pristineliving
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4 years ago Reflection by Abby
It was interesting learning and discussing some of the challenges that persist for PCMH practices within the clinical informatics setting. What particularly jumped out at me was the fact that population data was considered a challenge, and also an expectation. The more I think about it, the more it makes sense: as we drive further into the Big Data era, primary care practices are expected to use the vast wealth of data they (presumably) have at their fingertips in such ways that directly improve the care they provide.
Ostensibly, this is straightforward for large health institutions that already extract patient population data for things such as billing, cost analysis, and disease reporting. It's also understandable why this might be a challenge to PCMH organizations, who emphasize the P – personalized. They're much more oriented towards individualizing patient care. However, I think implementing many of the tools and technologies we have discussed will serve the dual function of not only making personalized care cheaper, easier, and more accessible, but also enabling these organizations to harness population data at the same level as their competitors.
Introduction of PCMH
In 2009, the United States spent 17.5% of its gross domestic product on healthcare, almost eight percentage points more than the average for the member countries of the Organization for Economic Cooperation and Development (OECD), while the per capita healthcare spending was $7960 (more than two times of the average in OECD). It was estimated that by 2020 the total health expenditures of the United States would be doubled from 2.6 trillion dollars to approximately 4.6 trillion dollars. Meanwhile, the U.S. healthcare system has faced the obstacle of unsustainable costs yet suboptimal health outcomes. One critical challenge for the current healthcare system is that the prevalence of chronic diseases has increased, thus raised the demand for Primary Care and General Internal Medicine. (This challenge mainly interfered with the expanding population of seniors and the low-income communities.) However, the majority of the healthcare system was more focusing on episodic care and acute illness, causing the understaffing of Primary Care fields. What’s worse, according to the Council on Graduate Medical Education Report, no more than 20% of medical school students or graduates considered prioritizing Primary Care Specialties, and only 2% were planning to work on General Internal Medicine. The high workload and low reimbursement of the primary care fields discouraged medical school students from joining the primary care after graduation). Therefore, overcoming such hurdles would require a fundamental transformation in healthcare delivery. The patient-centered medical home (PCMH) model was then established to solve the serial problems that current Primary Care units are suffering and improve the quality of healthcare with decreasing costs.
In the United States, the shift toward value-based health care was mandated by the Patient Protection and Affordable Care Act in 2011, and this was hastened by the passage of Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, which ended the Medicare Sustainable Growth Rate, and launched the Quality Payment Program (QPP) in 2017 (CMS, 2020). QPP has two major programs. The first program is the merit-based incentive payment system (MIPS) which requires a provider to report up to 6 quality measures (including one or more outcome measures), promote interoperability and meaningful use, demonstrate clinical practice’s effort of improvement, and report on resource use based on claims data (CMS, 2020). The second program is an alternative payment model (APM), which incentivizes payments to reward high-quality and cost-efficient care. APM includes the well-known accountable care organization (ACO), which provides for groups of providers who agree to share risk and responsibility for the delivery, coordination, and cost of care to their regional population (Iglesia, 2020).
The primary concept of the PCMH was brought up by the American Academy of Pediatrics in 1967 as a precursor of “medical home” in the form of Primary Care Pediatric practice for recording the medical history of children with chronic disease. Then in 1978, the World Health Organization indicated that practice and Primary Care should cover access to care, continuity of care, comprehensiveness, and integration of care, patient education and participation, team-based care, and public policy that supports primary care. In 2007, a joint statement of four physician organizations whose members constitute the majority of primary care clinicians in the U.S. identified seven principles of PCMH (see Table 1). In 2008, the National Committee for Quality Assurance (NCQA) designed the criteria for a formal PCMH updated in 2011 (see Table 2).
