Team-based coordinated care is a foundational piece of the patient-centered medical home (PCMH) model, and, when coupled with the use of an electronic health record (EHR) system, primary care physicians have the best opportunity to improve the quality of care they offer to their patients.
FP Eugene Heslin, M.D., relies on health information technology and coordinated team-based care to ensure his patients receive quality care.
That's the key finding from new research titled "The Patient-Centered Medical Home, Electronic Health Records, and Quality of Care,"(annals.org) published this week in the Annals of Internal Medicine.
"We found that primary care physicians participating in patient-centered medical homes improved their quality of care over time at a significantly higher rate than their non-PCMH peers," said lead author Lisa Kern, M.D., in an interview with AAFP News.
The AAFP has long supported family physicians' implementation of EHRs and their transition to the PCMH model of care, recognizing that health information technology plays a major role in making that transformation successfully.
An internal medicine physician, Kern is an associate professor of health care policy and research at Weill Cornell Medical College in New York, N.Y. She expressed some surprise at a second key finding.
- New research shows that organizational changes associated with the patient-centered medical home (PCMH) combined with use of an electronic health record (EHR) can boost the quality of care delivered in primary care practices of all sizes.
- Researchers found that the odds of overall quality improvement in PCMH practices with an EHR were 7 percent higher than in paper-based practices and 6 percent higher than in non-PCMH practices with an EHR.
- Specifically, improvement was seen in four of 10 quality measures chosen by six participating health plans.
"We found that EHRs alone were not necessarily sufficient for quality improvement. The PCMH model of primary care combines EHRs with organizational changes, including changes in the roles and responsibilities of clinicians and staff," said Kern. "It was the combination of EHRs plus organizational changes that was associated with the greatest quality improvement," she added.
Study Details Demonstrate Improvement
The study, conducted from 2008-2010, encompassed seven counties north of New York City in an area known as the Hudson Valley. A total of 675 primary care physicians -- defined as internists, family physicians and pediatricians -- and a total of 143,489 patients from 312 practices were part of the study.
Researchers assessed 10 quality measures selected by six participating health plans and divided the practices into three study groups -- PCMH practices that used an EHR (PCMH group), non-PCMH practices that used only paper records (paper group) and non-PCMH practices that used EHRs (EHR group).
Authors found that the odds of overall quality improvement in the PCMH group were 7 percent higher than in the paper group and 6 percent higher than in the EHR group.
Specifically, the PCMH study group improved significantly more than either the paper group or the EHR group for four of the 10 measures. Those measures were eye exams and hemoglobin A1c testing for patients with diabetes, chlamydia screening, and colorectal cancer screening.
Although the study cited no reasons why the PCMH was associated with quality improvement for some measures but not others, authors of a related editorial(annals.org) titled "Is There Value in Medical Home Implementation Beyond the Electronic Health Record?" suggested that such inconsistencies were neither unexpected nor uncommon.
"While teams focus attention in one area, performance in other areas can often stagnate or, worse, may decline as limited resources are diverted to other areas," wrote the authors. "Teams require strategies to hold the gains in one area while improving in others until long-term improvement in most areas is achieved."
Family Physician Projects Optimism
Eugene Heslin, M.D., of Saugerties, N.Y., told AAFP News that his small family medicine practice was "privileged to be part of the PCMH-EHR study group."
His now four-physician practice actually had five family physicians on board during most of the project and received initial Level 3 PCMH recognition from the National Committee for Quality Assurance in 2008, a feat it repeated in 2011 and was working toward in 2014.
Heslin said that although he had hoped the study results would positively reflect the power of the PCMH model, the researchers' findings couldn't have made him happier.
"To be able show to show as much as a 7 percent change from a PCMH model to the other two study groups that were using paper records or just an EHR, that's pretty big," said Heslin. "When we (physicians) talk about bending cost curves, we're pretty happy with a 2 percent or 3 percent improvement.
"This is a big ship we're turning here in the Hudson Valley, and we're doing it in a disaggregated market," said Heslin. He noted that the study included practices the size of his own, large multispecialty groups supporting 200-plus physicians, some federally qualified health centers and even "single-shingle docs."
"We're talking about true cross-sectional primary care as opposed to conducting (the usual) PCMH research in an integrated delivery network," said Heslin.
The study, funded by the Commonwealth Fund and the New York State Health Department, was intended, in part, to serve as an evaluation of ongoing work known as the Hudson Valley Initiative(www.hudsonvalleyinitiative.com) that is transforming health care delivery in the region through the combined use of health information technology, practice transformation and value-based purchasing.
That initiative is facilitated by three groups, including the Taconic Health Information Network and Community,(www.thincrhio.org) a nonprofit coalition-building organization.
"In the Hudson Valley, we had this disaggregated market with practices competing with one another, and yet we laid down our swords and said, 'To improve quality, we can all figure out how to work together and use our collective wisdom,'" Heslin said.
More to Study Moving Forward
Kern stressed that it was critically important that researchers continue to measure the effects new models of health care delivery have on patients.
"Health care is changing very rapidly in the United States, and we cannot assume that changes to health care delivery will have the intended effects," she said, adding that a follow-up study designed to determine effects over a longer period of time was in progress.
As for Heslin, his work within a PCMH practice, his expertise with EHRs and the latest study results have all strengthened his resolve to continue the hard work of process improvement.
"What the PCMH is doing, really, is teaching us how to do things in a process format. It doesn't take away from my creativity, but it adds to my ability keep track and build out all the pieces that I can't do otherwise.
"So I still make decisions; I still practice as a physician, but I have a whole infrastructure underneath me now that's organized," said Heslin.
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