Healthcare building blocks


The overarching premise for this plan is a belief that Advanced Primary Care (APC), defined as an augmented patient-centered medical home (PCMH) that provides patients with timely, well-organized and integrated care and enhanced access to teams of providers, is the foundation for a high-performing health system.
— New York State Health Innovation Plan, December 2013

There’s nothing equivocal about the direction of New York State’s healthcare planning. Its performance goals and the time frames for achieving them are blunt and specific: This is what we’re going to do year by year for the next five years and these are what the measurable results will be.

In five years four out of every five New Yorkers will be delivered defined health services at a predetermined price and quality (instead of fee for services), the plan says. Four out of five New Yorkers will be receiving augmented primary care. And consumers and purchasers will have all the information they need to make informed marketplace choices among healthcare plans.


“Medical homes have been shown to substantially improve access to needed care, receipt of routine preventive screenings, and management of chronic conditions, and to reduce or eliminate racial and ethnic disparities,” said the state plan promulgated last December. “New York State is proposing a far-reaching set of initiatives that are intended to support and create a more rational, patient-centered care system that is able to provide care that promotes health and well-being for all.”

Certainly sounds like a done deal, doesn’t it?

A more skeptical tone is found in an article in the Annals of Internal Medicine, an American College of Physicians publication. Given the state’s commitment to patient-centered medical homes (PCMH), one might think this huge study involving 312 medical practices covering 143,489 patients in the Hudson Valley conducted by researcher Lisa Kern and colleagues, sponsored by the state health department and the Commonwealth Fund, and published this month, might have drawn resounding conclusions supporting PCMHs.

But “Is There Value in Medical Home Implementation Beyond the Electronic Health Record?” strikes a more cautious wait-and-see note. It came up with the universal researchers’ recommendation: more research is needed.

Rather than identifying specific areas of improvement, editors Drs. Robert Reid and Michael Parchman wrote in an editorial that the study of the payoff from quality improvement efforts needed to be broadened. “Implementing the PCMH is an opportunity to take a unified approach to quality improvement,” the Annals editors wrote, in adopting “an approach that has the potential to yield more benefits than electronic health records [EHR] implementation alone.”

Low expectations can make even negative results can seem like success. It was remarkable in many respects to see quality improvements after only a single year, the editors wrote. One might have expected such a profound cultural change to have caused a decline in patient-care improvement, they said.

Paper vs. electronic
The study divided the patient population into three practice groups: those with traditional paper records, those with electronic health records that were not PCMHs, and those with EHRs that were PCMHs. They then identified ten highly recommended quality measures. How was the Hudson Valley doing?

The practices in the two categories that had electronic health records performed substantially better in terms of the quality measures than those that had paper records. And those practices with electronic records which went on to become PCMHs achieved better performance on the measures than those that didn’t, “suggesting that the PCMH had an additive effect on quality improvements over the use of an EHR alone.”

The magnitude of that difference (PCMH versus non-PCMH) in one year was not substantial. That indicated to the editors not that PCMHs didn’t work but that other “practice attributes” such as a clear distribution of tasks among medical team members, improvement in clinical workflow and “routine use of EHR-derived improvement data in daily work” needed development. And that will take time.

The Hudson Valley data published in 2014 reflected the status of healthcare through 2010. The situation’s a lot different in 2014. One big difference is that the adoption of electronic health records by hospitals and medical practices has continued to progress. With the adoption rate of EHRs in the Hudson Valley now over 90 per cent, the study of a subpopulation of practices still using paper records is a historical project, not the subject matter of health research.

Another difference is that experience with medical homes has moved forward substantially. The National Committee for Quality Assurance has extended medical-home recognition to more than 500 Hudson Valley primary-care physicians.

So this is a good time to revisit the track record of medical home implementation in the Hudson Valley. Are we headed in the right direction? Will fresh data confirm or question the assumption of better health outcomes because of the adoption of the PCMH model by New York State?

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