Table 1. Joint Principles of the PCMH
Table 2. NCQA PCMH 2011 Standards
PCMH represents a healthcare team embedded in the community that seeks to improve the health and healing of the community residents (Stange, 2010). The PCMH aims to personalize, prioritize, and integrate care to improve health at the individual, family, community, and even populations level. Therefore, the Agency for Health Research and Quality (AHRQ) formally defined PCMH as follows (Jackson, 2013):
The PCMH is then expanded to a framework to demonstrate a comprehensive primary care delivery model that could improve the primary care systems with lower costs. The framework could be seen in Figure 1. Currently, the PCMH model in various forms is being implemented by public and private health plans, integrated delivery systems, and individual primary care practices (PCPCC, 2012a). It is arguably the most successful primary care delivery innovation in the United States and will remain in the near future (Hoff, 2012).
Figure 1. The conceptual framework for the patient-centered medical home
Informatics implications of ACOs and PCMHs
Informatics implications of PCMHs
Seven informatic areas for PCMHs are as follows, listed by Bates and Bitton, 2010: 1) Clinical decision support: Provide diagnosis prediction, remind on disease progression, and suggest treatment plans to reduce errors and attain better outcomes. 2) Registries: Keep track of patient health conditions. Need improvement on considerations regarding patients with multiple chronic conditions. 3) Team care: Provide real-time communication tools and sharing of clinical notes between various parties involved in patient care since collaborative care on patients is key to PBMH. 4) Care transitions: Ensure patients are followed-up after discharge from a hospital or rehab facility to examine patients' health conditions. 5) Personal health records: Help patients manage their health by recording data and setting goals. Notify the care providers of problematic trends to make sure issues are dealt with without delay. 6) Telehealth: Offer clinicians a tool for distanced examination of health conditions or regular monitoring for patients. 7) Measurement: Report measures on quality, including immunization and screening information, and efficiency, including the cost of care.
Informatics implications of ACOs
As listed by the Certification Commission for Health Information Technology (CCHIT), major requirements for Health Information Technology and informatics to support ACO include (CCHIT, 2013): 1) Information sharing between different clinical entities, and also between healthcare providers and patients. 2) Data collection and integration from various sources. 3) Support patient safety. 4) Protect system security and patient privacy.
Specific processes and functions in ACOs that information technology and informatics can fulfill are: 1) Care coordination: Clinical data provided by different entities in the healthcare process be up to date and accessible to the multiple entities that work jointly to provide care so communication is unobstructed and diagnosis or treatment can be properly followed. 2) Cohort management: Integrate data across sources and build models to assess vulnerable populations at high risks to provide them with preventive measures and screenings. Provide electronic resources to educate patients on the self-monitoring of health conditions and deliver self-monitored data from at-risk patients to clinicians. 3) Patient and caregiver relationship management: Enhance communication for patients and care providers so they become partners to achieve better care and manage and improve chronic conditions. Communication should pay attention to health literacy levels, as well as the needs of visually and hearing impaired. 4) Clinician engagement: Provide useful choice of presentation of patient data so that clinicians may view the data as needed, for example, view medical history and see trends of health condition as graphs or charts. In addition, link-local and national public health information as well as new research findings pertinent to the disease or condition of interest. 5) Financial management: Track and analyze costs, keep records of payments, and distribute to different reimbursement systems. 6) Reporting: Report to various registries including research, disease-associated, and patient safety organizations (PSOs). Compute quality metrics for care providers to understand and improve their quality of care. 7) Knowledge management: Remind and alert on information related to patients. Share clinical knowledge and workflows to achieve better care.
The Role of Clinical Informaticians
In order for PCMHs to be successfully implemented and meet their goals of coordinated team care, six key standards must be both met and upheld. As defined by the National Committee for Quality Assurance (NCQA), PCMH practices must:
As you might notice, many of these are reflective of larger healthcare provision goals that we have already discussed. Each standard requires continued investment from health information technology (HIT) as well as the clinical informaticians that support its implementation.
Enhancing access and continuity
Primary care practices should provide all patients with electronic access to their PCMH. Based on available technology, the most realistic implementation of this is likely through a web-based personal health record (PHR) or patient portals. PHR implementation has already shown increases in patient engagement and self-efficacy. Mounting them on a web portal interface will increase both efficiency and productivity of care, benefiting both patients and providers. Portable records additionally offer the potential for real-time information exchange, such as lab feedback to the patient between clinic visits, which may in turn increase patient adherence to medication or lifestyle changes. Through the web-based PHR, providers may receive and process requests for follow-up visits and prescription refills, or provide educational information directly to the patient remotely.
