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What about the 'Medical Home'? Looking at IBM's vision for Patient Centered Medical Care

Recently I sat next to a neurologist on a flight who complained to me about a vexing problem. Elderly patients with dementia would arrive at her office to have their medications adjusted, but would bring no documentation of what they were already taking. Often the patient arrived from an Assisted Living or nursing home facility -- their excuse? Carrying the paperwork in the van was a violation of the patient's privacy.

I thought of this when reading about IBM's vision for the 'Patient-centered medical home.'  The key aspects of the IBM vision, shared with many other organizations, are described by the firm in a document called "Patient-centered medical home -- What, why and how?' -- to be published next week by IBM's Healthcare and Life Sciences practice.

To learn more from one of the authors, we spoke with Jim Adams, Executive Director of the IBM Center for Healthcare Management.  Jim serves on various national healthcare committees and on the advisory boards for healthcare organizations.  IBM's involvement emerged out of its own frustration with the ever poorer quality and ballooning cost of healthcare.  The gist of the 'medical home' concept:

Empower the Primary Care Physician (PCP).  The world of primary care is in serious jeopardy -- frustrated doctors and medical students are shunning the field and a national shortage is worsening.  The essential principle of the medical home concept is to significantly strengthen the primary care physician's ability to manage all care for patients, shoring the role up with higher quality information shared across the breadth of stakeholders in the healthcare ecosystem -- extending into the home and including the patient and family.

Provide pro-active, collaborative, coordinated care. As we all know, today's fragmented and non-communicative healthcare system requires us to coordinate our own care -- or do without it  -- including prevention, wellness, acute, chronic, and long-term care. Such care can be provided with or without visits to the physician's office. Medical home strategies include enhancing linkage of enhanced electronic medical records with 'robust' decision support capabilities. Jim noted: "Every part of the health care system is broken, but where should you start? Primary care is the most broken."

Fix the reimbursement model.  If incident-based care is replaced with a PCP-led care delivery team working 'at the top of their licenses', the reimbursement model needs an overhaul. According to the report, primary care doctors make half of what specialists make and 41% of primary care workload is not reimbursed in the current fee-for-service model. Says Jim: "We must change the reimbursement model from relying on face-to-face interactions to bundling payment for pre, post, and hospitalized care."

Deliver care in the context of family and community. The medical home concept includes a number of powerful and resonating principles -- including patient-centric and personal PCP care, whole person orientation, coordinated and integrated care, emphasis on quality and safety, and enhanced access.  No one can argue with these concepts -- certainly those who are being pushed out of the health care system by job loss or those who have become more and more cynical about the quality and cost of care and insurance premiums.

Empower patients with information and engage them in care.  Key to the concept of the 'medical home' is enabling PCPs and their patients to access portals, schedule appointments online, participate in e-visits, and be guided with health and wellness preventive advice or chronic disease management.

Powerful strategy includes vendors and partners aplenty. The concepts and solutions described in IBM's vision document (and slide presentation) are comprehensive -- striking in how well new processes and architectures are thought through, how thoroughly the stakeholders are described, and the step-by-step approaches for engaging regional healthcare systems in assessing their current status and beginning to overhaul their practices. IBM is partnered with vendors like Quantum, Google and university programs from schools like the University of Oklahoma, as well as insurance companies like Aetna and United Healthcare.

Specialists are at the root of the problem for seniors. So what's it mean? Certainly if the PCP role is upgraded as IBM describes, then their role as paper-based traffic router to specialists is replaced by a new, more comprehensive management role that hopefully improves communication with specialists like the neurologist above.  But once into the Medicare system and faced with chronic conditions -- seniors see many specialists (or as Jim dryly noted, "also known as partialists"), receive many prescriptions, with laborious and clumsy feedback loops and record keeping.

But is the PCP the right hub or another information spoke? As I read the document, I do wonder if things are too far gone, entirely too fragmented to put the primary care doctor at the center of the information sharing and process improvement efforts. With so many people lacking PCPs, and so many PCPs lacking infrastructure and incentives -- perhaps the better cornerstone for change is take a look at other edge participants in the chain.

Why not the pharmacy? Assuming seniors fill all of their prescriptions in one nearby pharmacy, for example, doesn't that seem like an obvious platform that is central to the process of care -- like CVS clearly believes. Link prescription information into and out of a PHR, accessed at point of prescription and augmented with new prescriptions and check-ins with kiosks of diagnostic devices in the pharmacy. Of course, pharmacies may not want the liability associated with this role -- but as in any supply chain, assigning the hub role is often based on frequency and information quality -- not desire.

Next up -- the home care agency or facility. The closer to the senior, the better the information. If it is feasible to share information with a PCP, then the home care, home health, and senior housing organizations should win this tug-of-war.  Staffs are on the ground and in the home -- now checking in with an elderly Medicare senior, what about this worker touching a screen of some type to update information? When combined with the prescription-filling trip, who knows -- maybe that is as close as we can come to a complete picture.

Your thoughts are welcome.

p.s.See June 26, 2009 Business Week article about Medical Home, saving the healthcare system with PCPs, and the role o IBM.





So here is a member of Information Technology (HIT) policy committee, Charles Kennedy, who is in an influential position to help shape the future course of an American health care system that is out of control and seriously in need of a fix. “There is this problem of exchanging information,” Kennedy said. “Ideally, what we want to have happen is that all the doctors know what they are doing, and act together in a coordinated team effort to give the best care. What we know is that most of these entities are not sharing data in any kind of meaningful way.”

So this is like the shipping and logistics supply chain a decade ago. No one knew where the ship was until it was in the dock. The only reason that ever changed -- to track goods along the route -- was because of obvious improvement to both efficiency and money for all players.

Why should doctors share data? PCP to specialists or to anyone else?  No motive, no incentive, no mandate.


As usual , they will spend more money to identify the problem than they will pay to fix it. In my own simple mind I would invert the plan to begin with the patient and what is known today and build on to that environment with all of the data bases that can check, recommend and identify issues that affect that patient. There still has to be an entry level from the patient that authorizes access to that data. Once again, we have a pile of information, it is just in a place where no one can use it. Compliance and HIPAA were not intoduced to stop treatment. They were introduced to protect our right to privacy.

From a recent speech and follow-up Q&A.




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