Medical Net Systems: Patient Centered Medical Home, Practice Management Software, EMR Software, Electronic Medical Records

Executive Summary: The Patient-Centered Medical Home (PC-MH) is a concept for the ideal medical practice of the future. The American Academy of Family Practice’s TransforMed program has reported that the technology to create the PC-MH framework is not ready and is fragmented. New solutions must be identified. Medical Net Systems EncounterSuite, an online integrated Electronic Medical Record (EMR) and Personal Health Record (PHR), provides a unified turnkey software framework for the PC-MH. This is accomplished through its integrated PHR/EMR, point of care wellness and disease management guidelines and best practices application, and three tracking modules, patient registries, Inbox (order tracking), and Tracking the Patient at Home module.

The American Academy of Family Practice’s (AAFP) Patient-Centered Medical Home (PC-MH) is a concept for the ideal practice of the future. The AAFP has sponsored an ongoing pilot study called TransforMed involving 30 practices in an effort to develop real world examples of the PC-MH. An interim report was not optimistic. “At present, it is clear that much of the vaunted technology is not ready for integrated use in primary care [. . .]” [1] In addition, rather than finding a unified solution, the study reported, “Currently the technology landscape for medical practices resembles a pile of different jigsaw puzzles all thrown together.” ^[2] Obviously a new unified solution must be found.

EncounterSuite [3] an online integrated Electronic Medical Record (EMR) and Personal Health Record (PHR) provides a unified turnkey software framework for the PC-MH. In this white paper we will describe how various EncounterSuite modules create the PC-MH framework. These modules include an integrated EMR/PHR, point of care wellness and disease management guidelines and best practices application, and tracking modules. The tracking modules are patient registries, Inbox (order tracking), and tracking the patient at home module.  

The EMR is the Keystone to the PC-MH Framework

Before discussing specific EncounterSuite modules that create the PC-MH Framework, a EMR should be easy to use and improve patient care. EncounterSuite has many such features.

• It’s Web-based. This minimizes a practice’s hardware and software requirements and support. Also a physician can access the EMR everywhere.
• The content is preloaded.
• Workload is transferred away from the physician.
  • Patient Generated Medical History (PGMH).
  • Prescription refills are pushed out to the staff.
• EncounterSuite has the look and feel of a paper chart.
• Adaptable physical exam. Systems can be added and removed to the patient’s physical on the fly.
• Treatment Favorites enable a complex series of orders to be entered with a couple clicks.
• The Assessment and Plan is a working problem list.

Integrated PHR/EMR and e-visits

EncounterSuite’s PHR is HIPAA compliant and stores Medical, Legal and Financial documents. The PHR is the patient portal to the practice.

In the integrated >EMR/PHR, the EMR and PHR share the same Past Medical History (PMH) and mutually update each other. This creates a real-time record that can be accessed and updated anywhere online. The PMH is comprehensive and complete.

When the physician signs an encounter for a patient, a copy of that encounter goes in the PHR chart. Similarly documents, messages, and labs entered into the EMR also go into the PHR chart. With this process the PHR becomes in essence the community health record for the patient.

Standalone PHRs require patients to complete and maintain them. This creates a vicious cycle of PHR attrition. Few patients make the effort to complete the PHR and fewer health care organizations ask about the PHR or try to incorporate the PHR into their medical record. Patients experiencing low PHR usage are less likely to maintain the PHR and the few PHRs that exist become out-of-date.

In contrast with the integrated PHR/EMR the PHR is automatically created and updated without patient input. Therefore a PHR derived from an integrated PHR/EMR is up-to-date and clinical relevant.

The integrated PHR/EMR enables the secure communication between the patient and the physician. This is used in EncounterSuite’s e-visit function. The patient uses the PGMH at home to document the e-visit complaint and the physician responds through EncounterSuite like any normal encounter. Since copies of signed patient encounters go into the patient’s PHR, the patient can access the physician’s response securely.

Point of Care Wellness/Disease Management Guidelines and Best Practices

The Guideline Wizard is a module embedded in the patient encounter. The Guideline Wizard displays guidelines for wellness (preventive testing and vaccinations) and disease management guidelines for that patient based on the patient’s demographics and medical problems.

