Nice writing, Joe. You raise questions that medical home advocates, who have much that is sensible to say, need to deal with forthrightly. It's probably time for hard thinking around several potential sticking points. Before too much more time passes, I see two shoes (hmmm, how many legs do we have here?) that will have to drop:

(1) What's the real deal being offered to payers? Professional medical associations representing primary care practitioners are the chief proponents of the medical home idea. They know no extra fees will be forthcoming without a bargain being struck, but what exactly are they putting on the table, other than an offer to make a good-faith attempt to tackle the care coordination problem if -- if -- someone will pay them to do so? I've read the advocates' statements of principles with respect and anticipation. What I find, at least so far, is a general promise to use unspecified health information technologies in care coordination. Other than this, there is a void -- no mention, for example, of having PCPs adopt electronic medical records, which will be needed if care is to be managed in the modern era. To your point, before any bargains can be struck, I suspect payers will want to have the professional associations make much more explicit commitments to minimum care coordination capabilities and competencies.

(2) What does all this mean for specialists? Are the would-be keepers of the medical home proposing a zero sum game? Pay us a fee, and we will reduce inappropriate use -- our call on what that may be -- by, you know, them. The harsh fact is, something very much akin to this may be needed if healthcare is to remain financially solvent. But, as in the omission of specifics around connected health tools, when does the discussion of tradeoffs get real, and when does work towards striking a viable bargain begin?

Still, hey, the discussion has to start somewhere. Advocates of the medical home are doing just that. But soon the discussion will have to get harder....

Could anyone tell me of an "all in one", web based portal, designed for family caregivers of the elderly, that currently exists which accomplished the following:
1. remote video surveillance
2. Web cam
3. Geo fencing
4. Data graphing of daily readings for blood glucose, weight, and BP, etc.

Please advise. I can be reached at triplemcr@aol.com

regards,

Chris Ratcliffe

Hi Joe

This was an interesting read as always!
I think the right concept is the "connected medical home" as you suggest.
As I reviewed some of the referenced documents you identified, it seemed to me that the name "Medical Home" is misleading and confusing. This seems to present a model that is more oriented toward providing community focused medical services (a "Medical Community"). In addition, it presents a business model for physicians to more easily provide services and be compensated within a community. It has nothing to do with the "Home" so why do they use that term? When I read "Medical Home", I immediately envisioned a patient's home connected to a network such that their primary care physician and the support organization that physician has set up is available to provide healthcare services. Ideally there will be intelligent devices in the home to assist the primary care physician to accurately diagnose a condition and remotely prescribe treatment. Perhaps the government should subsidize this approach whereas the patient does not have to travel to the physician's office thereby burning fuel and further polluting our environment.

Glad you are driving so many great initiatives in this space via The Center for ConnectedHealth!

Regards, Paul

The trajectories of connected health and the advanced medical home are no doubt on a collision course. The vision of the medical home is touted by multiple professional groups (i.e. ACP, AAFP, AAP), CMS, and even some insurance companies as the path forward in dealing with a fragmented and inefficient system. There is no argument that making this transformation to this new model will require nothing short of an overhaul of the key components of health services delivery (ala Donabedian): Structure, Processes, and Outcomes.

To further this discussion, its worth taking a closer look at how various professional organizations, government entities and payers have already begun to take steps in reaching that goal.

CMS - Medicare (Division B, Section 204 of the Tax Relief and Health Care Act of 2006). This 3 year project aims to introduce reimbursement and incentive payments to physicians, and evaluate the value of “targeted, accessible, continuous, and coordinated, family-centered care to high need populations.”

In terms of the financial obstacles, David Glendinning notes in his report in American Medical News, a publication of the AMA, (www.ama-assn.org/amednews/2008/06/02/gvl10602.htm)

“If Medicare's upcoming medical home demonstration project heeds the advice of a respected AMA-convened panel, primary care physicians participating in the project could receive a variety of additional payments, including a monthly per-beneficiary fee. The increased compensation could total as much as $100,000 per year— depending on the degree to which participating practices have adopted the Medical Home concept.”

North Carolina’s Medicaid program shows improved quality and cost outcomes after adopting several components of the Medical Home in their Community Care of North Carolina (CCNC) program. Estimates are that it has saved the state $195 to $215 million in 2003 and between $230 and $260 million in 2004.


The American Academy of Family Physicians launched TransforMED (www.transformed.com) in 2006 as part of a national demonstration project focusing on helping selected physicians redesign their practices following the Medical Home concept. More accurately, this initiative is guided by the New Model of care proposed in the Future of Family Medicine report of 2004 that builds on the medical home concept but includes specifics about adoption of technologies such as EMRs. This June will mark the end of this project, which followed 36 Family Medicine Practices of various sizes across the country in their efforts to transform their practices. No doubt, interesting lessons learned will further this discussion and identify “real world” challenges.

Capital District Physicians' Health Plan in Albany has chosen TransforMED for a $1M pilot project to transform primary practices into medical homes. The pilot will introduce a new compensation model that pays doctors for all they do— including phone calls and paperwork.

The National Committee for Quality Assurance (NCQA) has has an initiative called Physician Practice Connection, (www.ncqa.org/tabid/631/Default.aspx)

This program recognizes practices that effectively use health information technologies and systematic. “physicians that change their processes and structures to pass recognition standards will be well on their way to accomplishing many of the principles desired in a Patient-Centered Medical Home.”

With this evidence that providers and payers are seemingly on the same page, its fair to say that connected health technologies can facilitate the adoption of the medical home model of care and the more distal goal of improved clinical outcomes and economic efficiency.

My previous posting was meant to demonstrate how the concept of the medical home has already gained traction among multiple players in the health care marketplace. As Paul Dattoli points out, the name is somewhat confusing, but its origins are decades old. Its aim is simply to have a place where patients know they can go to first when they have health concerns, and that they have a receptive "family" of providers ready to support their medical needs. Perhaps a more timely analogy would be the 'Home Page" of a website.

While in theory the integration of health IT is recognized as important in these position papers and pilot projects, there are few to no details about what technologies beyond the EMR should be considered. In addition, there is a strong emphasis on the management of chronic disease. I see this an inevitable opportunity to inform, educate, and engage the leadership of these initiatives about the value of remote patient monitoring and the vision of connected health. It seems a natural next step to me.

Chris,

Here's a start-up I came across on Tech crunch offering a remote monitoring service to check in with elderly parents. What would be nice is to combine this capability with Health Advocates who coordinate care efforts with concerned daughters and sons of elderly parents.

http://www.techcrunch.com/2008/01/07/keeping-an-eye-on-grandma-over-the-internet/

Regards,
Geof