Scaling the PCMH Delivery Model with Automation

phytel | whitepaper

The Patient-Centered Medical Home:

Scaling the PCMH Delivery Model
with Automation

Contents
The Patient-Centered Medical Home................................................................................3
The PCMH Background

Challenges and Solutions.................................................................................................. 7
Role of Information Technology

Automation Tools

Conclusion........................................................................................................................13

The Patient-Centered Medical Home:
Because of the current national focus on accountable care
organizations (ACOs), attention has shifted away from the patient-
centered medical home (PCMH), an approach designed to rebuild
primary care and improve care coordination. Nevertheless, the PCMH
model is continuing to grow and to attract support from providers,
payers, and consumer groups.

According to a recent survey by the Medical Group Management Association (MGMA), 70% of
primary care physicians and non-physician providers are transforming their practices into patient-
centered medical homes or are interested in doing so. Twenty percent of the respondents said
they’d already been accredited or recognized as a PCMH.1

The National Committee for Quality Assurance (NCQA), which has recognized 4,400 physician
practices as PCMHs, lists three dozen health plans that use NCQA recognition in their PCMH
incentive programs.2 The Joint Commission, URAC, and some Blue Cross Blue Shield plans have
given their PCMH stamps of approval to many other practices.

Meanwhile, commercial payers have 63 PCMH pilots going across the country,3 and the Centers
for Medicare and Medicaid Services (CMS) is participating in multi-payer PCMH projects in eight
states.4 Altogether, more than 30 states are involved in PCMH demonstrations.5 And the Veterans
Health Administration has embarked on an ambitious three-year program to build PCMHs in more
than 900 primary care clinics.6

1. Madeline Hyden, “70 Percent of Study Participants Moving Toward PCMH Model, MGMA Research Reveals,” MGMA blog post, July 20, 2011.
2. NCQA, “Health Plans Using Recognition,” accessed at http://www.ncqa.org/tabid/131/Default.aspx.
3. Patient-Centered Primary Care Collaborative, “PCMH Pilots and Demonstrations,” accessed at http://www.pcpcc.net/pcpcc-pilot-projects.
4. Centers for Medicare and Medicaid, “Multi-payer Primary Care Practice Demonstration Fact Sheet,” accessed at
http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf.
5. Paul Grundy, Kay R. Hagan, Jennie Chin Hansen and Kevin Grumbach, The Multi-Stakeholder Movement For Primary Care Renewal And Reform. Health Affairs, 29, no. 5 (2010): 791-798.
6. Sarah Klein, “The Veterans Health Administration: Implementing Patient-Centered Medical Homes in the Nation’s Largest Integrated Delivery System,”
The Commonwealth Fund, September 2011.

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A study of seven PCMH demonstration projects reported that the strategy
resulted in reductions in ER visits ranging from 15% to 50% and decreases
in hospital admissions ranging from 10% to 40%.

Initial Results Are Promising savings from its PCMH model at $3.7 medical neighborhood.
million for a return on investment of more
Early evidence shows that the PCMH can Conversely, some observers view the PCMH
than two to one. And the Johns Hopkins
improve access to high-quality care and as an essential building block of ACOs.
PCMH program realized annual net Medicare
the management of chronic conditions. That is because ACOs must be primary-
savings of $1,364 per patient.9
For example, one study of care provided care driven and patient-centered—the
under PCMH principles found patients key characteristics of PCMHs—in order to
with diabetes had significant reductions in Two Key Challenges succeed in a risk-bearing environment.12-13
cardiovascular risk; patients with congestive For medical homes to be successful in
Another key to the success of both PCMHs
heart failure had 35% fewer hospital days; improving the quality and reducing the
and ACOs is the automation of population
and asthma and diabetes patients were more cost of care, they need the cooperation
health management. The goal of population
likely to receive appropriate therapy.7 of outside specialists and hospitals. Yet
health management is to keep patients as
the other providers in a PCMH’s “medical
A study of seven PCMH demonstration healthy as possible, thereby reducing the
neighborhood” may not be inclined to
projects reported that the strategy resulted in need for expensive ER visits, hospitalizations,
cooperate because their incentives are not
reductions in ER visits ranging from 15% to and procedures.14 As will be explained later,
necessarily aligned with PCMH goals.10 While
50% and decreases in hospital admissions it is impossible for providers to manage
the PCMH is designed to manage population
ranging from 10% to 40%.8 Another paper population health effectively without the
health and avoid unnecessary care, the
based on the experience of Group Health use of automation tools such as patient
revenue of specialists and hospitals depends
Cooperative, a large integrated delivery registries and analytic and care management
on the volume of services they provide.
system, showed that the PCMH model applications.
increased patient satisfaction and staff Because of this barrier, some experts say,
morale and improved quality without raising PCMHs cannot achieve their full potential
costs.9 unless they are incorporated into ACOs.11
The latter organizations not only have the
In fact, the PCMH model has been shown
same incentives that medical homes do,
to reduce overall costs. Community Care
but they also comprised of both primary
of North Carolina, for example, leveraged
care physicians and specialists. So, whether
a medical home approach to save $435
multispecialty groups, independent practice
million for the state’s Medicaid and SCHIP
associations, or health care systems
programs. Geisinger Health System (which
sponsor ACOs, they should, in theory, foster
includes a health plan) estimated its net
cooperation between the PCMH and its

