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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21 replies »

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  3. 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 of competency defense removed, the written word. From the written word I could tell you if a. it was a qualified professional.b.if they cared and knew what to do…..now i just have templates that can be filled in by…..yes my Yorkie. So expanding this broken model to take away the hands on Doctors visit is just continuing to go a path that has essentially failed. Now we get to a doctor fear of liability using a cyber community model……gee all that written responses stored on someones computer. I said, they said, and when and where. The computer fiancial system has failed and they still don’t get it. Numbers swerling in space, and virtual economy…..in the end it all gets real.

  4. 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 species to thrive surrounded by a hostile world. Within this arrangement, the thrivers move from place to place. Habitat is a more encompassing model than a home. We come back to a home to live our lives, but we move about our habitat gaining the resources we need and enjoying social interaction. Today’s patient/client/customer/consumer would flourish in an arrangement that recognizes the various settings individuals, families and communities navigate–well beyond their “home.” There is an ecological focus tied to habitat that could move us out of the fragemented “medical model.” That brings me to another limitation of the label “medical home.” Researchers and practitioners in contemporary medicine, nursing, social work, psychiatry, OT, PT, etc. increasingly are using “health” as their focus. This concept puts the emphasis on the patient and not on the provider. I encourage this set of thoughtful bloggers to consider the implications of moving from a medical home to a health habitat.

  5. 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 real medical come level service.
    What could you get by pumping $150,000 annually into each practice and instituting all the elements of the medical home practice that are discussed above? Would the doctor have fewer patients? Would he have more time for each one? Could he afford the time to spend an hour or two with each of them once a year developing a detailed wellness plan and implementing it? Would he have any free time for study, family or recreation if her were accessible by email and cell phone 24/7/365 to his still very large practice? Would exposure to his practice by students inspire them to go into primary care? The answer to all these questions is “NO”. He would have some more money and some more tools including EMR and secure patient email etc.
    I get about 50 non-spam emails a day. Only one or two are from patients, but then I have only 600 patients most of whom are elderly and do not use computers. These emails have to do with SIMPD business, like the one I got this morning from Dr. Kvedar prompting this post. I spend hours and hours every day dealing with them. Opening up email care for all patients and adding this chore to the typical 2,000 patient primary care doctor’s daily work load would crush him. It nearly crushes me. I am looking forward to May 9, 2009 when Dr. Marcy Zwelling assumes my job as SIMPD president.
    What would $150,000.00 provide for a busy primary care doctor with say 2,000 active patients? Well, it would provide about $75 per year or about six dollars per month additional revenue for each patient of his huge 2,000 patient load. The least expensive real patient centered medical home I know of costs $39 to $79 per month per patient (Qliance in Seattle) or about ten times the amount Keckley suggests. And of course each doctor in Qliance limits his practice to 800 patients to do this and is very busy indeed.
    I reviewed the financing of a medical home experiment in Penn. a few days ago. Nine and one half million dollars was to be spent over five years on this project helping 177 practitioners and all their patients get to medical home levels. This funding worked out to about 50 cents per patient per month. That is a joke, but it was being applauded in the press as a great move forward. Nobody did the math.
    Trouble is all those practices will also lose several dollars per patient per month in the next five years from third party payment cuts. Government and third party insurance are not willing or able to step up to the plate and provide the funding necessary to get there. But here is the kicker. Patients, more and more of them every day, are. They are willing to spend $100 a month or so to get the primary care attention they want and deserve, directly out of pocket. Insuring such primary care is like insuring lunch and costs about the same amount. It does not make sense to insure lunch does it. Neither does it make sense to insure primary care. It is not an insurable event.
    The benefits of actually spending his much money up front are incredible. There are virtually no more medical errors that kill 100,000 patients a year. There are no malpractice actions, not any, at least not yet. Eighty percent of ER visits end; they just don’t happen. Similar reductions in hospital admissions are achieved. Massive savings result, and incredible improvements in health and longevity. I know. I’ve been doing it for years.
    It is really incredible what happens when patients can immediately access their personal primary care doctor instantly 24/7/365 and he is rested, fresh and up to date almost all the time. That is what the now several thousand of us in direct practice do. We have learned how to finance the medical home. Bill the patient for it directly outside the third party insurance system. And it cost less than cable TV or cigarettes.
    You will keep talking, and we will keep acting. There are close to a million Americans now in our direct practice medical homes, but the academics rarely mention this. It is about time to do so, don’t you think?
    Thomas W. LaGrelius, MD, FAAFP
    President, SIMPD http://www.simpd.org 877-448-6009
    Owner, Skypark Preferred Family Care, Torrance, CA http://www.skyparkpfc

