This article presents a consensus statement about gaps in current electronic health record (EHR) functionality and needed enhancements to support primary care. Participating organizations are the American Academy of Family Physicians (AAFP), American Academy of Pediatrics, American Board of Family Medicine, and the North American Primary Care Research Group. NIAC member Steven E Waldren of the AAFP is among the authors.
Primary care attributes, established by The Institute of Medicine, were used to define needs and meaningful use (MU) objectives to define the functionality of the EHR. The authors indicate that current objectives “remain focused on disease rather than the whole person, ignoring factors such as personal risks, behaviors, family structure, and occupational and environmental influences.” They further state that “primary care needs EHRs to move beyond documentation to interpreting and tracking information over time, as well as patient-partnering activities, support for team-based care, population-management tools that deliver care, and reduced documentation burden.” The authors praise the stage 3 MU’s focus on outcomes, but contend that enhanced functionality is still needed. Among the things needed to accomplish this are:
- EHR modifications,
- expanded use of patient portals,
- seamless integration with external applications, and
- the advancement of national infrastructure and policies.
The important issue of patient-centered care is addressed, noting that an “understanding of the patient is critical to the establishment of long-term partnerships.” The consensus statement indicates that a patient profile should be available….in the EHR and that decision support tools should be tailored based on the factors therein. In addition, patients should be able to enter and edit their own information, which can improve accuracy and ease of data collection.
With regard to integration, clinicians need an effective EHR to serve as “the information backbone across all primary care attributes.” In addition, population-management tools are needed at the practice level. Because information and patient needs vary between providers, EHRs should allow “local tailoring of functionality and content while maintaining standardization.”
Additional information on this important consensus statement published by the Journal of the Medical Informatics Association may be found at: http://www.ncbi.nlm.nih.gov/pubmed/24431335 .
Tracking measurable outcomes within integrated primary care is essential to develop effective systems. However, health care organizations are slow to establish these new procedures and systems given a lack of existing evidence-based measures. In a 2012 white paper, the Institute for Healthcare Improvement (IHI) proposed a menu of measures, their targeted outcomes within health care settings, and the health care organizations that use these instruments. Under the broader framework of The Triple Aim, a widely known U.S. healthcare goal plan first disseminated in 2008, the IHI initiative described the measures and systems that reduce health care costs while improving patient satisfaction and outcomes.
IHI worked with more than 100 partners in the Triple Aim Prototyping Initiative to test the Triple Aim framework in the U.S .and internationally from 2007-2012. As outlined in this paper, population health, patients’ experience of care, and per capita cost are being successfully measured by a number of organizations that participated in the initiative. Several of these progressive sites include HealthPartners of Minnesota, Kaiser Permanente of California, Martin’s Point Health Care of Maine, and Bellin Health of Wisconsin.
Key measurement principles include:
- the need for a defined population;
- the need for data over time;
- the need to distinguish between outcome and process measurement, and between population and project measures; and
- the value of benchmark or comparison data.
Among the behavioral health factors tracked by these sites are smoking cessation, weight loss, and alcohol use. To more closely examine these methods and measures for adoption in your clinic, please visit this IHI resource.
San Mateo County’s public health system is now equipped to better treat substance abuse in all patients seen, thanks to Medical Director of Behavioral Health and Recovery Services Robert Paul Cabaj, M.D. “It was astonishing—the number of people in the public-health system with substance abuse issues,” Dr. Cabaj reported. “The vast majority of them were in primary care, and it was very clear that if physicians had some guidelines, they might better address the problems—but without them, they just stepped back and let someone else deal with it.”
Referral to outside substance abuse treatment, including 12-step programs, was previously physicians’ and psychiatrists’ go-to resource for these patients. However, San Mateo treatment guidelines, now empowers physicians in all health care settings to prescribe medications to treat substance abuse.
“MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. Medication assisted treatment (MAT) is clinically driven with a focus on individualized patient care.”
Putting these new increasingly popular guidelines into practice, which were developed for use by behavioral health and primary care providers, has also improved collaboration among providers, says Dr. Cabaj; thus, helping to bridge the fragmentation of mental health and physical health treatment. These changes have also contributed to reduced costs and improved patient care. “In addition to the reduction in emergency services,” states Dr. Cabaj, “we have also seen a decrease in the drinking days of participants, and many participants have been able to switch to less expensive oral medication over time.”