7. PCPCC, “Evidence of the Effectiveness of PCMH on Quality of Care and Cost.”
8. Kevin Grumbach, Thomas Bodenheimer, and Paul Grundy, “The Outcomes of Implementing Patient-Centered Medical Home Demonstrations: A Review of the Evidence on Quality,
Access and Costs from Recent Prospective Evaluation Studies,” August 2009, paper prepared for PCPCC.
9. Ibid.
10. Paul A. Nutting, Benjamin J. Crabtree, William L. Miller, Kurt C. Stange, Elizabeth Stewart and Carlos Jaen, “Transforming Physician Practices to Patient-Centered Medical Homes:
Lessons From the National Demonstration Project,” Health Affairs, March 2011, 30:3;439-445.
11. Grundy, Hagan et al., op. cit.
12. Fields et al. 2010.
13. Paul Grundy, Kay R. Hagan, Jennie Chin Hansen and Kevin Grumbach, The Multi-Stakeholder Movement for Primary Care Renewal and Reform. Health Affairs, 29, no. 5 (2010): 791-798.
14. Suzanna Felt-Lisk and Tricia Higgins, “Exploring the Promise of Population Health Management Programs to Improve Health,” Mathematica Policy Research Issue Brief, August 2011,
accessed at http://www.mathematica-mpr.com/publications/pdfs/health/PHM_brief.pdf.


PCMH Background:
There are many definitions of the PCMH. One of the best comes from
David Nash, MD, dean of the Jefferson School of Population Health at
Jefferson University in Philadelphia:
“The patient-centered medical home (PCMH) is essentially
delivery of holistic primary care based on ongoing, stable
relationships between patients and their personal physicians. It
is characterized by physician-directed integrated care teams,
coordinated care, improved quality through the use of disease
registries and health information technology, and enhanced
access to care.”15

A March 2007 joint statement by medical societies representing pediatricians, family physicians, and internists
calls the PCMH “an approach to providing comprehensive primary care for children, youth, and adults.”16 The
chief components of the PCMH include:

• A personal physician who is the first contact for his or her patients and who provides continuous and
comprehensive care

• A physician-led care team that takes collective responsibility for care

• A “whole person” orientation, meaning that the personal physician will provide for all of a patient’s health
needs and arrange referrals to other health professionals as needed

• Care coordination across all care settings, facilitated by information technology and health information
exchange

• An emphasis on delivering high-quality, safe care in partnership with patients and their families

• Enhanced access to care through open scheduling, expanded hours, and improved communication among
physicians, staff, and patients via secure e-mail and other modes

• Additional reimbursement to reflect the value of the PCMH’s activities and the costs of setting up the
necessary infrastructure.

NCQA has further defined the PCMH by establishing a set of criteria that practices must meet to become
NCQA-certified medical homes. These criteria have become increasingly important because most PCMH
demonstration projects use them as a measurement tool,17 and some health plans require NCQA certification
for incentive payments to practices.18

15. David Nash, “Healthcare Reform’s Rx for Primary Care,” MedPage Today, Aug. 18, 2010, accessed at http://www.medpagetoday.com/Columns/21750.
16. American Academy of Family Practice, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, “Joint Principles of the
Patient-Centered Medical Home,” March 2007.
17. Bruce E. Landon, James M. Gill, Richard C. Antonelli, and Eugene C. Rich, “Prospects for Rebuilding Primary Care Using the Patient-Centered Medical Home.”
Health Affairs 29, No. 5 (2010): 827–834.
18. Blue Cross Blue Shield Association, slide presentation, “The Patient-Centered Medical Home: BC/BS Pilot Initiatives,” slides 22 and 24.