The guidelines are derived from Michigan Quality Improvement Consortium (MQIC). Guidelines can be created, edited and inactivated. In each encounter if the patient has unmet wellness or disease management guidelines, the Guideline Wizard icon is yellow. An adjacent dashboard indicates the number of unmet wellness and disease management guidelines. Clicking on the icon opens a window listing all the guidelines for that patient. The data is color coded; yellow indicates unmet guidelines and white indicates completed guidelines. Each guideline shows the status of the last order related to the guideline.

For wellness and disease management guidelines, a physician can perform four actions. 

1. Not applicable. The physician indicates that the guideline should not be applied to this patient. The reason for the exclusion, the physician who made the annotation and a time-stamp are displayed in the guideline. The guideline is fulfilled.
2. Order now. The physician orders the test, vaccination, etc. suggested in the guideline.
3. Future order. The physician orders the test, vaccination, etc. suggested in the guideline for a future date. Future orders enable a physician to take an incidental patient visit and change it to a planned visit by scheduling in advance the labs, procedures, etc. required in the next planned visit.
4. Done already. The physician indicates that the patient has already completed the test and the guideline is fulfilled.

Orders are entered into the assessment and plan. When the physician signs the encounter, the orders go into the Inbox. The staff can then monitor their perspective Inbox to retrieve the orders and perform the actions required to complete them.

Diseases covered by disease management guidelines include diabetes, hypertension, congestive heart failure, coronary artery disease, and asthma. 

To insure that patients with specific diseases are on appropriate medications, disease management medication guidelines determine if the patient with a specific is taking the appropriate class of medication. An unmet guideline is fulfilled once the patient has been prescribed a medication from the suggested class.

Treatment favorites are macros that contain lists of orders. Clicking a treatment favorite inserts all of the predetermined orders into a problem located in the assessment and plan. The physician can continue to add and delete orders to customize the treatment for the individual patient. Best practices can be saved as a Treatment Favorite and applied in the appropriate patients.

Tracking Modules:  Patient Registries

Patient registries are the aggregation of all the guidelines for all the patients in the practice and are sorted by disease and by preventive medicine test. To fully understand a patient while reviewing the registry, a patient’s medications and chart can be assessed from the registry. Registry guidelines are displayed and processed in the same way as Guideline Wizard guidelines.

EncounterSuite’s online patient registries enable remote auditing, which more convenient and less expensive than on-site auditing. Audits using EncounterSuite’s online patient registries are fairer and more sophisticated for two reasons. First the status of the order is displayed so patient non-compliance is documented. Second patients, who have been excluded from certain guidelines, are displayed as such.

 Inbox

All orders in the practices go into the Inbox, where the orders are processed by the staff. Orders can be displayed by status or by patient. As the orders are processed, the order’s status changes so that the Inbox reflects how an order is progressing. For example, a lab order status before it has been placed by the staff is ‘needs to be placed’. Once the lab order has been placed and the lab result is pending, the status is ‘awaiting results’. When the lab result has returned and is awaiting the physician, the status is ‘awaiting result review’ and after the physician reviewed the result is order is complete. Only when an order is complete does the order achieve a final status and is removed from the staff workflow in the Inbox. Thus the Inbox tracks all the orders in the practice until completion.

Tracking Patients At Home

For various conditions, tracking patients’ medical data between office visits is a means to prevent clinical exacerbations and improve patients’ health. Congestive heart failure (CHF) is a major cause and cost of hospitalization. The average hospitalization cost ranges from $14K to $20K depending on whether the failure is primary or secondary. It is well known that a CHF patient’s weight can gradually increase before a patient goes into clinical failure. The Joint Commission mandates that on discharge CHF patients are told to take daily weights and report increases to their physicians. However there is no structure to insure that this occurs. EncounterSuite’s Tracking the Patient at Home (TPH) module provides that structure.

TPH works the following way. When a patient is diagnosed with CHF, the physician can place the patient in TPH for weight and set upper and/or lower limits for that patient.

Once in the program, the patient enters the weight in the PHR. If the patient’s weight is outside the patient’s limits, an entry is made in the practice’s Outside Limit Alert Report in the Inbox. From the report the physician can review the previous communications with the patient, the patient’s chart, and the patient’s data in the PHR. The physician can contact the patient and intervene appropriately. From the report, the physician can write orders and document the communication with the patient for the chart.

