A patient-centered medical home (PCMH) is defined by the way health care teams are organized and how they interact with their patients, but medicine is such an information-rich enterprise that many important features of the PCMH model are difficult or impossible to implement without state-of-the-art information management tools. This implementation guide from the Safety Net Medical Home Initiative describes how clinics can optimize health information technology to support medical home workflows.
Health information technology can facilitate the following:
- Scheduling appointments and monitoring access to care
- Defining and understanding each provider’s patient population and key sub-populations
- Defining and tracking care of individual populations and sub-populations including referrals and abnormal lab/imaging results
- Providing patient-specific educational material
- Providing individual care reminders
- Providing an after-visit-summary with key information at the end of each visit
- Maintaining a system of action reports to guide the team’s care management activity, and a system of outcomes reports for monitoring processes of care and population outcomes
- Using technology to optimize communication between patients and their care team including using a patient portal into the electronic health record (EHR)
According to the guide, “the final criteria for Stage 1 Meaningful Use of EHRs released in July 2010 by the Office of the National Coordinator, are not adequate to fully support a medical home by themselves; however, they do represent an achievable first step toward functionality that will support PCMH transformation. ” Accordingly, each of the PCMH processes discussed in this implementation guide is supported by and aligned with multiple Stage 1 Meaningful Use requirements. The guide details policy, procedural and technical requirements to implement each process.
The guide also includes tips for practices to implement some of these processes without electronic health records.
The Safety Net Medical Home Initiative is funded by The Commonwealth Fund and eight other funders, with technical assistance from Qualis Health and the MacColl Institute for Healthcare Innovation at the Group Health Research Institute. The initiative is working with five regional coordinating centers, which are each supporting the implementation of patient-centered medical homes in over a dozen safety net clinics.
Additional resources on quality improvement are available from the Safety Net Medical Home Initiative website.
Ignatius Bau 