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…
What do the President’s Council of Advisors on Science and Technology (PCAST), the recent Institute of Medicine (IOM) report and the New England Journal of Medicine article on value in health care by Porter have in common?
They call for increasing aggregation of information around individual patients even as they seek to avoid complications for and interference with providers.
Even so, the debate between provider-centered and patient-centered health information exchange is still very much with us. Recent progress with the Direct Project, Blue Button and Kaiser’s donation of terminology suggest a trend toward simplicity and open-source collaboration as essential catalysts for health information exchange.
The next logical step is a PCAST-inspired patient portal.
The essential elements of a PCAST Patient Portal are already available:
- Blue Button success proves that patients appreciate and will adopt enhanced portal features and that providers can readily connect their databases to the portal if the technical and policy requirements are truly minimal.
- The Direct Project shows that combined federal and industry support can produce accessible open source code for bidirectional health information exchange in record time.
Health care leaders are busy talking to attorneys and consultants about how to set up Accountable Care Organizations (ACOs). A recent Advisory Board survey found that 73 per cent of hospital finance executives said that creating such an organization was a top priority for their health system.
Last year my most popular keynote topic was patient-centered medical home creation; this year everyone wants a presentation on ACOs.
However not everyone has jumped on the ACO bandwagon. Bruce Bagley, MD of the American Academy of Family Practice was recently quoted as saying, “There are probably no experts about ACOs. It’s a developing concept.” And Jeff Goldsmith, PhD, of the University of Virginia stated at the same conference: “I think this is a stupid idea. Managed care without the risk – that’s like gin and tonic without the gin. How do you end up making choices if you’re not forced to make them?”
I started thinking about what an ACO would look like if it was truly patient-centered. What if we designed an ACO that gave patients what they say they really want?
Don Berwick wrote an article in Health Affairs in 2009 that examined what patient-centered should mean, and since he became the head of Medicare in 2010 it might make sense to start there. After all, Medicare is pushing the ACO concept by creating pilot projects and encouraging the shift from fee for service payments to global payments for medical care reimbursement.