Effort connects medical homes with 'essential' IT tools

While the patient-centered medical home has been touted as the foundation for a better coordinated and more efficient healthcare system, experts now say medical home practices need to be connected to other parts of the healthcare system. To this end, the Patient-Centered Primary Care Collaborative has released a report listing 10 “essential” health information technology tools needed to make these population health connections.

“Health IT offers an essential infrastructure and solutions for population health management that can be adopted incrementally over time and help providers continue on a path of quality improvement and primary-care transformation,” Dr. David Nash, founding dean of Thomas Jefferson University's Jefferson School of Population Health and a member of the PCPCC report review committee, said in a news release.

The 10 essential population health IT tools identified by the PCPCC are:

• Electronic health records, to document diagnosis, vital signs and other data needed for advanced analytics;
• Patient registries, to serve as central databanks to identify care gaps and report quality measures;
• Health information exchange, to coordinate care and share data between care team members;
• Risk stratification, to classify patients by their current health status and identify who may need interventions to prevent hospitalization;
• Automated outreach, to generate automatic messages to patients who need preventive care or chronic disease management;
• Referral tracking, to ensure that providers receive results of consultations from specialists patients were referred to;
• Patient portals, to share records with patients and encourage self management;
• Telehealth/telemedicine, to allow remote examination and treatment;
• Remote patient monitoring, to track vital signs of patients with chronic conditions and to alert providers when intervention is needed; and
• Advanced population analytics, to evaluate how different segments of patient populations are faring and assess the performance of individual clinicians and provider organizations as a whole.

“Improving population health presents a major cultural, operational and financial shift across a broad range of stakeholders,” according to the report. “While our current system is designed to respond to the acute needs of individual patients, it must transition to one that anticipates and shapes patterns of care for populations, and addresses the environmental and social determinants of health.”

The report cites a 2011 study by HHS' Agency for Healthcare Research and Quality as evidence of why such tracking and communication tools are needed. According to the AHRQ study, only 62% of primary-care physicians report getting consultation results from specialists, even though 81% of specialist reports are sending them. Also, 69% of primary-care providers report sending patient histories to specialists, but only 35% of specialists report getting them.

The report is scheduled to be the focus of an Oct. 15 panel discussion at the PCPCC annual conference in Bethesda, Md.