October 26, 2011

The journey to becoming a patient-centered medical home

By: Gregory Kiray, MD

At Indiana University Medical Group, we started our Cerner journey about six years ago. We started with PowerChart Office and moved to the Millennium Enhanced View. As of 2011, we have Cerner solutions fully implemented in our eight offices in Indianapolis, and we’re really proud to have eight sites that have achieved level 3 Medical Home certification from the National Committee for Quality Assurance.

A Patient-Centered Medical Home is an approach to providing comprehensive primary care. It facilitates partnerships between individuals as patients and their personal providers while providing better access to health care and increasing satisfaction. A medical home is a sophisticated primary care practice where technology is utilized with services to enhance the doctor-patient relationship and bring additional teammates into the care of patients. We actively work to improve the flow of information in the physician office setting, reaching outside of the usual patient/physician visits using technology to enhance the well-being of our patients.

Before becoming a medical home:

We did not track critical labs and referrals
Our physicians served as the sole provider of most primary care delivery with little interaction with other team members
We rarely knew when patients were hospitalized or discharged
We waited for patients to contact us for their care needs

As a medical home:

We measure and report numerous quality measures, including performing above the 90^th percentile nationally, and have received NCQA Diabetes Program Recognition for our diabetes care
We utilize a team-based approach including using Disease Managers to assist with education and medication management for patients with diabetes, hyperlipidemia, asthma, anticoagulation and other conditions
We track critical labs and referrals
We empower our MA’s and nursing staff to utilize standing orders to improve performance in preventative care such as immunizations
We proactively call patients to follow up after a hospital discharge or ER visit and schedule appropriate follow-up appointments within five business days
We use a disease registry to track patients who have gaps in their preventative care or are outside of goals for the management of their chronic conditions and proactively reach out to them to close these gaps
We offer advanced electronic communications including availability of a HIPAA-compliant web portal for patients to request appointments, ask questions, request medication refills and receive their test results
We extend appropriate routine/urgent care and clinical advice outside of usual 8-5 office hours
We proactively reach out to high risk managed care patients to provide additional support to them in an effort to prevent hospital admissions and readmissions

We have not been alone in our medical home journey; it has been a partnership between our physician practices, our Indiana University Health hospital system and Cerner. This partnership has allowed us to put in place Cerner’s sophisticated IT backbone that enables us to reach out beyond patient visits to really improve the quality of care we provide to our patients.

Patients enjoy the fact that our staff contacts them when they are released from the hospital. One of our nurses makes a personal call and says, “Dr. Kiray knows you were in the hospital and he’d like to see you for a follow up." The nurses also do a complete medication reconciliation during these calls to make sure everyone is clear on the patient care plan and medications after the transition from the inpatient and outpatient setting. Our patients appreciate this proactive contact by our primary care office where as in the past, we often wouldn’t know that one of our patients had been in the hospital.

Medical homes are about the management of populations through the use of quality reporting and patient registry tools. As a medical home office, we reach out and proactively contact patients to benefit the care – we do not sit around and wait passively for them to show up in our office. Through the initiative to achieve NCQA Medical Home certification, we have maximized the performance level of all practice staff by allowing them to work at the top level of their training, thus increasing patient satisfaction and our quality measures across our system.

Gregory Kiray, MD, is a general internal medicine physician and chief medical officer at Indiana University Medical Group in Indianapolis, Ind. Dr. Kiray is also an associate professor of clinical medicine at Indiana University.