The medical home concept is gaining traction fairly quickly. Essentially it is a clinical "home" where a patient's care would be coordinated by a primary care physician - and that physician would be paid for that coordination - thus aligning physician, health system and patient incentives leading to higher quality, lower cost care.
An interesting concept - but let's talk logistics - how many other physicians would a PCP have to interact and "coordinate" with in order to close the loop?
A recent Annals of Internal Medicine report attempts to answer that very question
Primary Care Physicians' Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination
They find that for every 100 Medicare patients a physician treats, the physician will interact with 99 in 53 different practices.
Seems to me the promise of medical homes can't be realized until there is sufficient technology diffusion throughout the system to ease the burden of care coordination. And that's just a necessary ingredient, but doesn't ensure success of the medical home concept. There's just no practical way that they typical primary care physician can manage that many relationships, transfers and analyses of complex medical information in a meaningful manner without technology. And even with the technology, unless they are paid enough, there won't be an incentive for the PCP to engage in medical home programs.
Sunday, March 1, 2009
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Rough drafts and swarm evolution
ReplyDeleteSree's point is excellent - for the medical home system to function well, and meaningfully realize higher quality, lower cost care - technology would have to facilitate communication between providers.
But it seems to me that the logistics of this are really not that much of a stretch from other vast, highly penetrant systems currently in existence- amely, the veterans' affairs VISTA CPRS medical record system, which is not sexy, but is highly functional. It could certainly be implemented in a rapid fashion, and serve as a rough draft for what will come in the future. Even this rough draft would likely realize a substantial savings for the system as a whole and improved clinical outcomes. Moreover, it has the added benefit that a majority of providers trained in the last decade have been exposed to it during their residencies.
Why not consider it as a starting point for the creating of health information architecture? I mean, you can' beat free, right? And integrated inpatient records, outpatient records, billing, imaging, and labs isn't too shabby, with universal information access, and tested security measures is a good jumping off point. To me, the idea of creating a new health care system de novo, and getting it right seems like a nearly undoable challenge.
Almost more important than the starting point is the mechanism of evolution built into the system. Swarm evolution, or allowing the user pool to edit and improve upon the status quo, has been a powerful force for optimizing user experience. The success of google labs' creations (Gmail anyone?)and wikipedia are just a few examples of this concept. Perhaps the best model for how to build evolution into the system is Apple's app store for the iPhone.
With a simple and versatile piece of hardware (the iPhone), and a set of designer tools to ensure consistency of user experience, the app store has allowed for an explosion of creativity, and the discovery of niche uses for the iphone that steve jobs would never have envisioned. With built in mechanisms for usage data, reviews and comments, the system engineers and architects will have realtime objective and subjective user data to help enact larger scale "firmware " updates.
With the momentum of the current administration and their commitment to improving health through an electronic health record system, I sincerely hope that the policy makers look at the technology models that have worked best for the past decade.
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