Physicians

The Connected Medical Home: Health 2.0 Says “Hello” to the Medical Home Model

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
registries.

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
information technologies.’

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
    information
  • 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
    relevant.

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
School

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Ma2x Ma2x TelechargerminimotoJoniHome Healthcare MarketMaryalice Jordan-Marsh, Phd, RN, FAAN Recent comment authors
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Ma2x Ma2x Telecharger
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Joni
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Joni

We have electronic record nightmare that is taking time and care from patients at every facet of healthcare. I beleive its Virtual Care and falls very short of real-time care. The electronic record is more restricted than the hardcopy. No one can access it, so the supposed benefits are just over gathering of information that helps prevent easy law suits and takes from the real care…… seeing of a patient. My concern is my yorkie could do a pretty good clinical note and no one would know it was a Yorkie, 7lbs of fur. So now we have a line… Read more »

Home Healthcare Market
Guest

Hey its a well presented and interesting post, good job, keep posting.

Maryalice Jordan-Marsh, Phd, RN, FAAN
Guest
Maryalice Jordan-Marsh, Phd, RN, FAAN

Dan Hoch has brought this discussion to a critical construct–the team. This audience might find Wielawski’ review of the Chronic Care Model to be very helpful. She makes a similar point in that we need to create teams where the patient is on the team and so are the nurses, social workers and others. http://www.improvingchroniccare.org/downloads/rwjf_anthology_icic.pdf If the Chronic Care Model and Connected Health continue to emerge a viable approaches, the “medical home” may be too rooted in old frameworks. Health habitat (Jordan-Marsh, 2008) may be a more apt construct. A habitat is an arrangement where conditions are good for various… Read more »

Thomas W. LaGrelius, MD, FAAFP
Guest

I think the most pertinent question everyone overlooks is how to pay for a real patient centered medical home. You do touch on one study by Paul Keckley above noting that it would cost $100,000.00 to $150,000.00 per doctor’s practice to implement the medical home concept. This is a gross underestimate in itself. The cost per practice in my view is more like $500,000 per year and each practice would have to be split in two and a physician added to keep the numbers of patients in the new practices at a level the physician could actually handle and provide… Read more »

Dave Kirby
Guest
Dave Kirby

Thanks to all for a great discussion about a connected medical home model. There is one aspect of achieving this general vision that has not been well covered here. How can health information exchanges and regional health information organizations (HIEs and RHIOs) best be organized and operated to support the connected medical home model? There is a significant amount of activity devoted to developing HIEs today, but most of the focus is on how to exchange data among professional providers. The attention that is given to including consumers in information exchange is focused on allowing consumers to control PHI flow… Read more »

David C. Kibbe, MD MBA
Guest

All: Many thanks for your generous and informative comments. I am learning much from them, and am humbled by my own deficiencies in trying to describe this emerging trend or movement toward participatory medicine. There are structural issues, e.g. the need for a data model that is simple enough, but sufficient to the task of supporting participatory medicine. Participatory medicine is definitely going to require sociological and psychological change, both for consumers and for clinicians. How we make it possible for people to elect a participatory medicine approach, and then provide them with the tools, is a problem worthy of… Read more »

John M. Grohol, PsyD
Guest

What people say they want, and then what they actually do, are usually two quite different things. This can be seen no more clearly than through the two datapoints mentioned above — most people say they want a doctor-filtered search for health information (e.g., these are the resources my doc recommends), but most people end up using not health-specific search engines, but good ‘ole Google for their health search starting point. This is not because doctors lack the ability or means to actually recommend health resources online (and some pioneering doctors and health professionals, in fact, do). It’s because the… Read more »

Dan Hoch
Guest
Dan Hoch

This is a great discussion. Thanks to all for contributing. I want to reiterate a point that Gilles Frydman made about a key component of participatory medicine. One of the priciple goals is to reclaim the “team” that is required to managed our health. Many of the ideas that Joe and David put forth are great ones, but there is a sociological change needed. Our systems, especially technologies, have to foster a level playing field where all the actors aggregate and share data and use every available resouce to analyze it to the betterment of the person in the center,… Read more »

Neal Kaufman, MD
Guest

As a pediatrician who has lived with and fought for medical homes for my patients and as the CEO of a medical software company, I want to add my compliments to those who have written the prior postings….quite well done. I would like to also add to the discussion a core concept that isn’t being stressed enough….that organized medicine needs to provide the day-to-day support patients need to prevent disease and to self-manage their conditions if they are ill. In the connected era that means just in time delivery of the personalized and up-to-date data and information a person needs… Read more »

Bill Crounse, MD
Guest

David and Joseph, Thanks for stimulating the debate. This is exactly the dialogue we need to transform health and healthcare in America. I hope both government and private payers will begin to see the light. I am in total agreement that the EMR, while important, is not the Holy Grail. Far more important are reimbursement and business models that will encourage disruptive innovation. We need to eliminate the perverse incentives that reward inefficiency and over-treatment. We need health information and medical services that can be delivered using the most appropriate and efficient modality according to each individual’s need and condition.… Read more »

Gilles Frydman
Guest

Deron wrote: “Gilles – Your point about expert patients knowing more about a specific condition is probably a bit of an exaggeration, but it is well taken.” No, it’s not an exaggeration. Not for anyone who is suffering from an unusual condition that requires particular expertise. And I’m not sure my statement is inaccurate or a bit of an exaggeration even for common diagnoses. Just today in the NY Times: In Breast Reconstruction, Some Hidden Choices. Here is an excerpt: “For many cancer patients undergoing mastectomies, reconstructive breast surgery can seem like a first step to reclaiming their bodies. But… Read more »

Joe Kornowski
Guest

A reaction from the patient and “integral” family caregiver perspective: Nicely done! Overall, this post and many of the comments are exactly on point. As patient and healthcare providers and other resources are networked online in a way that benefits all, quality of care, patient satisfaction and cost and time efficiencies — both patient-side and provider-side — will begin to be realized. On the scope of the needed participatory medicine experience, you write: “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… Read more »

Russ Richmond
Guest
Russ Richmond

The connected medical home is going to require data. Where is the data going to come from? Right now, it is laborious for patients to enter and upload their own data from monitoring devices, GH, or the Vault. It is even more difficult to imagine most patients transmitting data from their employer or health plan to their physician (even sophisticated users of a PHR). And EMR data lacks the 360 degree view required. My point is simple. Until there is an integrated data model, the connected medical home will be difficult to achieve. Any patient (or physician) outside of an… Read more »