1. EHR Functionality and the Patient- Centered Medical Home: Charting a Course When Charting Isn't Enough Redwood Health Information Collaborative - Webinar Series January 21, 2009

2. Jason M. Mitchell, M.D. Assistant Director AAFP - Center for Health IT Leawood, KS

3. Slide 3 AAFP - Center for Health IT Established: October 2003 Mission: To assist family physicians in acquiring and using EHR systems and other HIT that are affordable and standards-based, for the purposes of improving quality, enhancing safety and increasing efficiency in clinical practice www.centerforhit.org Steven E. Waldren, MD Director Jason M. Mitchell, MD Assistant Director David C. Kibbe, MD Senior Advisor

4. Slide 4 Objectives for this session: Understand the origins and key components of the patient-centered medical home (PCMH). Understand the central role of information technology as a tool to enable the PCMH. Highlight the core functionalities that electronic health record (EHR) systems must bring into the ambulatory practice.

5. Slide 5 EHR Adoption Paradigm *Rand Health. The Diffusion and Value of Healthcare Information Technology. 2005. Family Physicians All Physicians Rand Study*: 2016 before 80%+ physician adoption Innovators Early adopters Early majority Late adopters

6. Slide 6 Building Success in Your Practice Health IT Change Management, Process Redesign Leadership, Management, Teamwork Financial Stability

7. Slide 7 Jumping Ahead... Value Based Payment Consumer Directed Quality Reporting Connected Patients Volume Based Payment Health Plan Directed Claim Data Reporting Online Patients Current Health Care Sector Future Health Care System

8. Slide 8 Medical Home Definition AAFP Board of Directors - 2008 "A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a personal physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience and optimal health throughout their lifetimes."

9. Slide 9 Technology Hype Curve ? ? ? ? Where is EHR? Where is the PCMH? Source: Gartner Consulting

10. Slide 10 Origins of the Medical Home "Wherever the child is cared for, the question should be asked, ‘Where is the child’s medical home?’ and any pertinent information should be transmitted to that place" - AAP, 1967 Crossing the Quality Chasm: A New Health System for the 21st Century (the Chasm Report). IOM, 2001 Future of Family Medicine Project, 2002-2004

11. Slide 11 “Chasm Report”(2001) Six Aims Ten Rules Safe Effective Patient-Centered Timely Efficient Equitable Care based on continuous healing relationships Care is customized for patient needs and values Patient is source of control Knowledge is shared and information flows freely Decision making is evidence-based Safety is a system property Transparency is necessary Needs are anticipated Waste is continuously decreased Cooperation among clinicians is a priority

12. Slide 12 Characteristics of the New Model of Family Medicine (2004) Personal medical home Patient-centered care Team approach Elimination of barriers to access Redesigned offices Whole-person orientation Care provided within a community context Emphasis on quality and safety Enhanced practice finance Commitment to provide family medicine’s basket of services AND...

13. Slide 13 Characteristics of the New Model of Family Medicine (2004) Advanced information systems "A standardized electronic health record, adapted to the specific needs of family physicians and the patients they serve, will constitute the central nervous system of the New Model practice."

14. Slide 14 HIT Expectations of the New Model Integration of information from multiple, diverse sources into a single system to support the comprehensive information needs of primary care Based on common health information technology standards Up-to-date and accurate problem and medication lists and information about each patient encounter Export functionality to share standardized data elements for quality parameters and assessment measures Evidence-based clinical practice guidelines Order entryReferral tracking Disease and population based registriesIntegration of clinical and practice management functions Web interface for patients to provide clinical data and facilitate self-care processes (1 of 2)

15. Slide 15 HIT Expectations of the New Model Support practice based research concerning costs, processes and outcomes of care Clinical decision support systems for application of the latest evidence at the point of care Collection, analysis and reporting of clinical decisions and their outcomes Informatics infrastructure to support practice-based research, quality improvement and generation of new knowledge Easy integration in the daily practice of family physicians Reasonable cost Major enhancement to the efficiency and quality of care that is delivered User friendly Flexible Stable and reliable Delivered with appropriate training for physicians with varying levels of technical expertise (2 of 2)

16. Slide 16 "Required" features of an ambulatory care EHR system Harvard “Expert Panel” (NEJM article - 7/3/2008) “Basic EHR” - 15% Patient demographics, problem list, medication list and clinical notes Prescription ordering View lab and radiology results “Fully functional EHR” - 6% Notes include medical history and follow-up Lab and radiology orders are created and sent electronically Prescriptions are created and sent electronically Digital images of ordered radiology tests can be viewed Drug interactions or contraindications Abnormal test results are flagged Reminders for guideline based interventions or screenings (No mention of registry or data analysis functions)

17. Slide 17 "Required" features of an ambulatory care EHR system Patient-Centered Medical Home An "EHR system" isn't just a "system" but a "system of systems” Identity management system - (EMPI) Communication/messaging system - (eVisits) Schedule/resource management system - (Workflow optimization) Medication management system - (eRx) Care coordination/integration system - (Referrals/Consultations/Results) Advanced data analysis and visualization system - (Registries) Diagnostic ordering and results management system - (Lab/Xray) Advanced data capture and documentation system - (Notes) Patient education system - (not crumpled, dated handouts) Practice web portal - (patient self-service) Point of care clinical decision support system - (Evidence-based) Point of care financial decision support system - (Efficiency/Value) Practice administration/management system - (Integrated)

18. Slide 18 "Required" features of an ambulatory care EHR system Patient-Centered Medical Home "Infrastructure" Tools Semantic Interoperability Not just the ability to view others "documents", but to incorporate and understand clinical data from other sources into your own system Primary Care Data Model (Ontology) Defining and organizing the "nouns" and "verbs" of family medicine and their relationships System design and dependencies Workflow analysis and management tools

19. Slide 19 NCQA PPC-PCMH Recognition Nine Standards PPC 1: Access and Communication PPC 2: Patient Tracking and Registry Functions PPC 3: Care Management PPC 4: Patient Self-Management Support PPC 5: Electronic Prescribing PPC 6: Test Tracking PPC 7: Referral Tracking PPC 8: Performance Reporting and Improvement PPC 9: Advanced Electronic Communications http://www.ncqa.org/tabid/629/Default.aspx#http://www.ncqa.org/tabid/629/Default.aspx#pcmh

20. Slide 20 NCQA PPC-PCMH Recognition Without an EHR / Electronic registry / e-Prescribing “Level 1” PPC-PCMH may be possible “Level 2” and “Level 3” will not be achievable without full- featured, well-implemented, and optimally-utilized HIT systems

21. Slide 21 Conclusions Semantic Interoperability remains the IT (clinical?) priority It’s just so darn hard Quality and Safety are the "hallmarks" of the Medical Home It's not the paper that kills, it's the process An "electronic" version of the "paper chart" won't cut it It’s about “data” not “documents” EHR = “central nervous system of the New Model practice” Won’t get above NCQA “Level 1” without it Do current “EHR”s represent the needed “system of systems”? (1 of 2)

22. Slide 22 Conclusions EHR for Family Physicians No longer a matter of "IF" but "When" and "What" Most implementation failures are not due to the technology "Sociotechnical" factors Plan for organizational and user process issues No reports of problems due to "over" training This is not a “one time”, “big bang” process Ongoing adaptation and updates Annual updates are not an "option" but a "necessity" Choose carefully, Implement wisely, Use optimally (2 of 2)

23. Questions? - Comments! www.centerforhit.org Jason M. Mitchell, M.D. jmitchell@aafp.org (800) 274-2237 x 4102