The patient-centered medical home concept has generated tremendous discussion during this dynamic period of proposed healthcare reform. Whether or not this model will finally take hold remains to be seen. It is clear, however, that a new paradigm in chronic disease management must occur. The combination of an aging population, increase in co-morbidity, and an emphasis on ambulatory management, places a heavy burden on technology to come to the rescue.
For those not familiar with the medical home model, it goes like this: a personal physician oversees a team that takes care of chronically ill patients at the practice level. Care is coordinated across the continuum (acute, subacute, ambulatory, long-term care, home care). Adherence to evidence based guidelines are the foundation for a payment model that may support $40-$51 per member per month, depending on illness severity and the physicians level of medical home designation.
The National Committee for Quality Assurance (NCQA) has emphasized the following:
- Access and communication
- Patient tracking and registry functions
- Care management
- Patient self-management support
- Electronic prescribing
- Test tracking
- Referral tracking
- Performance reporting and improvement
- Advanced electronic communications
Success of this crucial shift in healthcare delivery is incumbent on significant financial incentives.Clearly, the infrastructure and resources needed to accomplish the above tasks can seem formidable to primary care clinicians. The ability to automate much of this work can mean substantial dollars remaining in the hands of physicians.
Electronic data is only a small piece of the solution. Aggregation of disparate information is another small piece. Semantic normalization, however, is crucial for difficult burden of advanced analytics and disease-specific dashboards.
Most important, in my opinion, is the ability to monitor specific populations in real-time, using advanced and meaningful decision support coupled with appropriate messaging and alerts. Semantic interoperability is thus the cornerstone for the long-term success of the patient-centered medical home model.
