The concept of participatory medicine is taking hold, fueled, at least in part, by what we see as two complementary forces, these being the patient-centered medical home (PCMH) and Health 2.0. Health 2.0 is very much a grass roots phenomenon, dominated by a small but significant group of patients who are testing the hypothesis that the wisdom of the crowd can rival the wisdom of physicians. The PCMH is a concept, not new, but gaining tremendous traction in the provider sector now as a best-try effort by some providers to be truly patient centric in their approach. The two should be complementary and mutually self-supporting. One might even suggest their respective champions should be collaborating right now, when the scent of health reform is in the air in our nation’s capital. But they are not. Lets examine why and explore ways in which to create a natural bridge between these two concepts and their champions.
The medical home concept was first introduced by the American Academy of Pediatrics in the 1960s. But several factors are now converging to update this original concept for today’s health care environment. The growth in chronic illness, the emergence of new reimbursement models designed to improve quality and control costs (e.g. pay for performance), and the greater availability of monitoring and messaging technologies have providers, payers and patients taking a fresh look. This is a good thing, in that it is an effort by organized medicine and large corporations to get into the reform conversation.
But the aspects of the medical home that are getting the most airtime are largely focused on rounding out office staff, adding new roles that take work away from the physician so that the physician can tend to more patients, and taking a population view of the patient panel. This vision is idyllic, but several challenges suggest that as conceived it will be tough to get it out of the womb.
The biggest is that the growth in demand for services, fueled
largely by growth in chronic illnesses, has already outstripped the
demand for both nurses and primary care physicians. We can’t train
enough professionals to outfit all of the medical homes to this
specification, and even if we did, the major cost in healthcare is
human resources, so it stands to reason that this model would add far
more cost than it would take away. An excellent monograph by Paul
Keckley suggests that to implement the medical home in this fashion
would require an up front investment of $100,000 per doctor and an
ongoing increase of expenses by $150,000, hardly a reasonable
proposition in a time of health care cost cutting. The second big
challenge is that true population management requires sophisticated
information systems. While there is great focus on the value of the
electronic medical record, or EMRs, there has been little discourse on
physician adoption of technologies routinely used in the population
health industry such as predictive modeling software and disease
Health 2.0 is often subtitled ‘consumer-generated health care,’
possessing a spirit of personal activism and self-directedness in the
use of technology. In an increasingly web savvy culture, where health
and health care are not only important but are also costing us more in
out-of-pocket expenses, it’s no great surprise that health care
consumers are taking to Health 2.0 web sites and services in droves.
Surveys now indicate that over 80% of the adult population in the
U.S. has performed a medically-related search on Google, and over 10%
of people with high speed Internet connections do at least one health
search every day. In fact, the Pew Internet and American Life Project
reports that 75% of online patients with a chronic problem said that
‘their last health search affected a decision about how to treat an
illness or condition."
However, there are very clear signals that consumers and patients
don’t want Health 2.0 to substitute for a relationship with their
doctors. In fact, just the opposite: they want their doctors to help
them understand how to best utilize the new Internet resources, and to
guide their experiences to the best sites and the most valuable web
services. A recent Deloitte survey on consumers and their use of the
Internet for health and health care found that ‘nearly 80% want doctors
to provide online services,’ and one in four respondents said they were
willing to pay for these services. The study concludes that ‘in
general, consumers want access to more information, are looking for
better service, and believe their physicians should make better use of
What if these two concepts were to collide? We hope the collision
would be similar to the original accidental mixture of peanut butter
and chocolate that led to the advent of the peanut butter cup – a
synergistic marriage. We propose the term Connected Medical Home for the mixture and here’s what it might look like.
For the patient:
- Robust and frictionless online communication with one’s provider,
with the medical home practice the default source of best practice
- Fewer trips to the doctor’s office, improved prevention, and improved well being.
- Monitoring of relevant physiologic information such as blood
pressure, blood glucose, step counts and medication adherence all fed
into one’s personal health record.
- A ‘blended’ version of that record available to one’s physician and
one’s loved ones, so that care coordination is made easier across
settings of care and episodes of care.
- Access by both patients and their physicians to communities of
consumers/patients with similar health challenges and goals where this
kind of rich information would be displayed (according to the
consumers’ wishes) and trusted relationships with like individuals
would help move individuals to a state of more healthy behaviors and
sustain them. Conceivably, a primary care provider could
participate in such a community of her patients or subsets of her
patients adding wisdom and coaching as the community felt it was
For the doctor:
- One might spend part of the work day caring for a few, very
complicated patients, each requiring 45-60 minutes of concentrated time
in the office.
- The other part of the day would be spent ‘surfing’ various dash
boards offering quality measures on one’s patient populations,
identifying outliers who need attention.
- Access to trended information about one’s patients (blood
pressures, activity levels, medication adherence, etc.) in context, fed
from their private PHR and viewable at that moment in time when a
complex medical decision is required
- Patients and other health care professionals guided by decision
support would make other medical decisions. The decision support would
be constantly refined, backed by self-learning software taking data
from the physiologic information, the online support groups, and other
data such as laboratory tests.
- One would spend some of this online time communicating with patients who have questions that need a doctor’s attention.
In short, web-comfortable consumers want
a ‘participatory medicine’ experience with their healthcare
professionals that involves modern forms of communication and coaching.
They want to be ‘connected’ online with their doctors and nurses, and
they prefer having their health information searches guided, if not
filtered, by their personal doctors and medical homes.
Yet, most discussion on the medical home
focuses on the care team and coordinated care, and refers only in
passing to the idea of monitoring. This model may sound appealing but
this is clearly not feasible in today’s cost containment climate.
For the medical home concept to truly be
effective, we believe that the emphasis should be in the other
direction. Specifically, for the right patients, instituting the use of
monitoring and messaging technologies with proper integration to
providers, will result in improved population management, take some of
the burden off of primary care physicians and keep costs in check.
The medical home model, as proposed to
date, does not demonstrate that we ‘get it’ and are willing and able to
embrace the paradigm of Health 2.0. Until we do, there will exist a
divide between health care providers and their online patients. Lets
start implementing the connected medical home.
David C. Kibbe,
MD MBA, is the Senior Advisor, American Academy of Family Physicians,
Chair, ASTM International E31Technical Committee on Healthcare
Informatics, and Principal of The Kibbe Group. He’s a frequent
contributor to THCB and an advisor to the Health 2.0 Conference. Joseph C. Kvedar,
MD is Director, Center for Connected Health, Partners HealthCare
System, and an Associate Professor of Dermatology at Harvard Medical