To learn more, read the original articles:
Additional information on medication assisted treatment can be found at:
A recent study reports one in five Michigan residents have been diagnosed at some time in their lives with depression: a higher rate than the national average (18%). “Economic stress, poor access to health care, unemployment, are all risk factors (for depression) and Michigan unfortunately is saddled with those burdens more than other states, so I wouldn’t be surprised that it’s at the higher tier among states (for depression),” said Dr. Gregory Dalack, chair of the University of Michigan Department of Psychiatry. Furthermore, fewer physicians are choosing to specialize in psychiatry, contributing to “a mismatch in demand and capacity,” stated Marianne Udow-Phillips, director of the Center for Healthcare Research and Transformation.
This has prompted more mental health consultation programs to better support health care providers, many employing telemedicine to reach more remote populations in need. Some of these programs are led by the University of Michigan such as the Michigan Child Collaborative Care program (MC3), which provides psychiatric consultations via teleconferencing, and another that places care coordinators in more underserved areas that connect local providers with on-call psychiatrists by phone. Telemedicine services, largely paid for by employers, also provide psychiatric consultation to a reported 10,000 Michigan patients. This growth in consultation need is not only due to the burgeoning number of patients that are being enrolled in the Affordable Care Act, but also the increasing severity of mental health presentations. “The patients are becoming more and more complex,” says Kim Michaels, a nurse practitioner with K-Town Youth Care in Kingsley, Michigan, “and it’s getting to the point where we need help.”
Since the 1990s, the Veteran’s Health Administration (VHA) has used telehealth to deliver consistent, organized and holistic primary and specialty care. Today, it is the biggest consumer of home telehealth technology in the world. Telehealth in the VHA “involves use of information and communications technologies to deliver medical care remotely by connecting multiple users in separate locations.” It incorporates “health informatics, disease management, and telehealth technologies” to promote access to care and positive health outcomes through, primarily, clinical videos, prerecorded information-sharing and “care coordination/home telehealth.”
In response to the increasing number of elderly veterans who use costly institutional care for their chronic health conditions, the VHA’s Office of Telehealth Services (OTS) developed the Care Coordination/HomeTelehealth (CCHT) program in 2003. The CCHT currently serves at least 70,000 veterans at 140 VHA medical centers and offers routine home care and case management for diabetes, congestive heart failure, hypertension, post-traumatic stress disorder, chronic obstructive pulmonary disease, and depression. It uses remote home monitoring devices that report health status and biometric data to remote care coordinators (i.e., usually nurses or social workers but also dieticians, occupational therapists, physicians, and pharmacists). Care coordinators work in synchrony with the patient’s clinician and make referrals to additional care services. The CCHT’s most commonly used technologies are messaging and monitoring devices to help patients assess their health status and record vital signs. It also uses video telemonitors and videophones to enable audio-video consultations within the home.
The CCHT program has produced many positive outcomes. In 2010, “veterans reported patient satisfaction levels greater than 85% for home telehealth services offered through CCHT.” The program is also correlated with a 25% decrease in (nursing home) bed days of care and a 20% reduction in hospital admissions, for patients receiving home telehealth for 6 months vs. pre-enrollment statistics. Additional successful outcomes are high patient acceptance of the program and reduced health resources utilization in highly rural and urban areas for mental health conditions and for patients with comorbidities. Costs per patient are also more favorable compared to the “VHA’s home-based primary care services” and “market nursing home care rates.” Moreover, CCHT fosters patient involvement and prevents hospital or emergency department visits.
The CCHT program attributes its successes to streamlining of its program practices; technical assets (e.g., the electronic health record); staff and increased training; a strong case for large-scale change; support for and shared decision-making among leaders and personnel across the whole system; and consistent efforts to achieve team-based, patient-centered, low-cost care. To sustain home telehealth, the VHA will have to overcome challenges with translating their practices into mainstream services, making the case for the economic impact of their services and adapting to ongoing changes in technology. Finally, home telehealth cannot be successful without integrated models of care that enhance sharing of information among providers, care coordination, the patient-centered medical home, and patient engagement.
Read our other recent story on telehealth: http://integrationacademy.ahrq.gov/node/5870
The United States healthcare system is in need of significant redesign and revitalizing primary care is among one of the top priorities of the Patient-Centered Primary Care Collaborative (PCPCC).This has been partially motivated by the rising healthcare costs that burden American employers. These employers have become “increasingly frustrated and tired of buying high-cost, frequently low-quality health care that is poorly coordinated.”