Medical Home Certification care management with information, helps qualify a practice as a PCMH—the
The medical home certification process tools, and resources group must collect and submit patient
grew out of another NCQA program that experience data using a specially designed
recognizes physicians for effectively using
• Track and coordinate care: Track PCMH version of CMS’ Consumer
information technology and managing and coordinate tests, referrals, and Assessment of Healthcare Providers and
population health, and the PCMH
19 transitions of care Systems (CAHPS) survey.22
certification criteria also focus on health IT.
• Measure and improve In June 2012, NCQA announced plans
The NCQA standards measure access and
performance: Use performance to launch a specialty practice recognition
communication, patient tracking and registry
program that will encourage specialists
functions, care management, patient self-
and patient experience data for
to work more closely with primary care
management support, electronic prescribing, continuous quality improvement.21
practices to coordinate care—in other words,
test tracking, referral tracking, performance
As many of these criteria require the use to make the medical neighborhood more
reporting and improvement, and advanced
of health information technology, it is friendly to medical homes. Again, health IT
electronic communications.20
noteworthy that NCQA made a conscious plays a prominent role in the criteria, many
Specifically, the NCQA’s 2011 criteria attempt to align them with the government’s of which are aligned with the proposed
for recognition as a PCMH consist of 27 requirements for Meaningful Use in its Meaningful Use stage 2 requirements.23
elements in six domains, as follows: electronic health record incentive program.

• Enhance access and continuity: NCQA also placed a much greater emphasis
Accommodate patients’ needs with on improving the patient experience than

access and advice during and after it did in its 2008 PCMH requirements.
The 2011 recognition criteria incorporate
hours, and provide patients with
the Institute of Healthcare Improvement
team-based care
(IHI)’s Triple Aim, which includes patient-
• Identify and manage patient centeredness, quality improvement, and
populations: Collect and use data decreased cost of care.

for population health management NCQA has also developed an optional
Distinction in Patient Experience Reporting
• Provide self-care support and
to help practices capture patient and family
community resources: Assist
feedback. To earn this distinction—which
patients and their families in self-

19. NCQA, “Physician Practice Connections,” accessed at http://www.ncqa.org/Default.aspx?tabid=141.
20. NCQA, “Physician Practice Connections—Patient-Centered Medical Home,” accessed at http://www.ncqa.org/tabid/631/Default.aspx.
21. NCQA, “NCQA Patient-Centered Medical Home 2011,” brochure, accessed at http://www.ncqa.org/LinkClick.aspx?fileticket=ycS4coFOGnw%3d&tabid=631.
22. Ibid.
23. Ken Terry, “Medical Specialists Encouraged to Use More IT,” InformationWeek Healthcare, June 13, 2012, accessed at
http://www.informationweek.com/healthcare/policy/medical-specialists-encouraged-to-use-mo/240001986.


Challenges and Solutions:
A PCMH must build a number of scalable core competencies.

To scale population health management, the care team in the practice must ensure that patients receive the
preventive and chronic care recommended in evidence-based guidelines; that patients’ conditions are tracked
in a systematic way; that the practice reaches out to noncompliant patients and those who don’t regularly see
their doctor; that the practice provides patient education and self-management coaching; and that steps are
taken to address poor health behaviors.

Because relatively few physician practices operate in this mode, the systematic application of population
health management has been largely left to employers, health plans, and disease management companies.
The PCMH represents, in part, an effort to make physicians and patients central to this process. The Agency
for Healthcare Research and Quality (AHRQ) has even coined a term for this new approach: practice-based
population health (PBPH).24

A 2008 study of the preparedness of large group practices to become medical homes showed that most
lacked key elements of the required infrastructure and practice approach.25 Yet these groups have far more
resources to make the necessary changes than small practices do. A recent study showed that small and
medium-size groups (under 10 doctors) have only about one-fifth of the capabilities required in a PCMH.26

This is not to say that small practices cannot become medical homes. Some have achieved amazing feats
of self-transformation. But, even if they already have EHRs, small practices may not be able to afford other
PCMH components, such as dedicated care coordinators and care managers. To expand their hours and
provide after-hours access to patients, they must incur additional labor costs. And, as previously noted, they
may find it difficult to persuade specialists and hospitals to cooperate with them on care coordination.

