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Tag: Patient-Centered Medical Home

Huddle of One

By dinosaur, md

There’s nothing new under the sun, or in medicine. I’m not talking about monoclonal antibody targeted chemotherapy; I’m talking about taking care of patients, and specifically about running a medical practice. Not even the incursion advent of all our fancy new electronics has (or should have) a fundamental effect on how we take care of our patients.  The latest thing to come down the pike is the so-called Patient Centered Medical Home, a collection of policies, procedures, and practice re-structuring (webinars, templates, guidelines, etc. all available at low, low prices, of course) that essentially makes large group practices function like a solo doc from the patient’s point of view.

Because the buzzword of this new model is “teamwork”, we’re all supposed to begin the day with a brilliant new concept called the “huddle“:

The team huddle is promoted by many clinicians and practice coaches as an innovative approach to support medical home transformation through visit pre-planning, team building and communication, and workflow redesign.

Radical!

One problem: how do I do that all by myself? I mean, here’s what I generally do every day:

  • Make sure to arrive at least 30-60 minutes before the first scheduled patient
  • Look over the schedule to get a sense of the day, who’s coming, who may need extra time, any new patients
  • Double-checking that rooms are re-stocked with key supplies (ie, three paps on the schedule; wasn’t the speculum drawer low the other day? Couple of well baby visits; enough needles for all their shots? Better top up the bin from the supply closet.)
  • Looking over the charts (now electronically; previously the paper ones — adding pages, seeing whose insurance info needs updating, etc.)
  • Go over all the above with staff whenever they arrive (usually after me)

I’ve always just called it “getting ready for the day,” an organizational strategy for business management that’s called “being prepared” in most other occupations. But now it has a new name: the Huddle. Complete with instructional videos, for chrissakes.

As far as “patient-centered-ness” goes, I’ve used a somewhat different set of concepts from Day One called “Customer Service”. Having people instead of machines answering the phone, same-day appointments, personally communicating test results; all Disney-level customer service, now re-named things like “Open Access”, have been integral to my practice from the git-go.

Why is it happening? One of the oldest reasons in the world, of course: money to be made. I’m sure there are too many doctors and medical practices out there who, sadly, need this kind of help. Sadder still, they have to be force-fed it under the guise of running a “more efficient” practice.

Whatever happened to good old common sense? Next thing you know they’ll be all over us making sure we wash our hands. (Joke intended.) Seriously, though. This whole thing about co-opting perfectly sensible things from other industries for medicine — checklists, for example — and carrying on as if having re-invented the wheel is getting old.

Spring Training for Health Care Teams

By Thomas H. Lee, MD


Two years ago, I wrote a piece in HBR called “Turning Doctors into Leaders,” which began with the sentence “The problem with health care is people like me” — that is, physicians who had been trained in an era when excellence in medicine was defined by what you did as an individual. In the short period since, the concept that medicine is actually a team sport has become increasingly accepted. Because of medical progress, there is too much to know, too much to do, and too many people involved to give patients excellent care, unless we get better at working in teams. A lot better.

Sounds good — but it’s a lot easier to write or talk about than to do. In fact, organization and collaboration are unnatural acts in much of medicine, where payment is still fee-for-service and the culture of individualism still dominates. Progress is being made — more in some regions and at some delivery systems than others. In this post, I will assess that progress by giving grades in various key functional areas akin to those that sportswriters are currently giving baseball teams as they get ready to break spring training. Like those sportswriters, I will try to blend optimism and realism.

Ability to put a team on the field — C. The payment system actually is changing, and ambitious pilots like Medicare’s Accountable Care Organization contracts are underway. In these new contracts, providers share heavily in savings and losses. And, as a provider, I can tell you that we really hate to lose (i.e., bear financial losses for care we have given).

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Doctorology: Communication. It’s All Good

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By Dinosaur, MD

“Doctor’s office; please hold.”

You’ll never hear that when you call me. Never. You’ll also never get an automated answering system (I’m just referring to office hours, of course. Evenings and weekends the phone goes to Google Voice. More on

that below.) We are also in the middle of a communication revolution. There are now so many other ways patients can contact me other than the telephone, the silly thing is almost becoming obsolete. I took amoment the other day just to go through all the various ways patients contact me.