  6. 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 as a way of better managing privacy.
    There are a few groups who are focused on HIE models that balance the flow of health information among providers, patients and lay caregivers. (e.g. the SoPHIE (https://www.dtmi.duke.edu/wiki/display/pohie/Home) , LouHIE (http://www.louhie.org/About%20LouHIE.htm ) .
    For the connected medical home model to succeed, I think that the public discussion around HIEs will have to shift significantly towards this more balanced information exchange model. I’d welcome comments on how to influence this shift.

  7. 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 research and formal study. And the role of alternative medicine and providers is simply unavoidable, and could be hugely positive.
    Regards, DCK

  8. 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 psychology of looking for information online suggests people have a set starting point — a search engine — that isn’t going to change just because one set of people want it to. As Dan said, a lot of what is suggested would require significant sociological and psychological changes within society — changes that are unlikely to come in our lifetime.

  9. 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, the patient. Doctors, nurses, therapists, care providers and especially the patient/groups of patients all contribute. Egos get in the way of productivity of any group of people, and this one is no different.

  10. 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 to have the knowledge to make wise choices. It means supporting patients to easily and accurately keep track of their performance. It means providing tailored messages and experience that speak to each person based on their unique characteristics, their performance on key behaviors and their needs at that moment in time. It means helping patients link directly to family and friends for critical support, and link to their many providers to help integrate medical care with everyday life.
    In other words, connected healthcare can extend the practice of medicine. It can mimic what skilled clinicians –doctors , nurses, therapists, educators, dietitians– do, but at a fraction of the cost and in a more convenient way.
    I am not saying that we should eliminate people from doctor- patient interactions. On the contrary, patients should have the freedom to choose which way they want to receive the support they need to be healthy and successful.

  11. 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. I believe we are about to cross the chasm to a new kind of delivery system; one that many of us have been envisioning for more than a decade.

  12. 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 even as promising new operations are gaining traction at academic medical centers, plastic surgeons often fail to tell patients about them. One reason is that not all surgeons have trained to perform the latest procedures. Another reason is money: some complex surgeries are less profitable for doctors and hospitals, so they have less of an incentive to offer them, doctors say…… Then Ms. Hodges discovered a chat room on the patient-information Web site breastcancer.org, where women share detailed information about breast reconstruction beyond what they may have heard from their doctors.
    Ms. Hodges learned of newer, more complex procedures that involve transplanting a wedge of fat and blood vessels from the abdomen or buttocks, which would be refashioned to form new breasts.
    “It’s unfortunate that a lot of general surgeons, breast surgeons and plastic surgeons don’t mention it,” said Ms. Hodges, who underwent one of the surgeries, known as a GAP flap, last year.”
    We see this every day. And of course groups of expert patients with unusual conditions know more about it than the average physician. Why is it so difficult to accept? It doesn’t transform any of the patients into physicians and it can only impact negatively the patient-doctor relationship if the doctor is lacking self-confidence.
    All doctors are going to have to learn to say: “I just don’t know, but I’ll find out.” Very few can do so today. And by not doing so they are responsible for a significant number of bad diagnosis, another reason the system is dysfunctional. A simple example: if you are an oncologist and have a patient diagnosed with an leiomyosarcoma, the chance is that you’ll treat that patient, while the patient would receive far superior care if treated by one the true leiomyosarcoma specialists in the country. That is the #1 message on the ACOR system. And I am convinced that this simple message has saved thousands of life by simply directing patients to real experts, instead of being treated by doctors who play with fire by just not acknowledging they are not equipped, knowledge-wise, to deal with the condition.

