Healthcare Analytics, Population Health Management, Healthcare Big Data

Population Health News

How the Patient-Centered Medical Home, MU Offer Mutual Support

By Jennifer Bresnick

- “Competing initiatives” is the phrase most often used to describe why many healthcare providers seem stuck in the health IT dark ages, unable to overcome financial and organizational obstacles, but not all care delivery reforms have to butt heads.

patient-centered medical home

The patient-centered medical home model, which promotes data-driven care coordination, attention to detail, streamlined population health management, and a culture of doing what’s best for the patient, can help providers develop the skills to play nicely with other major industry reforms such as meaningful use and accountable care.

Stage 2 meaningful use is currently changing the healthcare landscape with its focus on patient engagement and quality reporting, and Stage 3 is set to follow with even more demanding targets for care coordination, clinical analytics, and population health.  As funding drains from the EHR Incentive Programs and penalties loom in the near future, healthcare organizations must master a new set of core competencies – many of which are also prominent features of the patient-centered medical home.

In this chapter of our practice transformation series, explains how meaningful use and the patient-centered medical home intertwine to bring improved care quality, coordination, and health IT reliance to providers who are fighting for revenue, productivity, and better outcomes on all fronts.

How can the PCMH model support providers as they conquer Stage 2 meaningful use while preparing them for the future of value-based reimbursement, patient engagement, and data-driven population health management that will become the hallmarks of Stage 3?

READ MORE: NCQA Revamps Patient-Centered Medical Home to Ease Adoption

Increasing patient engagement and communication

Meeting the Stage 2 patient engagement threshold of 5 percent has been a major challenge for healthcare providers, many of whom have been alarmed by the five-fold increase of the target in the proposal for Stage 3.  Successfully coaxing patients to log in to a patient portal to view, download, or transmit their information can be a battle for providers who deal with populations that may be elderly, don’t speak English as a first language, don’t have regular access to reliable internet, or don’t see a reason to participate.

However, providers who structure their patient engagement programs around the larger principles of the patient-centered medical home may not have as much trouble attaining these goals.   Where meaningful use primarily focuses on how providers interact with their EHRs, the PCMH is geared towards improving how providers interact with their patients.  By combining technology with best practices, healthcare organizations can boost engagement and avoid some of the financial and clinical pitfalls of an indifferent population.

Patients who do not maintain regular contact with the healthcare system aren’t just leaving providers in the lurch during their Stage 2 attestation periods.  They are more likely to drop their health insurance, less likely to meet their financial responsibilities, and are less likely to maintain appropriate medication adherence for chronic disease management.

By developing a patient-centric care team that both stresses the importance of maintaining personalized contact and managing that patient’s journey across all points on the care continuum, a PCMH provider gives patients some tangible reasons to stay in touch.  It is much easier to get a patient to engage when they directly accrue the benefits, such as making it easier to book appointments and refill prescriptions through a patient portal, providing access to messaging with nurses or care managers, and viewing test results from their specialists and primary care providers all in one place.

READ MORE: CMS Picks Care Coordination Hubs for Accountable Health Program

Aiding population health management reporting

Population health management is a major part of both meaningful use and the PCMH, and the two programs can once again complement each other by pairing health information exchange and reporting capabilities with a way to make effective use of clinical quality reporting to improve patient care.

wordleBoth the PCMH and the latter two stages of the EHR Incentive Programs require a degree of reporting on patients and their activities.  PCMH providers may select immunization data as the basis for sending patient reminders; Stage 2 meaningful use providers must be able to report that data to their local registries.  Meaningful use requires eligible providers to use certified EHR technology to identify and provide patient-specific educational resources for ten percent of patients; the PCMH requires the same for at least fifty percent.

These overlapping requirements highlight the importance of clinical analytics capabilities that allow for patient stratification, a key foundational element for proactive population health management.  They also clearly illustrate how the patient-centered medical home can help providers go above and beyond the basics of success in the EHR Incentive Programs while gathering necessary data to feed the Stage 3 Common Clinical Data Set (CCDS), which promises to be an important part of the burgeoning big data analytics scene.

Focusing on care coordination and health information exchange

READ MORE: Big Data Analytics Link Economic Wellness to Population Health

The patient-centered medical home is all about care coordination, and so is Stage 3 of meaningful use.  Health information exchange and EHR interoperability will be tested during the 2018 transition to the last phase of the EHR Incentive Programs, but PCMH providers may be able to get a jump on those workflows right now.

Not only does the patient-centered medical home framework require clinicians to document the self-care capacities of at least half of their vulnerable patients, but they must also actively provide tools, instructions, caregiver education, and resources for patients who need ongoing support at home. Much like meaningful use, the PCMH model also asks providers to use electronic health information exchange to manage patient referrals and follow-ups with specialists or other providers, including the transmission of problem lists, medication and allergy lists, and test results.

The summary of care document should already be familiar to Stage 2 attesters, and it will make another appearance during Stage 3.  The last stage of meaningful use will demand the ability for providers to integrate the document, which includes the aforementioned data elements, into their electronic health record.  Providers must perform medication reconciliation, update the problem list, and ensure that allergies are accurately represented in order to meet the care coordination measure.

With PCMH-style care teams and patient navigators in place to support the development and deployment of these coordination techniques, the eventual leap to Stage 3 could be significantly less burdensome for primary care providers.

Laying the foundation for value-based reimbursement

Neither meaningful use nor the patient-centered medical home function in isolation, and both hope to position healthcare providers to take advantage of yet another major shift in the delivery of quality care: value-based reimbursement that places outcomes, patient satisfaction, clinical quality, and financial accountability at the center of innovative payment structures.

While the fate of the accountable care schema laid out in the Sustainable Growth Rate fix may still be up in the air, there is no question that lawmakers, CMS, and private industry are all pushing heavily for a total overhaul of how providers are paid for their work.  As the EHR Incentive Programs raise health IT proficiency levels and the patient-centered medical home equips providers with the workflows and strategies to manage populations in an effective way, the healthcare industry is slowly but steadily gathering the tools it needs to make accountable care a reality.

Next week, in the final installment of’s practice transformation series, we will explore how the patient-centered medical home can expand that sense of accountability into the community by forging meaningful partnerships with resources and organizations that are critical for managing the whole experience of the patient, from the waiting room to the decisions he makes outside the office walls.


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