The PCPCC, which consists of wide variety of stakeholders including employers, physicians, patient and family advocacy groups, clinicians, and health care administrators, has made it its mission to build a stronger primary care by advocating for the patient-centered medical home. They achieve this through the work of five Stakeholder Centers and four special interests task forces including one for behavioral health.
Primary care providers also face challenges as they try to provide treatment for complex patients with multiple chronic illnesses with limited appointment time. Dr. David Nace, chair of the PCPCC Board of Directors, says “we need a new kind of primary care, built around the patient-centered medical home.”
Principles of the patient-centered medical home are:
- personal physician,
- physician-directed medical practice,
- whole-person orientation,
- coordinated and/or integrated care, and
- quality and safety.
Dr. Nace explains the importance of addressing behavioral health concerns in primary care and urges clinicians and psychiatrists to “get educated and engaged.” He describes how easy it is to participate in the PCPCC and take advantage of the networking and educational opportunities provided by the collaborative and the Behavioral Health Task force.
“We are in a remarkable period of transformation in American health care, and there will be winners and losers,” Nace said. “The winners will be people who step up and work with others. The transformation will happen locally and will be based on building relationships.”
Read more here: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleID=1838361&utm_source=Patient+Centered+Primary+Care+Collaborative+List&utm_campaign=a7f9c0abe3-Week_in_Review_Jan_241_24_2013&utm_medium=email&utm_term=0_56f71f22aa-a7f9c0abe3-250366413
The number of elderly persons with severe mental illness (i.e., schizophrenia, major recurrent depression, bipolar disorder) is increasing, thereby creating a need to better understand the health care needs of this group of patients. Dr. Hendrie from the Indiana University Center for Aging Research and his colleagues recently published research examining health care utilization, health outcomes, and cost of care among the elderly patients with severe mental illnesses.
Their findings indicate that these patients are a major burden for our health care system. One study found that compared to age-matched primary care patients, patients with severe mental illnesses had higher rates of health care utilization, greater frequency of falls, and increased rates of substance abuse and alcoholism. Likewise, a second study that looked at a sample of patients with schizophrenia showed they had higher rates of comorbid chronic illnesses as well as increased mortality risk, health care utilization and cost of care compared to those without schizophrenia. These studies both highlight the challenges faced when providing health care for these patients and suggests that integrated models of health care can help meet the needs of elderly patients and decrease the burden on the health care system.
In a mid-January 2014 blog post, NIAC member, Kavita Patel, MD, MSHS and colleague Jeffery Nadel indicated that current efforts to improve the cost and quality of health care are aptly focused on primary care. According to the 2010 National Ambulatory Medical Care Survey, 560 million or 55.5% of the almost 1.1 billion physician office visits every year are to a primary care physician. Under the Affordable Care Act (ACA), numbers will continue to increase. In addition, primary care is often the point of entry to the vast medical system and offers a setting in which patients develop trusting, long-lasting relationships with their primary care physicians (PCPs) and focus on wellness.
Fortunately, the ACA has encouraged the development of Accountable Care Organizations (ACOs) which offer innovative care delivery and payment models that promote the transformation of primary care. One such model is the Patient-Centered Medical Home (PCMH) which is expected “to be an impactful first step in reforming U.S. health care”. According to the four major primary care societies, joint principles of the PCMH include “personal physician care”; “physician-directed medical practice”; “whole person orientation”; “coordinated and/or integrated care”; “high quality and safety in care, enhanced access to care”; and “payment that supports enhanced services.” Although more studies are needed, current evidence suggests that PCMHs have positive effects on both patients and the larger health system. Among the positive outcomes attributed to the PCMH are reduced costs, decreased emergency room visits (probably due to “increased access to the practice in off-peak hours and increased availability of next-day appointments”) and fewer in hospital admissions. Another benefit is increased availability of next day appointments with PCPs.
Widespread adoption and sustainability of PCMHs will require a “transitioning away from fee-for-service reimbursement to new payment models (that) can properly align financial resources with (delivered services).” Currently, many of the core principles of PCMHs are poorly reimbursed or not reimbursed at all by Medicare and commercial payers. As a result, upfront and ongoing costs deter practices from using the PCMH model. New payment models such as per-member per-month payment, bundled or episodic payments, shared savings arrangements, and full or partial capitation are all possible solutions. Payment reform along with patient satisfaction improvement, team-based care delivery, and robust physician leadership can all foster accountable, person-centered care.
