traditional check boxes, and take days to get to market instead of months. Imagine the possibilities. 

Click on a game below to launch.  Bird Hunt is a flash game, so you will need a flash browser. The Olympic Mountain Summit game is not. 

Fred was just diagnosed with type 2 diabetes and now he is afraid to enjoy the things he used to. This game combines his love of hunting with diabetes education. 

Johnny Three-Scoops and Earl Strong-Fit will not only be fighting for their individual victories tonight, but the fate of their entire teams may lie in the outcome of this single event. With only 3 events left, and this being the only event in which their respective teams have a real contender, this could decide the gold.

Can you help TEAM HEALTH reach the top first by correctly answering the questions?



For more fun, FREE Games visit our website: www.mhealthgames.com

Revisiting how Christensen’s “disruption innovation” in healthcare means decentralization

By: Jonah Comstock | Mar 26, 2014   

The term “disruptive innovation” has become so much of a buzz word, it’s not uncommon to hear it applied to just about any radical shift in care. But for Harvard Business School professor Clayton Christensen, who invented the term, it has a very particular meaning. Most innovations are “sustaining innovations” — they make an existing product better and cheaper for its existing customers, and allow producers to sell it at a better margin. Disruptive innovations actually drive costs down, but ultimately end up more profitable because they open up the market to customers that didn’t exist before.

At Better Health Boston, a one-day event for healthcare industry stakeholders hosted by McKesson Corporation, Christensen talked about how the idea of disruptive innovation really applies to healthcare — and what the healthcare system needs to do to go forward.

As an example of a disruptive innovation cycle, Christensen talked about the computer business, specifically the move from $2 million mainframes to $200,000 minicomputers to $2,000 personal computers, and finally to $200 smartphones. He pointed out two things: each innovation brought computing technology to a larger segment of the population, and none of the market leaders in any part of the chain was able to stay a market leader in the next part (with the possible exception of Apple).

“[Makers of minicomputers] got no signal that the personal computer mattered to their customers, because it didn’t matter to their customers,” he said. “We started using a PC for simple things and then the tech got better and better and better, until we could solve all our problems with a personal comupter and we didn’t have to buy a mainframe anymore. And the leaders in that space got killed. … It’s not that the market leaders didn’t see it coming. It’s that it made no economic sense.” 

In healthcare, the market already includes all the possible consumers. The way disruptive innovation will happen, he believes, is in the form of decentralization. Rather than just innovating diminishing returns on better and better hospital-based treatment mechanisms, innovation will consist in taking equal or even inferior versions of technology that exists in hospitals and moving it outward — to clinics, retail clinics, and, eventually, the home.

The way that technology enables that shift outward in care is by doing what Christensen calls “commoditizing experience.” As the scope of medical knowledge has increased, doctors have already made a shift from intuitive care, where educated guesses and trial and error came to bear in treating patients, to evidence-based medicine, where doctors devise treatment plans based on what’s worked best historically in patients with the most similar symptoms.

The shift from evidence-based medicine to personalized medicine, where the doctor uses detailed data about a particular patient to devise a highly specific treatment plan, will be the same kind of shift. Each gradation makes diagnosis and treatment easier to teach, allowing more parts of care to scale out from physician specialists to nurse practitioners to patients and families.

Decentralization will also solve what Christensen considers a fundamental business problem for hospitals.

“In a typical hospital, overheads account for 85 to 90 percent of total costs because of the complexity of offering a ‘one size fits none’ offering,” he said. “It turns out there are three different business models inside a hospital, and those three business models are incompatible.”

The diagnostic function of a hospital functions similarly to a consulting firm, he explained, and works best with a fee for service business model. The acute care and surgery functions of a hospital are a process business, like manufacturing or education, and should have an outcomes-based business model. Finally, chronic disease management and patient community-building are facilitated networks, like telecom companies or insurance companies, and they want a membership-based payment model. Decentralization of care would enable each of those businesses to operate more efficiently, with less overhead.