  13. 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 with their doctors and nurses, and they prefer having their health information searches guided, if not filtered, by their personal doctors and medical homes.”
    But that isn’t nearly comprehensive or integral enough. To deliver real value to the patient in a way that really advances a Health 2.0 world, any participatory medicine model needs to include information-sharing and create regular and reliable online connections not only with doctors and nurses, but with:
    — the local hospital that has (its version of) the patient’s records and the ED likely to see the patient when the patient and family run out of levers in critical circumstances (assisted by the primary care, specialist or on-call physician); I bring the same printed list of conditions/meds/providers/allergies/insurance everytime my wife makes a trip to the ED, and it is like the movie “Groundhog Day” when the staff commends me for doing so (for three years now!);
    — CAM providers, given that a high percentage of patients empowered by the web also are likely to feel similarly empowered by and utilize alternative and complementary/integrated care, at least to supplement conventional care;
    — any and all pharmacies used by the patient;
    — the patient’s family, especially where a family caregiver is involved; and, certainly not least
    — the patient’s health insurance company (just today I received a notice of patient responsibility for a charge from my wife’s regular specialist just because his office had not yet provided the medical record for the service rendered during hospitalization — come on, folks, this isn’t even “Health 1.0” stuff!).
    Of course, some of these connections will be easier to implement than others. But the point is you start where it is cheapest/easiest (knowing you won’t get it right initially), learn as you go, and then you iterate based on established or evolving standards (driven by the entities with the most leverage, as usual). The scope needs be comprehensive from the outset, however; otherwise, you’ll just find that you’ve built “bigger silos” instead of a comprehensive solution.

  14. 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 IDN, a national health system, or an academic study is pretty much excluded from participating.
    So there is a structural deficit. The data model. In my view, this is the rate limiting step. Were it not, I believe primary care physicians would have figured this out a long time ago. Once you have the data, the remaining issues are really business intelligence ones that have been solved in many other industries.
    I welcome thoughts on how this important problem may be solved for the average patient or primary care doc. Is there a platform emerging, beyond 100% consumer directed, that will be the answer?

  15. The connected medical home challenges the current clinical/business model, but it stops short of the change we need. We need to challenge the physician group practice as the center of the healthcare universe mentality. To truly be effective at treating specific conditions, we need to organize practitioners around those conditions instead of around body/organ systems.
    Gilles – Your point about expert patients knowing more about a specific condition is probably a bit of an exaggeration, but it is well taken. However, if practitioners were organized around conditions, they would become very skilled at treating those conditions and you probably couldn’t make the same claim.
    Non-physician practitioners will play a bigger role in the future of healthcare than most physicians realize. They are not a threat to physicians, they are a supplement to physicians. In my practice, they are a nice income boost to physicians.

  16. When people are sick or just want to manage their own care they’re seeking caring, convenience, and comfort that will heal, enable and delight them at the lowest possible cost.
    The “place” or so-called medical home for patients to access the above items could be with an individual primary care provider visit(physician, nurse practitioner or PA), online virtual office visit, group visit, or phone visit.
    Patient preference, IT savvy and acuity dictate the optimal location where an individual episode takes place. The impact can be significant on quality, demand and cost, e.g. innovative practices have reduced office visits by 2/3 by leveraging online and phone care, group visits reduce ED visits and costs, while increasing satisfaction, mid levels produce comparable outcomes at 1/3-1/2 the cost of physicians, EMRs can improve quality and increase practice revenues etc.
    Consensus regarding a common aim or purpose of care, e.g. to heal, enable and delight at the lowest possible cost makes health 2.0 a vital enabler of the poatient centered medical home.
    I would respectfully disagree with the notion that delegating of physician activities isn’t vital to the success of the “medical home” concept. Having assisted literally hundreds of practices, I’ve found physician frustration with non-clinical and low level tasks that could be delgated, automated or even deleted to be a major cause of burnout, inefficiency and low incomes particularly in primary care.

