The alignment of Meaningful Use and Patient Centered Medical Homes (PCMH)

The move toward Patient Centered Medical Homes (PCMH) is an important building block to creating a more coordinated, evidence-based health care delivery system, which is able to measurably increase health care quality and satisfaction while at the same time lower total-cost-of-care to the system. That’s a tall order.

Where does a PCMH fit into this vision of how health care must evolve? The principles of a PCMH were elaborated by a joint document in 2007 issued by the 4 main Primary Care Physician organizations – the American Academy of Family Practice (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA).

The principles described in the Joint Document are (1) each patient has an ongoing relationship with a personal physician, (2) the physician leads a team at the practice level who collectively take care of patients, (3) there is a whole-person orientation, (4) care is coordinated and managed across all elements of the complex health care system, (5) quality and safety are central to health care delivery, (6) enhanced access is available to patients, (7) payment appropriately recognizes the added value provided to patients in a PCMH.

There is a formal Recognition process for PCMH’s, offered by the National Committee for Quality Assurance (NCQA). Revised and updated standards and guidelines for undergoing NCQA Recognition have been published for 2011.

The role of Health IT in a Medical Home
A recent article in Medical Economics highlighted the importance of moving a PCP practice to a PCMH, and the challenges involved in that. One of the central backbones of achieving the kinds of things needed in order to become a PCMH is the implementation of robust Health IT (HIT), in particular a fully-functional Electronic Health Record (EHR). Of note, the federal effort around Meaningful Use has many of the same elements as what is needed by a PCMH – they are aligned around the same overall concepts, though the specific criteria differ in some of the details. In fact, the NCQA’s PCMH Standards and Guidelines (available free) includes a PCMH/Meaningful Use Crosswalk, as a handy guide to “filling in the gap.”

The main things a doctor who is interesting in moving to a Medical Home should begin to implement now are these four: (1) have e-prescribing, (2) have a patient portal, (3) have an electronic medical record system, and (4) have a registry type of functionality. A good EHR system should provide these things, or at least have their full capabilities in its immediate roadmap.

How small can a PCP practice be in order to become a PCMH?
An intriguing question asked by PCPs is how small can a practice be in order to function as a Medical Home. Can a solo practice do it? Can a 3-physician practice do it? Does it have to be hospital affiliated, or hospital-driven?

The biggest hurdles in the path towards becoming a PCMH are implementation of technology. The advent of web-based EHRs (like Practice Fusion) has lowered this barrier dramatically for small practices. And the gaps between being an EHR needed for Meaningful Use and what is needed for PCMH are part of the near-term roadmap. So, minimization of the barrier of technology costs can allow smaller practices to function this way.

Medical Homes are about team collaboration, and care coordination. Technology are tools, but there needs to be sufficient infrastructure within a practice to be able to do something with those tools – there needs to be personnel to take the lists of at-risk patients identified by registries (for example), review them, and contact patients pro-actively who may have “fallen through the gaps.”

How small is too small? That is not a question that can be answered firmly – with sufficiently robust technology, and with a cultural orientation within a practice that embraces the principles of medical homes, it is quite possible that small practices can indeed become PCMHs. Our job as EHR developers is to build the tools that will allow this question to be borne out by experience “in the field.”