Christensen thinks actual disruptive innovation in healthcare hasn’t really begun yet. But technologies on the horizon — from home health sensors, to telemedicine, to increasingly sophisticated population health management, could start to move that needle.

http://mobihealthnews.com/31470/revisiting-how-christensens-disruption-innovation-in-healthcare-means-decentralization/

Q&A: 3 pillars of population health

June 07, 2013 | Tom Sullivan, Editor

The overarching concept of population health management continues taking shape amid an American healthcare system undergoing feverish digitization — and while some of the larger, IT-savvy health networks may more effectively be managing patient populations within two years, for most it will likely take six to eight years.

To that end, Daniel Newman, MD chief medical information officer of MEDfx, is slated to outline the triptych of population health pillars during a session next week at the Government Health IT Conference and Exhibition in Washington, DC.

Ahead of the show, Government Health IT Editor Tom Sullivan interviewed Newman via email about those puzzle pieces, how far the country is from widely employing such technologies and practices, and why true population health management looks at the whole person rather than merely their disease state.

Q: You list the 3 pillars of population health management as analytics, care improvement, and patient engagement. Are the technologies already available and, if so, what are the hard parts of each?
A: Analytics:  Analytics can be thought of in two buckets: 1) Deductive analytics, which includes reporting and retrospective stratification and 2) Inductive analytics, which includes predictive modeling and stratifications.  The technologies to do retrospective reporting and stratification are available and have been for some time. One of the major difficulties is getting the data into a form that can be easily used for reporting. Gathering data from multiple systems (PM, EMR, Lab, radiology, etc.) both within and across systems and then normalizing the data to standard terminologies so you can run queries is labor intensive and difficult to accomplish. Unfortunately, much of the data in healthcare applications is often unstructured, meaning not codified to a standard, due to usability issues for clinicians and/or not having a standard coding scheme available. The more accurate data you have, the more the outputs can be trusted. Predictive modeling and inductive analytics are being developed by several groups right now. Predictive modeling will be able to tell us where patients’ health will be given their current status. These models will need to be thoroughly tested and have continuous improvements to ensure their accuracy.

Care Improvement: The biggest issue with care improvement is that patients move around so frequently and to do care management well you need the data from all of these sources. While some systems have enough data to adequately perform well at this step, many patients care is too fractured between EMR systems to make this feasible. Technologies like private Health Information Exchanges coupled with the national eHeatlh Exchange will be able to begin closing this gap. Once you have the right data, the next step is developing rules and systems that will enable clinicians to use this data in real time. While there are some systems out there that do this, a comprehensive system has not yet been brought to market.

Patient engagement: Most people think of patient engagement and go right to the idea of a patient portal. Patient engagement is a set of actions one takes to improve patient activation. Patient activation is how educated, informed and involved patient are in managing their own health issues. Patient engagement is not just a patient portal issue. Every step in the care of a patient — be it inpatient, outpatient, care management etc. — has an opportunity for patient engagement. Making sure we consider patient engagement to not just be a technology but a series of activities with a goal is essential to having a good strategy. Portals can be excellent ways to engage a patient, but too many are flat views of a patient’s information or are not implemented with the full concept of an engagement strategy. Without understanding and measuring the effect of your patient engagement strategy, patients will be less likely to use your portal. From a technology perspective, portals are easy to find, however most sit on top of a single instance of a database and do not show comprehensive information. Expanding the data in these portals and making sure they are aligned with a strategy are the most difficult parts of patient engagement.

Q: Even optimistically here, how far is the US from being able to put those pillars into nearly ubiquitous practice?
A: Many years. I would expect some of the larger systems to have pieces of this in place in the next 1-2 years. I would not expect this to be ubiquitous for 6-8 years at best. These systems will need continuous cycles and measure and improvement to reach their optimal states.

