Patient-centered medical homes need better IT tools

To serve patient-centered medical homes (PCMHs), health IT needs to evolve from digitized patient record repositories into interoperable electronic collaboration platforms to further care coordination, according to research published in the Journal of the American Medical Informatics Association.

In interviews with 28 people involved in three PCMHs, the researchers found that the individuals developed workarounds to make up for the functionality that their IT systems lack.

A basic need identified in the study includes monitoring tools that manage panels of patients and allow PCMHs to risk-stratify patients based on multiple types of data--clinical and claims--to identify and track those most in need of care coordination.

The study identified the need for effective tools in five areas: monitoring patient populations; notifying clinicians and other staff when specific patients move across care settings; collaboration among multiple providers; data extraction tools for reporting activities; and interoperability. To accomplish these tasks, many participants described using homegrown care coordination systems separate from electronic health records.

In their monitoring efforts, for example, participants described building data repositories and developing condition-based registries within those repositories. However, they also said they used homegrown tools built from Excel spreadsheets, Microsoft Access databases, and various paper forms, all of which present barriers in notifying care coordinators of a patient's status.

Participants described a need for health IT notification tools that visually communicate patient utilization patterns, which would allow PCMHs to perform more effective outreach.

They also described a need for dynamic electronic care plans that help teams of clinicians quickly get up to speed on a patient's status and set goals for that patient. They were undertaking this work themselves because neither their current EHR systems nor any other types of health IT supported this perceived need. Each individual interviewed expressed frustration with interoperability problems, as well. 

Results have been promising for organizations that have created PCMHs, according to a review of three separate studies published in Health Affairs, though progress varies by practice size. One of the barriers for small to medium-size practices was having electronic access to hospital records.

In addition, although EHRs can help clinicians coordinate patient care, the way they are currently designed doesn't support teamwork well, according to another study published in JAMIA. Researchers for the study also found that systems typically lacked care management and population health management functionalities, causing workers to create workarounds or use separate systems.

To learn more:
- here's the research