In the AAFP’s TransforMED pilot, which ran from 2006 to 2008, the three dozen participating practices—some
of them quite small—managed to achieve a number of PCMH goals. However, a report on their effort pointed
out that the pace of change is exhausting for practices and that they must have an “adaptive reserve” to keep
going down the path of self-transformation. In addition, the report underlined the difficulty that doctors may
have in assuming new roles vis-à-vis their staff.27

Experts have made several suggestions about how smaller practices might be able to turn themselves into
medical homes.28 One possibility is to use the kind of “practice transformation” consultants that were available
to half of the practices in the TransforMED pilot. The government could also create regional extension centers,
akin to agricultural extension centers, to help doctors over the hump. And both North Carolina and Vermont
have successfully used community resource centers to supply shared care coordination services that small
practices could not afford on their own.29

24. U.S. Agency for Healthcare Research and Quality, “Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care,” July 2010.
25. Diane R. Rittenhouse, Lawrence P. Casalino, Robin R. Gillies, Stephen M. Shortell, and Bernard Lau, “Measuring The Medical Home: Infrastructure in Large Groups,” Health Affairs 27,
No. 5 (2008): 1246-1258.
26. Diane R. Rittenhouse, Lawrence P. Casalino, Stephen M. Shortell, Sean R. McClellan, Robin R. Gillies, Jeffrey A. Alexander and Melinda L. Drum, “Small and Medium-Sized Physician
Practices Use Few Patient-Centered Medical Home Processes,” Health Affairs 30, No. 8 (2012): 1575-1584.
27. Paul A. Nutting, MD, MSPH, William L. Miller, MD, MA, Benjamin F. Crabtree, PhD, Carlos Roberto Jaen, MD, PhD, Elizabeth E. Stewart, PhD and Kurt C. Stange, MD, PhD, “Initial
Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home.” Annals of Family Medicine 7: 254-260 (2009).
28. Landon, Gill et al., op. cit.
29. Ibid.


Building the Medical How Much Will It Cost? a PCMH. The costs of tracking patients and
Neighborhood improving quality—both health IT-intensive
Most PCMH demonstrations sponsored by
While these approaches might help practices tasks—were particularly high. In total, the
health plans use a mixed or hybrid payment
build medical homes, their success as PCMHs community health centers that functioned as
model to reimburse physicians for the extra
will still be determined by how well they medical homes added $2.26 per patient per
work and expense of providing a medical
collaborate with other providers. The potential month in operating costs, or about $500,000
home. They pay physicians fee-for-service
role of ACOs in this area has already been per month for the average clinic.35
for the clinical work they do, plus a fixed
mentioned. But it may not be necessary to wait
care coordination payment for each patient But the authors observed that another
until ACOs are widespread to begin improving
and some kind of quality incentive. While study of an integrated delivery system’s use
the ecosystem in which the PCMH operates.
other approaches have been suggested, little of a PCMH showed that it saved $18 per
Under a $20.75 million grant from the Center data exists on how well they might work in patient per month in averted hospitalizations
for Medicare and Medicaid Innovation, encouraging PCMH activities. 31 and ER visits. Most of those savings
VHA Inc., the national health care network, accrued to payers, indicating the need
There’s also no agreement on how high the
TransforMED, and Phytel, a technology for reimbursement sufficient to cover the
care coordination fee should be in the hybrid
company that specializes in automated, infrastructure costs of PCMHs.
model. For example, the North Carolina
provider-led population health improvement
Medicaid program paid primary care doctors As noted earlier, some PCMHs that are part
solutions, are working together on a project
a coordination fee of $2.50 per patient per of integrated delivery systems have lowered
to expand the PCMH concept to the patient-
month. In contrast, in a multi-payer pilot in
32 costs and achieved a return on investment.
centered medical neighborhood. The goal is
Pennsylvania, the state required payments But it’s unclear whether that model would
to connect acute-care hospitals with primary
of $4 per patient per month to practices work for smaller, unaffiliated practices. What
care, specialty, and subspecialty practices to
that had attained level 3 NCQA certification is clear is that the cost of creating and
deliver higher-quality, more patient-centered
as medical homes. Some estimates of
33 maintaining a medical home could be much
care at an affordable cost.30
appropriate care coordination fees are much lower if the practices were highly automated.
VHA, TransforMED, and Phytel anticipate that higher.34
This approach requires the intelligent use
their combined work across 16 communities
One reason for the uncertainty about these of health information technology. By linking
will save Medicare up to $53 million over a
fees is that not much is known about the together some currently available health IT
three-year period. TransforMED, the leading
costs of establishing a PCMH. A recent tools, physician groups can automate much
PCMH expert, will apply Phytel’s population
study of federally funded community health of the work that might otherwise be too
health management solutions, and VHA
centers found that a fully functioning PCMH costly and difficult for them to do. Moreover,
will contribute its knowledge of quality
was associated with an operating cost per automating the manual processes of care
management and ambulatory care strategies
patient per month that was 4.6% higher than coordination and care management makes
for hospitals.
the cost of operating a similar center without it possible to scale the medical home to
practices of every size.

