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As health care moves rapidly toward a value-based delivery model, a greater emphasis will be placed on care coordination. We must ensure that patients not only get the right care at the right time in the right setting, but also that every part of the delivery system is connected and understands that a patient's need will be critical going forward. Information technology will be instrumental in making sure that these connections take place and in providing clinicians with valuable new decision support tools.

H&HN, with the support of AT&T, has created this yearlong series called Connecting the Continuum to explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans. Each month, we will examine such topics as health information exchange, mobile health and transitions of care. Follow the Connecting the Continuum series in our magazine and in our e-newletter H&HN Daily.

Organizing for the team-oriented tenets of a patient-centered medical home involves a whole lot more sophistication than is typically found in primary care physician practices, especially when it comes to health information technology. That’s because much of IT at the primary care level is built for that traditional practice.

Electronic health records are “focused on delivering good care to the patient in front of you,” says David Bates, M.D., longtime expert on the role of IT in patient safety and quality. Things like a highly functional problem list and good prescribing tools are available to help manage patients, and doctors can get at needed patient documentation in those electronic records, he says. “But most of the records are a long way from doing a really good job of all the things that someone might need in a medical home.”

Others go so far as to say that the current generation of EHRs isn’t capable of enabling medical home operations, which require close relationships, patient visits in groups, keeping tabs on them at home, and tying together teams of physicians, medical assistants and health coaches. “Typical electronic health records don’t even know those [activities] exist,” says Rushika Fernandopulle, M.D., CEO of Iora Health, which designs and operates clinics for intensive management of chronically ill people. The company is building an IT system from scratch to suit its very different needs, he says.

Still, some entrepreneurial thinking has enabled providers to tap into the existing EHRs as they’ve built successful medical home models.

The Hudson Valley Medical Home project in New York, for instance, involves six health plans and 15 practices within Taconic IPA that piloted a model with teams of clinicians systematically managing their sickest patients using registries, information sharing and other communication aids supplied by their IT systems.

Outcomes are still being analyzed for publication, but the group actually ended the pilot early and expanded it to the entire independent practice association because clinical indicators clearly were improving faster than those outside the pilot, says Annette Watson, Taconic senior vice president.

A key capability is the ability of all team members to access and use the same records at any time, says Susan Stuard, executive director of Taconic Health Information Network and Community. That enables them to do pre-visit planning or phone consultations, marshal all available information to the visit itself, and allow physicians, nurse managers and various others to enter information into the chart afterward, all the while keeping in communication with one another, she says. The information then “can contribute to clinical decision support, and the follow-up that’s necessary for closed-loop referrals and for quality indicators.”

Decision support delivers a lot of the value of EHRs, especially for the medical home, but most include very little in the way of a base set of rules for such support, says Bates, medical director of clinical and quality analysis, information systems, at Partners HealthCare System in Boston.

Vendors say the means are there to build anything an ambulatory group wants, “but the harsh reality is that it takes a lot of time and effort to build good rules, and even if you could build good rules with most of the vendor products that are out there, it’s not practical to ask people to do that,” he says.

Providers should be looking for a good set of alerts and reminders around preventive care, especially diabetes and coronary disease, which have “quite a lot of well-specified guidelines” for proactive treatment, says Bates. Also important for practices is a set of aids for picking the right doses of medication depending on patient condition, including adjustments for level of kidney function, which Bates says is rare of EHRs in ambulatory settings.

But considering how far EHR adoption has come in less than a decade, the “relatively primitive” design modeled on a paper chart is still good enough for the present, says Jeff Hummel, M.D., medical director for health informatics at QualisHealth, a Seattle-based consulting firm. Up to now the biggest priority was “to get the medical profession to start using computers and start putting clinical information into those computers as structured data.”

The process of gradually escalating the level of meaningful use of EHRs required of providers and IT vendors is aimed at ultimately producing the information-usage capabilities of computers that higher-function care models such as medical homes will require, he says.


A medical home isn’t just the result of adding components and sophistication to a PC practice. It’s transformational change. “Health IT is a necessary but insufficient component of that,” says Hummel. “You probably can’t do it without a really good health IT system, and using it properly. But if all you’ve got is the health IT and you think that now it’s going to be like stepping off a log, it’s not. There are a lot of ways to do it wrong, and a lot of ways health IT done wrong can be very disruptive.”

QualisHealth and the Sandy MacColl Institute combined to conceptualize the building blocks of a medical home starting with leadership that needs to understand the structural and cultural changes needed, and moving on to a quality-improvement strategy that also manages costs. After ensuring that every patient is assigned to a provider, the next step is to create population profiles that determine how best to build teams.

A panel with a high percentage of geriatric patients with cognitive impairment will call for a different mix on the team compared with one that’s largely young, or young but with a high HIV burden. With well-defined personnel, the individualized content needs for each team member can be built into IT reporting, he says.


Armed with sufficient health IT and a sense of what ails a patient panel, medical-home practices can take initiative in ways they wouldn’t or couldn’t do before, says Annette Watson of Taconic IPA. Activities such as nutrition counseling, exercise education and other interventions that may not need one-on-one visits are suddenly able to be provided in an efficient, targeted way.

One pediatric practice in the Taconic pilot program found value in organizing a group on managing obesity in children, she says. EHR tools lifted out cases of children with a high body mass index for their age. The practice brought in experts on nutrition and exercise, facilitated by a registered nurse who was the primary, familiar contact with parents and their children.

Medical-home team members also can look at patients with more than one risk; for example, a diabetic with uncontrolled blood-sugar level plus high blood-cholesterol levels and poorly controlled blood pressure, says Watson. “Being able to use the EHR proactively through some of the new and improving functionality — the registries and other reporting tools — has really been part of the process.”

IT capabilities required for medical home

1 | Clinical decision support: Systems that aim to improve decision-making around diagnosis, treatment, prevention and disease management. They make predictions, transmit routine care reminders and e-prescribe medication.

2 | Registries: Applications that define patients with specific conditions and identify disease status. Some also facilitate disease management.

3 | Team care: Communication tools that allow practices to record goals shared by providers and patients, and to track medical interventions and progress.

4 | Care transitions: Communication tools that automatically compare medication lists and other treatment aspects that can change from one care setting to another.

5 | Personal health records: Electronic source of patients’ health information that can be used by a patient or proxy to help manage illness and become more engaged in improving health.

6 | Telehealth: Technologies allowing providers to check in with moderately to severely ill patients at a distance to assess vital signs and symptoms, or to regularly monitor patients with stable chronic conditions to prevent worsening.

7 | Measurement: Ability to determine performance in areas such as preventive screenings and immunizations, treatment goals met for chronic diseases, and cost of care being delivered.

Source: David Bates and Asaf Bitton, “The Future of Health Information Technology in the Patient-Centered Medical Home,” Health Affairs, 2010.