Medical Home Identification

Introduction

This is a draft of the PCC White Paper: Medical Home Identification. This draft is a work in progress, not the official white paper.

Introduction

Chronic disease care delivery requires continuous coordination of the activities of multiple healthcare providers in multiple settings. A patient may see multiple specialist doctors and other clinicians on a recurrent basis along with a Primary Care Provider (PCP). Many patients have more than one chronic problem in additional to acute episodes. In the current, fragmented health care delivery system, each of a patient’s providers may be unaware of other providers that are treating the patient. Testing and therapies are often duplicated, resulting in unnecessary costs and risks to the health of the patient. Lack of coordination can also result in failure to follow-up on the delivery of ordered services, again adding risk to the patient’s health. In some cases, multiple providers receive copies of reports of services performed, such as laboratory tests, but this can cause confusion among providers over who is primarily responsible for addressing the results.

An emerging approach to coordination of health care delivery is intended to address these problems as well as providing additional benefits to the entire system. This approach is commonly called the Patient-Centered Medical Home (PCMH). In this approach, the patient selects a provider who serves as the patient’s medical home. This provider is responsible for keeping track of all of the care a patient is receiving from all of the clinicians with which the patient deals. This model is the very kernel of the activities which the IHE Patient Care Coordination Domain aspires to facilitate. Successful coordination of a patient’s health care can not be accomplished without IT support for the key workflow steps involved. The patient’s medical home will need the capability to track all of the patient’s providers and all of their care activities. The medical home will also have to serve as a communications hub among all of the patient’s providers, ensuring that each is aware of relevant actions by others. Finally, each provider of care to the patient will need the capability of automatically informing the medical home of actions involving the patient.

The interoperability requirements of patient care workflow can be thought of as support for a conversation between two or more clinicians at each step. What is needed is a simple nomenclature for the workflow steps, to serve as triggers, and specification of the payloads and communication methods that are appropriate for the steps. It is assumed that, for most steps, copying and forwarding of existing messages and documents, with appropriate “covers” will be sufficient.

The workflow for exchange of information between providers needs to address:

• Ordering
• Scheduling
• Communications between Providers
• Task Lists
• Reporting

Glossary

Term

Definition

Issue Log

Open Issues

1. Issue
2. Issue

Stakeholders

• Patients
• Primary care clinicians
• Specialists
• Quality measurement organizations
• Payers/employers

Use Cases

Current environment

1. Patient visits his Primary Care Provider (PCP) for a health issue. (Note: It is conceivable that patient comes in for a preventive visit and a reason for consultation is discovered.)
2. PCP evaluates the health issue, and makes a determination that the patient needs to be referred to a specialist.
3. Patient and PCP decide on a specialist based upon their preferences, insurance restrictions, etc.
4. PCP writes an order, or creates a referral letter to give to the specialist. (Note: There may be standardized referral forms from the payer or state (i.e., Maryland has a Universal Referral Form); in some cases, the referral is given to the patient, in others faxed to the specialist; if the patient schedules the visit, then he/she would need the referral)
5. Patient contacts the specialist for an appointment. (Note: Again, could be patient, office, physician (especially for an urgent/emergent referral))
6. Patient visits specialist, fills out form indicating problems, meds, allergies, reason for visit, insurance information, et cetera.
7. Front desk enters information into Specialist EHR.
8. Specialist reviews patient details, and interviews patient.
9. Specialist contacts PCP for more detail.
10. PCP faxes copy of details to specialist. (Note: Some of this information can be transmitted verbally; other information might come from lab or hospital…)
11. Specialist orders follow-up treatment with another healthcare provider.
12. Patient contacts the follow-up provider for an appointment.
13. Patient visits follow-up provider, fills out form indicating problems, meds, allergies, reason for visit, insurance information, et cetera.
14. Front desk enters information into follow-up provider EHR.
15. Patient receives treatment from follow-up provider.
16. At next visit to primary care provider, PCP asks patient for an update on referral.

Future scenario

"I am ordering something that I can’t do myself, and I what to know what happens . . ."

1. Primary Care Provider (PCP) sends order for consult and summary report to Specialist 1.
2. Specialist 1 requests additional information from PCP.
3. PCP responds with additional information.
4. Specialist 1 orders tests.
5. Specialist 1 receives results and forwards them to PCP with update note.
6. Specialist 1 sends order for consult and summary report to Specialist 2.
7. Specialist 1 sends summary report and note to PCP.
8. Specialist 2 requests additional information from Specialist 1.
9. Specialist 1 responds with additional information.
10. Specialist 2 sends report to Specialist 1.
11. Specialist 1 sends copy of report and note to PCP.

Actors/Transaction

File:At.jpg

{{{1}}} Actor Diagram

{{{1}}} Actors and Transactions

Actor	Transaction	Opt.	Section
Actor 1	Transaction 1	R	#Transaction 1

Options

{{{1}}} Options

Actor	Option	Section
Actor 1	Option 1	#Option 1

Option 1

A description of option 1.

Process Flow

{{{1}}} Process Flow

More text about process flow

Actor Definitions

Actor

Definition

Transaction Definitions

Transaction

Definition

Volume II

Transaction 1

Use Case Roles

[[image:ucr.jpr|frame|center]

Actor

Actor 1

Role

Role of Actor 1

lather, rise and repeat for each actor

Referenced Standards

STD

Description

Interaction Diagram

File:Int.jpg