American College of Physicians: Internal Medicine — Doctors for Adults ®

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Turning the advanced medical home vision into everyday reality

From the September ACP Observer, copyright 2006 by the American College of Physicians.

By Lynne M. Kirk, FACP

I walked into my office this morning and opened the electronic medical record (EMR). More than 100 of my diabetic patients had transmitted their blood glucose measurements during the previous 24 hours. I forwarded this to the diabetic nurse clinician who then adjusted therapy for those who were not within the optimal range based on a protocol that my four-internist group had developed. I quickly reviewed these orders and added my approval. The dietician will e-mail the recommended changes to the patients. Similar information was available for hypertensive patients monitoring their blood pressures, anticoagulation patients monitoring their INRs at home, and congestive heart failure patients monitoring their daily weights. I reviewed and approved these also.

I moved to my schedule for the day. Two patients had made appointments online in the slots I keep open for acute problems. The remainder was scheduled visits for follow-up of chronic medical problems.

My first patient had self scheduled the previous afternoon. He had a sore throat and was concerned that he had bacterial pharyngitis. When he had made his appointment, the EMR had prompted him to enter his chief complaint and several symptoms. Based on these he had met the criteria (based on the EMR's evidence-based clinical decision support tool) for an office visit and a rapid strep screen. This information was available to me when I saw him, thus facilitating the appropriate use of antibiotics. In addition to the patients with acute or chronic problems that I saw, the nurse practitioner did health maintenance, and chronic and acute care visits for several other patients.

I must admit, what I’ve described above is not exactly how my practice operates today, but is more what I would like it to be. Like you, I am frustrated because I don't have the resources and support for the care I provide to my increasingly aging patient population. Our reimbursement system, which only pays for episodic care, just doesn't work for physicians who have to coordinate much more than just office visits for patients with multiple chronic diseases.

To improve this dysfunctional payment system, ACP earlier this year proposed the "The advanced medical home: A Patient-Centered, Physician-Guided Model of Health Care," (read the paper online) and is now taking significant steps to test the model.

This model builds upon the pediatricians' 30-year-old medical home concept to identify a practice where a child, especially one with chronic disease, receives primary care and coordination of care. The American Academy of Family Physicians has also advocated for a reimbursement system that recognizes the importance continuous, comprehensive care.

For the advanced medical home model to work, according to ACP, the following needs to occur:

  • Physicians need to partner with patients to manage and coordinate what has been fragmented care. Payers would need to acknowledge and support that these efforts occur outside of the visit.

  • Primary care physicians need resources to help them use health information technology to coordinate patients' care and share information with other providers. The technology also would help schedule needed health care in a timely fashion.

  • Physicians need to use computerized, evidence-based clinical decision guidelines at the point of care.

  • Physicians need to use e-mail and telephone consults to give patients non-urgent medical advice.

  • Third-party financing, reimbursement, coding and coverage policies need to change to support advanced medical home practices.

As always with new concepts such as the advanced medical home, the challenge is to take something that makes so much sense on paper and turn it into reality. The College is trying to meet this challenge in a variety of ways, including:

  • The Center for Practice Innovation works with 34 small practices across the country to understand the challenges they face in moving toward the advanced medical home model.

  • Closing the Gap, the College's practice-based, team-oriented quality improvement program, that helps doctors, nurses another other office staff improve care of patients with chronic diseases.

  • The College is helping to guide demonstration projects, such as Medicare's Health Support Program, that test advanced medical home concepts.

When I read about the advanced medical home, I thought, “That’s how I would like to practice.”

And making the model a reality is not out of reach. In fact, most of us incorporate many of these concepts into our practices despite our current system's barriers. There is evidence in the literature that if we can help our patients better control their chronic diseases we can decrease the frequency—and associated costs—of the life-altering complications of those diseases.

Fortunately, internists are problem solvers. Our current dysfunctional health care system is a big problem that needs to be solved for our profession and especially for our patients. Let’s get to work on the details.

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