Physicians can tailor TPH so their efforts are maximized by adjusting the data entry frequency for each patient. Physicians can closely monitor brittle patients on a frequent basis. Stable patients may not have any data entry frequency set. Such patients can use TPH to enter unstable data points in their PHR which then automatically inform their physicians of their status change. This flexibility makes TPH manageable for a busy physician office.

When patients fail to enter their data on time, they are listed on the Non-Compliant Patients Report. From this report, staff can contact that patients and document their communications in the chart.

In additions to weights, TPH can follow blood pressure, blood sugar, peak flows, and abdominal girth.

All parties benefit from the TPH. Patients are more involved with their healthcare and are monitored more closely. Physicians are able to intervene earlier and prevent clinical exacerbations resulting in healthier patients. Physician organizations have healthier patients, more professionally satisfied physicians, and a powerful marketing tool to acquire new business.

Some Important Unique Data Structure Features

EncounterSuite has two features that markedly differentiate it from most other EMRs:

1. EncounterSuite has fully-loaded content in contrast to many other EMRs. In the history, for example, there are over 400 categories covered and 11,000 questions. When physicians need to add content to their EMR, it creates a tremendous amount of work. “It was a lot of work for the doctors, who spent hours of personal time at home. [. . .] we spent up to six months putting in information to make it work the way we wanted it to.” [4]
   
   The significance of an EMR with fully loaded content is that all practices use the same content. Since the data is written to the database as discrete data elements, the result is a relational database with the same data across practices. This means that physician organizations can create robust reports across practices.
   
   
2. Unlike most EMRs, EncounterSuite can identify all patients with a certain disease regardless of how physicians label it. We call this diagnostic equivalence. It is the basis for the disease management guidelines, the disease management registries, and the prospective clinical trial alert.

These two features could produce additional profit centers: recruiting patients for clinical trials and gathering pharmacoepidemiological data. 

More importantly these two features provide a sound software/database foundation from which new powerful modules can be built. Other EMRs, which lack a unified data structure, are unable to track and report across practices.

Future Features

There are several interesting future features we would like to develop.

• Patients who are trying to quit smoking, drinking, lose weight, etc. could call a certain number and get a prerecorded message of encouragement. These messages could include: pre-recorded messages by patient or a family member; or picked from a list of pre-recorded amusing messages such as a nagging wife/husband/mother, drill sergeant, etc. Such messages would be amusing and generate a buzz for the practice.

• For patients in the Tracking the Patient at Home module who do not have Internet access, a telephone and SMS text feature so a patient can enter data via the telephone or cell phone.

• Patients could be phoned by EncounterSuite to remind them to take their medications

EncounterSuite’s robust content and software core enables powerful features to be added. For example, EncounterSuite has a Patient Generated Medical History (PGMH). The system uses adaptive questionnaire technology, asking the patient appropriate follow-up questions based on the patient’s positive responses. The PGMH contains a comprehensive History of Present Illness (HPI). This HPI can be applied to the e-visit feature. Rather than a brief, “I have a rash,” the patient will be asked a series of questions resulting in a communication describing the rash onset, location, appearance, associated symptoms, treatment, etc. This would improve the quality of the e-visit.

The Medical Net System staff’s clinical experience and EncounterSuite’s many additional features can be applied to other aspects of the PC-MH. For example, EncounterSuite could be used to improve the quality of group visits. Using Medical Net Systems Client Expert module, a series of question using adaptive questionnaire technology can be created by the health care provider (HCP) and administered to the patients attending the group visit. Using Medical Net Systems History Reports, the HCP can review a summary of the patients’ answers and also drill down to see which patient said what. Based on this information, the HCP can tailor the group visit to meet the general needs of the patients and also identify critical individual needs. If a patient were to receive individual counseling, etc. during the group visit, the communication can be documented in the patient’s chart using EncounterSuite’s messaging module.

Summary

EncounterSuite can provide the framework for the Patient-Centered Medical Home. Medical Net Systems is committed to developing the software needed to support the PC-MH as the concept evolves. EncounterSuite has a sound data and core structure upon which new powerful modules for PC-MH can be created.