Generally speaking, patients have been slow to adopt these web-based PHRs and providers have been hesitant to share information through them for a number of reasons, including lack of understanding or awareness of these tools; low health literacy; concerns of data accuracy and reliability; concerns about security and privacy; and limited understanding of workflows such that the tool can be integrated into daily life. In order to meet these informaticians must understand how to increase PHR use such that it is of benefit to patients while supporting efficient and secure communication between parties.
Identifying and managing patient populations
A key aspect of population management is the collection of large-scale patient information such as demographics and clinical data. In turn, these are useful for aggregating to assess and document risk factors, and identification of patients for proactive care. Some health systems have begun to integrate patient registries as a means of organizing patients with a given condition and collecting disease-specific measures. These registries may be used to remind patients and clinicians of needed services as well as providing patient and outcome tracking to improve clinical efficiency and identify high-risk patients. Patient registries can also engage EHRs to identify and manage larger patient populations.
Patient registry implementation is largely challenged by the wealth of highly functional, multi-disease tools that already exist in the healthcare space. Informaticians, then, need to determine the best way to use the registries to manage health proactively at the population level. One way to do this might be identifying high-risk patients not seen for a period of time and reach out with calls about return visits.
Planning and managing care
A key dimension of patient care is identifying patients with specific health conditions and outlining appropriate care management. An important aspect of PCMH that already begins to address this is the EHRs provision of point-of-care reminders, which increase the potential for team-based care – such as identifying patients in need of a flu vaccine or listing lab tests required prior to a doctor's visit.
Practices must assess patients progress toward and barriers to patient treatment goals. A HIT implementation that best addresses this need is an interactive tool – particularly one capable of electronically documenting medication lists (to facilitate medication reconciliation and monitor adherence), issuing decision support reminders, and screening patients (such as through a questionnaire at intake). By allowing different team members to provide necessary patient care throughout an encounter, team-based care is at its most effective.
Providing self-care and community support
Assessing patient and family self-management abilities is a central aspect of both managing patient care and supporting patients outside of the clinical setting. Parts of this assessment include working with patients to develop their plans for self-care and providing the necessary tools and resources that allow them to meet their goals. This standard is likely the greatest challenge still facing PCMH, largely because of the tendency to focus only on the clinical setting.
HIT is thus ideal for reaching patients in real-world settings once they have left their primary point of care. As we have already discussed, patient portals are ideal points of contact between patients and providers once they are outside the clinical setting. Portals allow providers to assess patients' ability to care for their health conditions while documenting the patient's self management-goals and providing access to community resources and tools.
Electronic Health (eHealth), mobile health (mHealth), and telemedicine technologies are likewise underdeveloped areas for connecting with the patient in their real-world environments. eHealth and mHealth allow for easy tracking of personal health measurements (e.g. blood glucose), medication, and dietary intake that can be transmitted directly to the provider. Unfortunately, there lacks a large body of research evaluating the utility of these tools as integrated into clinical practice. However, we have already seen large-scale moves towards more robust telemedicine in the COVID era, where in-person visits are replaced by patients obtaining their own data and forwarding measures or results to their providers for their interpretation.
Tracking and coordinating care
HIT allows for tracking and patient follow-up, as well as coordination of tests, referrals, and outside care. The integration of tools could also electronically track specialist referrals. At the bottom line, different members of the care team must be able to access patient records and current measures both within and outside the primary care setting.
Measuring and improving performance
Practices need to be able to track care quality and demonstrate improvements in their performance over time. EHR systems currently offer the ability to track improvements in disease management directly as a result of process changes, thus allowing teams to use patient data as a driver of quality improvement. In terms of PCMH, performance improvement over time requires a broader eye on population health, where patient care has historically focused on individualized delivery. PCMH practices are able to meet this challenge with existing systems by integrating tools that electronically report disease quality measures to external entities (e.g. federal or state governments) to benchmark data and promote quality improvement.
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