Read the related article: http://www.brookings.edu/blogs/up-front/posts/2014/01/16-future-patient-centered-accountable-care-patel?utm_source=Patient+Centered+Primary+Care+Collaborative+List&utm_campaign=8e63ff6156-Week_in_Review_Jan_241_24_2013&utm_medium=email&utm_term=0_56f71f22
Over 70 randomized, controlled studies suggest collaborative care—the collaboration among primary care providers, primary care-based behavioral health providers, case managers, and psychiatrists to better target and deliver mental health treatment—improves outcomes and service cost-effectiveness. The passing of the Affordable Care Act is thought to quicken its adoption to meet the increasing population need. The Accreditation Council for Graduate Medical Education (ACGME) is aware of this demand, but how are psychiatry training programs shifting their focus from inpatient and specialty care to foster the development of integral members of multi-disciplinary primary care teams? In July 2014 the following ACGME objectives for psychiatry residency curricula will go into effect: consultation skills to engage with primary care providers and other skills related to effectively integrating behavioral health into primary care.
As leaders in developing the collaborative care model, the University of Washington’s Advancing Integrated Mental Health Solutions (AIMS) Center has created such a curriculum for dissemination of the collaborative care model. Within only two sessions, psychiatry residents will learn these consultation skills, how to track outcomes using valid measures, and how to provide stepped care. Curricula to implement these skills within an integrated primary care rotation are also available, given the availability of this type of rotation at each training site. The role of psychiatry is changing and the AIMS approach provides an evidence-based, APA-supported, and direct method to equip the next generation to competently deliver collaborative care. With emerging structural changes in the health care delivery system, trainees need to be prepared to meet the new challenges so they can thrive as essential team members in integrated care models such as Accountable Care Organizations and the Patient Centered Medical Home.
Read the original article: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1827559
Although “integrating primary and behavioral health has been recognized as having significant potential to prevent behavioral health issues from becoming severe,” it is often difficult to achieve in rural areas where behavioral health providers are scarce. Fortunately, telehealth (or telemedicine)—described as “the use of medical information exchanged from one site to another via electronic communications to improve patients' health status”—can address this problem. According, to the Agency for Healthcare Research and Quality (AHRQ) Health IT Portfolio, telehealth is valuable “in regions where physician-to-patient ratios are inadequate or where there are not enough medical specialists available to meet the population’s needs.”
Larson et al. (2003) reveal several ways in which telehealth offers solutions to rural health care issues. First, telehealth can bridge the gap between rural and urban health care availability “by providing access to more health care services for rural residents.” Secondly, it can provide services virtually and allow urban health care professionals to serve rural patients. In addition, to attend to the “often older, sicker, and less educated” rural population, telehealth can offer geriatric care and education to rural patients and providers. It can also address problems with the “misdistribution of providers.” Finally, telehealth can bring specialty care to rural populations, particularly for Native Americans and other isolated communities.
Other benefits of telehealth include fewer medical errors, increased availability of clinical supervision, reduced travel time and costs for rural residents, and attention to “issues of privacy and stigma for patients and caregivers in rural communities.” Many studies have shown that telehealth specifically “(facilitates) collaborative care to patients without onsite specialists” by offering “direct intervention with the patient by a distant specialist,” “consultation between a primary care and behavioral health provider” and “education and training in diagnosis and care for behavioral health.” Additional ways in which telehealth is used includes “transmission of data or images for analysis, “remote monitoring (of patients by providers),” and “telepharmacy.”
Unfortunately, there exist many barriers to fully adopting telehealth. Some barriers specific to care coordination include “lack of reimbursement and/or incentives for providers,” “lack of training for primary care providers in assessing behavioral health”, poor treatment of behavioral health conditions, and lack of co-located behavioral health and primary care services. Patients and providers are reluctant to adopt collaborative behavioral health care due to “lack of understanding of the value of behavioral health care services,” “lack of technical support for collaboration,” concerns about practice workflow, additional time for new assessments, and poor and low “communication among primary and behavioral health care practitioners.” With training and education of providers, outreach to patients, collaboration between behavioral health and primary care providers, support for telehealth and Integration, online tools for collaborative care and operating manuals/guidelines, our rural population and overall health system can reap the benefits of telehealth and Integration.