The patient-centered medical home will require a shift from scheduled, discrete patient encounters focused on a chief complaint to a continuous, open-ended relationship that addresses the whole patient. This shift will require the physician in charge of the medical home to be more acutely aware of all issues impacting the patient’s condition, including issues that may require a specialist. This burden will be shared to some extent by patients who will have increased responsibility for their own health, including accurate communications and compliance with physician orders.
Even in the traditional office visit, the physician may not fully investigate an important nuance of the patient’s presenting condition. The medical home concept sharpens this risk because the appropriate investigation is no longer based solely on a specific presenting complaint, but should address the whole patient over the course of the relationship. Thus, an issue not on the physician’s radar screen can become significant with the benefit of hindsight, and the physician is accused of not appropriately addressing the issue when it first arose.
A specific example of this risk is the primary care physician’s enhanced role with respect to specialist referrals. One of the goals of the medical home is to centralize the flow of the patient’s healthcare through the primary care physician. As such, the primary care physician will have increased responsibility for identifying issues in the patient’s condition that require the expertise of a specialist whom, but for the medical home, the patient would have sought out directly. Couple this duty with another goal of the medical home, cost containment, and the primary care physician may be responsible not only for identifying these issues, but also addressing them.
These risks can be offset to some degree by the increased involvement of the patient, another hallmark of the medical home. Patients will have increased responsibility especially given their access and ability to contribute to the medical record. Thus, the onus will be on patients to raise issues that are affecting them, accurately report these issues and to follow up if they are not being addressed to their satisfaction.
In approaching the management of this new risk landscape, it is critical that the EHR be used as more than a tool for obtaining and organizing data. Instead, the EHR should:
- Connect the dots of the patient’s health care picture as defined by the physician’s medical judgment and clearly explain the decision making process;
- Have the capability to link various elements of the record so the physician can pull prior examinations, labs and imaging together into a single narrative that sets out and explains the plan of care;
- Have flexible clinical decision support tools to allow variation based on the patient’s condition;
- Identify the source of data, i.e., patient, and integrate information from specialists outside the home; and
- Support communication with patients through explanations, disclosures and acknowledgments so as to require participation and create a clear record of the patient’s understanding and acceptance of their role in their own care.