  17. The definition of Participatory Medicine we crowdsourced on e-patients.net is very different from David Kibbe’s use of the meme. When writing “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” I am afraid this is missing the main point: there is no rivalry! e-patients work in tandem with the doctors who accept to treat them respectfully and equally.
    No one is talking about replacing doctors. e-patients just augment the knowledge pool of the medical team, since they are an integral part of the medical team. None of this require any “gadget and internet tool”. It just require doctors to finally drop for good the paternalistic attitude that is so clearly expressed in this post and its comments.
    Any patient suffering from an unusual condition and able to communicate with others suffering from the same condition will tell you the same thing: with very few exceptions, expert patients know more about a specific condition than doctors do.
    It is the doctors who need guidance, not the e-patients!

  18. Thanks D Zuckerman and Duke Carlson, for your commments. Let me delve a little more deeply into the social networking aspects of the Connected Medical Home, both with respect to the ‘clinical encounter’ and group visits, both of which are social events as well as therapeutic events.
    My question is “where do these need to occur?” Traditionally, people must go to the office or hospital to have an encounter or visit. Modern health care professionals assume that the person or persons must bring the problem to the solution, whereas in other industries where innovative disruption has occurred, the disruption inverts this system, so that the solution is delivered to the person with the problem. Think about mobile phones and Blackberries, personal computing, tabletop copiers and printers, etc. etc.
    In the Connected Medical Home model we need to re-invent the encounter and group visits, such that at least some of the time these can occur wherever the person/patient is located. This could hugely expand the reach and effectiveness of physicians, while providing the social support and non-expert sharing that you both comment upon as being vital and part of the healing process.
    Kind regards, and again thanks for your comments. dCK

  19. Group medical visits are an interesting low tech tool widely in use that allows patients to utilize the power of a physical encounter with their medical practitioner shared with patients with similar problems. I would envision these type of encounters orchestrated by the physician leading a medical home being very valuable.
    I wonder if Mr. Keckley included such a tool when he was doing the math involved in calculating the cost of improving medical care. I have been involved in coordinating these group medical visits and there is great value in the face to face support patients give to each other with the direction and support of their physicians. These visits can really extend the reach of an individual doctor.
    I agree with the 2.0 concept but see it really as just amped-up patient education and outreach. I think what is really needed is a shift away from more gadgets and internet tools to remind people about their health problems and more health promotion and this may happen best and more cost affectively with group medical visits

  20. I like Connected Home Model. Who doesn’t want to be connected? Patients Like Me and Sermo certainly confirm that concept. There is no question that many patients want and should be engaged and participatory in his/her own healthcare and the decisions surrounding that care. Knowledge and tools can support that endeavor and many qualified people are developing tools to enable the ‘connection’.
    I strongly believe that nothing can take the place of the ‘clinical encounter’, in whatever format that might look like. Thus, what can we do to enhance the quality of that clinical encounter? I would suggest that it is far more than HIT and EMRs as exists today, which seem to focus on transactional medicine. I think we need to look deeper and work more with clinician-informaticists and sociologists studying IT applications. We need to focus on the personality, values, attitudes, social class, interests, opinions of both patients and clinicians as opposed to primarily the technology.
    I think your Connected Medical Home ‘features’ are great, now we need to evaluate the real and perceived ‘benefits’ seen and/or desired by the constituency involved and how we might affect a behavioral change.
    I like the challenge.

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