30. Phytel press release, “VHA, TransforMed and Phytel Awarded $20.75 Million Health Care Innovation Grant,” June 20, 2012.
31. Katie Merrell and Robert A. Berenson, “Structured Payment for Medical Homes,” Health Affairs 29, No. 5 (2010): 852-858.
32. Grundy, Hagan et al., op. cit.
33. BCBSA, “The Patient-Centered Medical Home,” op. cit., slide 25.
34. Robert A. Berenson, “Payment Approaches and Cost of the Patient-Centered Medical Home,” presentation at PCPCC meeting, July 16, 2008, slide 25.
35. Robert S. Nocon, Ravi Sharma, Jonathan M. Birnberg, Quyen Ngo-Metzger, Sang Mee Lee, and Marshall H. Chin, “Association Between Patient-Centered Medical Home Rating and
Operating Cost at Federally Funded Health Centers.” JAMA. 2012;308(1):60-66.


Role of Information Technology:
Observers agree that information technology, including the EHR, is
essential to the PCMH’s success. But EHRs lack some of the features
required to do practice-based population health.

AHRQ cites the inability of most EHRs to generate population-based reports easily; to present alerts and
reminders in such a way that providers will use them rather than turning them off; to capture sufficiently
detailed data on preventive care; and to interoperate with other clinical information systems.36

Some EHR vendors are moving to correct these deficiencies. For example, some applications allow users
to adjust the level of alerts to their own needs and tolerance levels. And, while another report points to the
difficulty of using the registries embedded in some EHRs,37 those are also being improved to help physicians
meet the meaningful use criteria.

Nevertheless, practices need a variety of health IT tools beyond EHRs to meet AHRQ’s requirements for
PBPH.38 These include the ability to:

• Identify subpopulations of patients

• Examine detailed characteristics of identified subpopulations

• Create reminders for patients and providers

• Track performance measures

• Make data available in multiple forms.

36. AHRQ, “Practice-Based Population Health.”
37. Nutting, Miller et al., op. cit.
38. AHRQ, “Practice-Based Population Health.”


Automation Tools be filtered by payer, activity center, provider,
health condition, and care gaps. The same
A growing number of practices use external,
filters could be applied to patients with a
web-based registries to supplement their
particular condition, such as diabetes, to find
EHRs. These registries compile lists of
out where the practice needed to improve
subpopulations that need particular kinds
its diabetes care and to prepare actionable
of preventive and chronic care, such as
reports for care teams on individual patients.
annual mammograms for women over
40 or HbA1c tests at particular intervals Other IT tools that will also be important
for diabetic patients. The continuously include online health risk assessments,
updated data in the registries comes from automated education materials and health
EHRs, practice management systems, labs, coaching, automation of actionable data for
and pharmacies. Evidence-based clinical care teams, automation of care management
protocols, which can be customized by reports, and biometric home monitoring of
physician practices, trigger alerts in the patients with serious conditions.
registries. When a registry is linked to an
outbound messaging system, patients are As an example, the following table shows

notified by automated telephone, e-mail, or how information technology can be used to

text messages to contact their physician for automate population health management.

an appointment. Some registries can also
send actionable data to care teams prior to
patient visits.39

To be an effective tool for population health
management, a registry should include all of
a practice’s patients, and be patient-centric, To be an effective
not condition-centric. It should also have a
sophisticated rules engine that combines
tool for population
disparate types of data with evidence-based health management, a
guidelines, generating reports that provide
many different views of the information. For
registry should include
example, the entire patient population could all of a practice’s
patients, and be
patient-centric, not
condition-centric.

