HealthData Management - January 2013

survey and fax it back, where it lands in
Volpe’s record.

“It’s information gathering and pro-
cessing,” Volpe says. “The worst thing is
if a patient comes in and I don’t know any-
thing about the surgery coming up. How can
I do a pre-op evaluation if I don’t know what
will happen? If I don’t, we might have to tell
the patient to come back another time, and
they have to deal with baby-sitting and park-
ing all over again.”
Some practices seeking that higher level
of data exchange are looking beyond the
fax. Legacy Health, a Portland, Ore.-based
delivery system of six hospitals, is look-
ing to build a private health information
exchange, says CIO John Kenagy. Legacy
has adopted the medical home model in
18 primary care clinics spanning about 65
physicians. They use an integrated ambu-
latory/inpatient/ED EHR, from Epic. And
the hospital can exchange data with other
providers in the area also on Epic, through
the vendor’s proprietary exchange service.
“That’s done easily,” Kenagy attests.
But many referrals go elsewhere, and
to connect with those practices, Kenagy is
building a private exchange, using software
from Certify Data. The exchange will serve
purposes beyond the medical home, with
most initial use for handing inbound lab
orders from the community. But in time,
the medical home physicians could use the
set-up to move continuity of care records
back and forth between specialists.

The third leg

The EHR and data exchange are two
legs of the medical home stool; quality
reporting is the third. Reporting capa-
bilities are a must for NCQA recognition
and beyond that, many payers tie report
production to whatever reimbursement
incentives they offer.
Spangler, the practice manager at Fam-
ily Medical Associates, runs a number of
reports directly from the group’s EHR,
from Greenway Medical Technologies.
The group runs reports to see which pa-
tients are overdue for visits. “We have a
large diabetic population,” she says. “If the
patient has not been seen for six months,
and their A1C is high, we can generate a
report with their contact information and
call or send a letter,” she says.

Tickling patients

The group also uses the EHR’s built-in
“tickler” capability to track patients. If a pa-
tient is sent for an outside lab, the staff en-
ters a request for an electronic reminder to
follow-up and make sure the lab was done,
Spangler adds.
As an added lure to patients, the prac-
tice has expanded its service lines, now
offering its own lab, bone density testing,
allergy services, dietary counseling and a
weight loss clinic. It’s also hiring a psycho-
therapist to join its physicians, physician
assistants and nurse practitioners. “You
need a practice team” to make the medical
home work, Spangler says.
That very notion of a “practice team” is
what makes the medical home so distinct
from conventional primary care. Many who
have embraced the model say it requires
everyone in the group practice to play new
roles. And as Volpe notes, the requirements
can be demanding. At his solo practice, he
is propped up by “ 1. 8 to 2. 1 FTEs,” includ-
ing his wife, a nurse who works two days a
week. “Everyone in the practice does ev-
erything,” he says. “The medical assistant
doubles as office manager. She takes vital
signs, records chief complaints, helps with
pre-authorizations, attends meetings, and
reaches out to patients via e-mail or snail
mail. Another medical assistant is cross-
trained as a billing person.”
Medical homes also create a new role
for physicians, who must yield a certain
amount of autonomy and responsibility
in exchange for delivering better care and
having more face-time with patients. “In
the medical home, the care shifts from
having the physicians being the center of
focus to the patient,” says Moss, the Da-
vies winner. “It shifts from the physician
being the sole person to interact with the
patient to a team. Now patients meet with
the pharmacist and the nurse care man-
ager. The medical assistant who used to
put people in the room is now helping
reconcile meds.”
This new role for physicians is just one
of the many challenges facing practices
which embrace the model. Physician
adoption of the EHR—and the new work-
flows—can be a sticking point. And EHR
limitations can hinder the effort as well.
Then there are practical matters of cost
and dealing with the bevy of organiza-
tions outside the medical home.

EHR ambivalence

One part of upstate New York is attempt-
ing to meet those challenges head-on.
The Adirondack Region Medical Home
Pilot Program launched in 2009, driven by
state grant funds aimed at increasing EHR
adoption and boosting clinical outcomes.
More than 200 physicians in 31 indepen-
dent primary care practices are participat-
ing, says Pam Minichiello, project director
at the Massachusetts eHealth Collaborative,
a consulting firm enlisted to help drive EHR
adoption. The effort has already reached
some milestones, not the least of which is
meeting NCQA requirements. “The grant
required practices to achieve Level II and 29
practices got to Level III,” she says.
The practices had all adopted EHRs—from
nine different vendors—before the effort,
but with varying degrees of optimization,
Minichiello recalls. “Some were still setting
up templates,” she says. Changing physician
attitudes about proper documentation was
a challenge. “Many used structured docu-
mentation but only minimally, and were
also doing dictation. Others had no lab inter-
face. They were not used to quality metrics.
Getting all that in place and increasing their
utilization was the hardest part.”
In addition, working with EHR ven-

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