Q: When the topic of population health management arises, many people point to diabetes, obesity and blood pressure as the sort of de facto standard examples of conditions we could, and should, be managing better in patient populations. What are some of the less well-known?
A: While the management of these diseases is essential to population health management, it’s important to not limit population health management to just disease management. True population health is looking at the entire person, not just their disease states. It’s important to realize that it isn’t just diseases and medical management, but social and environmental issues and barriers that affect care. For example, someone with asthma that is poorly controlled due to environmental factors in their house or patients that are not well controlled because they don’t have the money to pay for transport to the clinic. Population health is about looking at all these variables and making sure you know the right interventions to improve health. That being said, there are definitely diseases that are focused on because they have good evidence that optimal management leads to improved quality of life and lower costs. These include COPD, Asthma, CHF and Ischemic heart disease. While these are well known, there are less well-known examples like Rheumatoid Arthritis and HIV and mental health. Though these will obviously be a focus, hopefully we will be able to institute a global view of each patient and understand the many complex reasons people do poorly.

http://www.govhealthit.com/news/qa-3-pillars-population-health

Infographic: Analytics Is the Nervous System of IT-Enabled Healthcare

New iHT2 report provides strategies for managing sophisticated analytics tools in the health care industry. 

The Institute for Health Technology Transformation (iHT2) has released their latest report entitled, “Analytics: The Nervous System of IT-Enabled Healthcare,” to help executives from hospitals, health systems, and other provider organizations identify and understand models for innovative uses of data that can enable them to reduce costs, improve gaps in care, stratify patient populations, improve quality, and provide more accessible care.

“Analytics is the backbone and the nervous system and the learning center of the health IT-enabled healthcare system,” says Jonathan Weiner, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health and director of the university’s Center for Population Health Information Technology.

A 2011 McKinsey report estimated that the healthcare industry can potentially realize $300 billion in annual value by leveraging patient and clinical data. With healthcare providers transitioning from a volume-based to value-based reimbursement, a new healthcare delivery model is emerging. In order to succeed in this new environment, healthcare providers are:

• Accountable care organizations forming (ACOs) to improve care coordination
• Preparing for bundled payments  for acute and post-acute care, as well as Medicare penalties for avoidable readmissions
• Restructuring their care delivery systems

Areas of focus the report includes are creating a nervous system and solid infrastructure foundation that leverages storage, processing, analysis, and data management to make better, evidence based business and clinical decisions.

“The healthcare industry must identify and establish proven strategies and best practices to manage data and to conduct the advanced analysis necessary to generate real insights that can benefit the health system. Those healthcare organizations focused today on gathering patient and clinical data, decoupling the data from siloed applications and solutions, and determining which data points to measure will be well positioned for the evolving future state of the healthcare landscape,” said John P. McDaniel, National Practice Leader—Provider Market at NetApp Healthcare.

The report also includes the following infographic shown below that summarizes the key findings:

Background

• Chad Brisendine, VP & CIO, St. Luke’s Hospital and Health Network
• Jeffrey L. Brown, CIO, Lawrence General Hospital
• Charles DeShazer, MD, Chief Quality Officer, BayCare Health System
• John McDaniel, National Practice Leader, US Healthcare Provider Market, NetApp
• Jonathan Weiner, DrPH, Professor of Health Policy & Management and Health Informatics; Director Center for Population Health Information Technology, Director PhD Program in Health Services

Each year, the Institute for Health Technology Transformation (iHT²) hosts a series of events & programs which promote improvements in the quality, safety, and efficiency of healthcare through information and information technology.

Forward Schedule:

• Health IT Summit in Fort Lauderdale - June 12-13, 2013
• Health IT Summit in Denver - July 24-25, 2013
• Health IT Summit in Seattle - August 21-22, 2013
• Health IT Summit in New York - September 17-18, 2013
• Health IT Summit in Beverly Hills - November 6-7, 2013
• Health IT Summit in Austin - December 11-12, 2013

The Institute for Health Technology Transformation (iHT²) 2012-2013 Online Thought Leadership Series is comprised of 60-minute interactive, sponsored Webinars covering current issues and industry trends for healthcare IT executives.