Telephone

Still the most reliable fallback. Most synchronous form of communication: both parties willing and able to talk in real time. After hours, Google Voice (free) transcribes messages and texts them to my smart phone. As a rule, patients do not call my cell phone, although I’m not shy about giving out the number. Then again, those who have my cell number usually use it for…

Texting

At the moment, it’s just a few patients, but I anticipate more and more of them will partake as time goes on. It doesn’t happen very often, and so far it’s never been inappropriate. Med refill requests and pictures of kids’ rashes have been the mainstay so far. I like it. By it’s very nature, the people choosing to text me understand the limitations of synchronicity, ie, they don’t get bent out of shape if I don’t answer them right away, and they understand that it’s just for relatively minor issues. I also use it to communicate simple quick questions to specialists with all the same mutual understandings (minor issues only; response time unimportant).

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The Organic Medical Home

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By Rob Lamberts, MD

What comes to mind when you hear the term “medical home?”  Perhaps you favor the definition put forth by our government (AHRQ):

The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.

1. Comprehensive care
2. Patient-centered
3. Coordinated care
4. Accessible services
5. Quality and Safety.

The presence of these five attributes to care should then constitute a medical home, right?  It depends on who you get your definition from.

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The Patient-Centered EHR

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By MARGALIT GUR-ARIE

The term patient-centered has become a serious contender for the most flippantly used term in health care publications and conversations. Of course meaningful use is still #1 on the popularity charts, with ACO quickly moving up, but even meaningful use and ACO are almost always accompanied by patient-centered as a way to add legitimacy and desirability to the constructs.

Even Paul Ryan’s new recipe for fiscal Nirvana is touting patient-centered health care as one of a litany of fictional achievements made possible based on an array of wishful thinking assumptions. But perhaps the most common usage of patient-centered terminology is the Patient Centered Medical Home (PCMH), which is touted as the ultimate patient friendly solution to our health care difficulties. Since PCMH is heavily reliant on Health Information Technology (HIT) to achieve patient-centeredness, and since Meaningful Use of Electronic Health Records (EHR) is being increasingly aligned with this goal, it may behoove us to explore the features and functionality that would qualify an EHR to support a patient-centered approach to health care delivery.

But first, what exactly is patient-centered health care? From reading the NCQA medical home specifications, the Meaningful Use definitions, the HIT suggestions from PCAST and the brand new ACO regulations, all of which assert a patient-centered approach, one would conclude that patient-centered care is made possible by providing all patients with timely electronic access to the entirety of their medical records including lots of patient education, electronically coordinating a multitude of transfers of care, empowering non-physicians to provide most medical care, measuring a bewildering array of health care processes and constantly evaluating and reporting on population metrics, while somehow allowing patients and families to express their wishes regarding the nature of care within the boundaries specified by each proposal. I am excluding the Ryan budget proposal here, since other than having “patient-centered” typed in various spots, there is no reference to actual health care delivery, or what is left of it after most seniors, sick and disabled folks are reduced to begging for medical care. Computers and EHRs can, and to some extent already do, support many of the above activities, but is this truly patient-centered (singular) care, or should we add an “s” and refer to a plurality of patients-centered, or population-centered, care?Continue reading…

Selecting an EHR for the Patient-Centered Medical Home

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By MARGALIT GUR-ARIE

The conceptual definition of a Patient Centered Medical Home (PCMH) speaks of a physician directed medical practice, oriented to the whole person, where patients have enhanced access to a personal physician and care is coordinated and integrated focusing on quality and safety, nothing more and nothing less, other than appropriate payment to physicians for all activities.

Since concepts are rarely enough, the National Committee for Quality Assurance (NCQA) took it upon itself to provide concrete requirements and formal certification for medical practices desirous of being recognized as Patient Centered Medical Homes. The NCQA PCMH definition consists of nine Standards used to score the practice. This is NCQA’s attempt at translating the original PCMH concept into measurable activities and here is where Health Information Technologies (HIT) and EHR in particular, are formally associated with the PCMH concept. Conspicuously absent from the NCQA standard are the “personal physician” and unless you consider the assessment of language barriers sufficient, so is the “whole person orientation”. Most NCQA PCMH elements are geared towards data collection, data analysis, tracking and reporting. Theoretically, you could earn NCQA PCMH designation without an EHR, but the amount of typing, writing, filing and calculating would easily consume your entire day. If you are serious about PCMH designation, you will need an EHR. But which one should you get? Are some technologies better than others for PCMH purposes?Continue reading…