39. Ken Terry, “Do Disease Registries=$$rewards?” Medical Economics, Nov. 4, 2005, accessed at http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.
jsp?id=190114


Identification of Automation Opportunities in the Manual Care Management Process

Care Team Process Step
for “At-Risk” Patients Manual Tasks Automation Opportunities

1. Identify “at-risk” patients • Review charts of patients scheduled for • Utilize algorithms and data mining to identify
upcoming office visits all patients within provider panel with care gaps,
irrespective of visit date or payer
• Review charts of patients associated with
a specific payer contract with “pay-for- • Stratify and prioritize patients based on risk
performance” incentives evaluation algorithms

2. Document gaps in care • Review multiple screens and fields within EMR • Create reports across multiple sources of data
and Patient Management System to identify care for entire provider panel population to identify
gaps and appointment dates care gaps based on evidence-based algorithms

• Review paper charts for additional information • Flag patients with upcoming visits

3. Communicate gaps in care to • Discuss gaps in care with provider as part of • Automate provider-level reports on patients
treating providers visit preparation process with care gaps

• Prepare cover sheet for paper chart • Automate creation of patient care summaries
for use in visit and between-visit management

4. Communicate treatment needs to • Make phone calls to patients, often by nurses •Utilize automated technologies to generate
patients as well as other staff, which only reach a limited outreach by phone, email and/or text according
number of patients to patient preference for all patients in provider
panel with preventive and/or chronic care gaps
• Mail reminder letters for preventive care

5. Assessment of “at risk” patients • Conduct assessments during office visits or • Send all patients online health risk assessment
over the phone using paper or other tools that tool; results can be used for individual and
may or may not integrate with EMR population management activities

• Offer online health risk assessment part of
patient portal

6. Educate patients about treatment • Generate printout of patient treatment plan at • Offer patient treatment plans and education
plan and care needs end of visit; may be handed to patient or mailed tools through secure patient portal for ongoing
patient support
• Make phone calls to patients for treatment plan
follow up • Push reminders and other communications to
individual and subpopulations of patients through
patient portal as well as phone, e-mail, and text


Medical homes can use automation tools to support the efficient functioning
of care teams

Health risk assessment (HRA) is fundamental the need for chart reviews. The summaries, include the ability to track, monitor, and
because it serves as the basis for the generated by registries, will remind providers engage patients; to tailor interventions to
interventions to be applied to patient of a patient’s care gaps and the need to different segments of the population; to
populations. HRA stratification enables work with him or her on modifying health measure performance for quality reporting;
practices to sort their patients into three behavior. Care teams can also streamline the to automate care coordination; to ensure
categories: healthy people, people in early visit preparation process by identifying care that care gaps are filled; and to do all of this
stages of chronic diseases, and people with opportunities and having patients get tests without increasing the workload of doctors or
advanced chronic diseases. These groups done before visits. staff members.
are always changing. Those who are well
To support the work flow of care managers,
today may be sick tomorrow, and those who
medical homes can deploy software
have an early stage of disease today may
that automatically sets priorities for their
be in a more advanced stage tomorrow. So
communications with patients, based on the
regular administration of HRAs can help keep
severity of their condition. Using data from
medical homes apprised of which patients
EHRs and registries, this type of application
are likely to need additional care in the future.
can tell a care manager whether he or she
To reinforce the lifestyle modification needs to call a patient directly or whether
messages delivered in the office visit, medical electronic messaging will suffice.
homes should use tailored communications
Biometric home monitoring, which has been
and interventions to achieve and sustain
around for more than a decade, is finally
behavior change. These include online
starting to get some financial support from
educational materials that may be linked to
health plans.40 As a result, it may be feasible
HRAs, along with automated reminders to
for medical homes to start using it to keep
patients. Practices can also take advantage
tabs on their sickest patients with such
of the new mobile technologies, such as
chronic conditions as heart failure, diabetes,
smart phones and texting, as well as patient
and high-risk pregnancy. Because doctors
Web portals that may be attached to EHRs.
don’t have time to monitor the continuous
Medical homes can also use automation stream of data, this would be a natural task
tools to support the efficient functioning of for care coordinators.
care teams. These include accurate and
The benefits of using these health IT tools
usable patient data summaries to minimize

40. Ibid.


Conclusion

The PCMH continues to make progress. Much remains to be learned about the most
effective techniques for building and maintaining a PCMH. But three conclusions can
already be drawn from the pilots that have already been done:

Successful medical homes will have to perform population health management; they will
need a variety of health IT tools to do that and to coordinate care effectively; and they
will have to gain the cooperation of the other providers in their medical neighborhoods.

Major changes in practice work flow and work roles must accompany the proper
use of information technology. In the end, practices must be reengineered to provide
effective, PCMHs—and the environment in which they operate must also change to
permit seamless care coordination. But all of this change can be less painful and lead to
more productive results if practices use the right combination of technologies to scale
population health management.


Scaling the PCMH Delivery Model with Automation

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