1. Who’s in Your Neighborhood? The Patient-Centered Medical Community David C. Willis, MD Medical Director Greater Ocala Health Information Trust, Inc.

2. 2 Learning Objectives Review Medical Home Concepts Understand the value of a Connected Patient-Centered Medical Community Explore medical information Interoperability Understand ways to evaluate EHR interoperability Healthy Ocala example Discuss challenges and opportunities to develop Patient-Centered Medical Communities

3. 3 Patient-Centered Medical Home TransforMed AAFP MGMA NCQA: PPC-PCMH program Patient-Center Primary Care Collaborative IBM Healthcare

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5. 5 Elements “Outside” the Medical Home Access to Care and Information Accessible patient and lab information Online patient services Electronic Visits Practice-Based Services Prevention screening and services Ancillary therapeutic and support services

6. 6 Elements “Outside” the Medical Home Care Management Population management Chronic disease management Patient engagement Care Coordination Community-based resources Collaborative relationships Care Transition

7. 7 Elements “Outside” the Medical Home Quality and Safety Evidence-based best practices Medication management Regulatory compliance Health Information Technology Electronic orders and reporting E-prescribing Evidence-based decision support

8. 8 Summary: Elements “Outside” the Medical Home Of the Fifty (50) bullet points... Seventeen (34%) require outside information and resources Of the Eight (8) Core Elements... Six (75%) require the export or import of information from outside the medical home

9. 9 The isolated PCMH It’s only running on 2 of 8 cylinders! It strips away the power of the PCMH.

10. 10 The isolated PCMH Limited E-Rx Limited Data Access Limited Communication Limited Coordination of Care Limited EBM Resources Limited Communication

11. 11 The Connected PCMH PCMH Specialty Practices Hospital Emergency Services Patients Pharmacies

12. 12 “Interoperability” HIE RHIO NHIN EHR HL-7 PHR CCHIT CCR / CCD

13. 13 Interoperability Definitions HIE RHIO NHIN EHR PHR CCHIT HL-7 CCR / CCD - health information exchange - regional health information organization - National Health Information Network - personal health record (patients) - electronic health record (providers) - Certification Commission for Health IT - continuity of care record / document - health language 7: interoperability

14. 14 How to Connect... Federated Data Model decentralized request/retrieve of information “virtual” chart Centralized Databank single database Health Record Banking (PHR) centralized record storage lifetime record patient-dependent Health Information Exchange (no database)

15. 15 Built upon the Health record Data Bank Model under ASP-based vendor 501c4 organization with a Not-for-Profit Community governing Board Interoperable PHR for patients Health IT adoption support for providers through local medical society Cost is shared by patients, providers, sponsoring employers, and healthcare institutions Healthy Ocala The Greater Ocala Health Information Trust, Inc.

16. Online interoperable PHR Physician portal Healthcare System EHR E-Prescribing Health IT Services Secure Messaging Radiology Laboratory Rehab Centers Emergency Dept Health Risk Assessment Medical Library My Health Files Medication Manager Healthy Ocala

17. 17 Significant social and political capital necessary to achieve success Must inherently foster the patient- provider relationship Medical and non-medical community stakeholder involvement The system must provide “benefit” to its users It must be cost-effective Challenges of PCM-Community 17

18. 18 Local HIE and RHIO efforts Local medical societies, provider groups, hospitals ARRA and HITECH Stimulus Opportunities CMS Health IT adoption - must satisfy ‘Meaningful Use” Regional Extension Centers - education for providers about EHR adoption State-level HIE grants Workforce grants How to achieve “connectedness”