Medical Home Monitor
Medical Home Monitor
July 19, 2010
Vol. III, No. 6

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Technology & the Medical Home
  2. Successful Use of EHRs
  3. New Chart: Benefit-Based Incentives
  4. Podcast: Sharing Data Among Physicians
  5. E-Mail Improves Care
  6. E-Survey: Reducing Avoidable ER Visits
  7. Benchmarks: HRAs
  8. Editor's Pick

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Medical Home Q&A's:

Medical Home Monitor

ER Registry

Q: How will the hospital registry work to reduce readmissions, what type of information is collected and who will have access to it?

A: Registries are a big component in what we do at Kaiser Permanente in Colorado. We have a hospital registry where we know if someone has been hospitalized within 24 hours. Any provider in the medical office can click on our Health Track within the medical records to see how many of their patients were at a certain hospital. We have a telephonic medicine center that is staffed overnight by paramedics who field calls from non-Kaiser Permanente hospitals. We have an electronic medical record (EMR), so we can offer these hospitals more information about our patients. It’s not uncommon for them to say, “We have your patient. Can you give me a list of their most recent medications?” We have forged a strong relationship with the community EDs so they call us when they have our members. When they call us, we are able to enter that information into the member’s record which will then be extracted into the ED registry. The registry includes a subset of core hospitals that we will get an electronic feed from so we know our member shows up. We will get an electronic feed within 12 hours that includes a name, record number, date of birth, the diagnosis and other generic information. We are hope the registry will capture 90 percent of our ED visits within 24 hours. The providers and the offices will have access to it as will administrators.

Sara Gray, senior manager of emergency services at Kaiser Foundation Health Plan of Colorado.

For more details on Kaiser Foundation Health Plan strategies to reduce avoidable ER visits, please visit:

Tools of Technology

Q: What kind of technology-enabled tools are required for the patient, the physician, the nurse and administrative staff to effectively support the new medical home models?

A: (Joann Sciandra) We do most of our information exchange through EpicCare's EMRs. We’re able to send telephone messages to the front desk and to the doctors. EpicCare would be our main source on the case management side. Being a health plan, we have Wisdom™ Care Management System, which we use with our case managers’ software to communicate with other departments within the health plan.

(Diane Littlewood) Our support is our medical management and utilization management departments and the activity of our nurses. We do monitor visits, phone calls and coordination. We’ve recently instituted 24/7 on-call into our case management process. We’re able to demonstrate the value that this brings to case management by understanding the interventions and the work that the case managers do.

Joann Sciandra, RN, BSN, CCM, regional manager of case management for health services at Geisinger Health Plan

Diane Littlewood, RN, BSN, CDE, regional manager of case management for health services at Geisinger Health Plan

For more on the use of technology in the medical home, please visit:

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Electronic Health Records: Improve Health, Increase Safety, Cut Costs

HHS announced two final rules last week to improve America's health, increase safety and reduce healthcare costs through expanded use of EHRs, laying the groundwork for incentive payments.

With “meaningful use” definitions in place, EHR system vendors can ensure that their systems deliver the required capabilities, providers can be assured that the system they acquire will support achievement of “meaningful use” objectives and a concentrated five-year national initiative to adopt and use electronic records in healthcare can begin.

As much as $27 billion may be expended in incentive payments over ten years. Eligible professionals may receive as much as $44,000 under Medicare, $63,750 under Medicaid and hospitals may receive millions of dollars for implementation and meaningful use of certified EHRs under both Medicare and Medicaid.

One regulation defines the minimum requirements that providers must meet through their use of certified EHR technology in order to qualify for the payments. The other rule identifies the standards and certification criteria for the certification of EHR technology, so eligible professionals and hospitals may be assured that the systems they adopt are capable of performing the required functions.

For more details, please visit:

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New Chart: Benefit-Based Incentives
Incentives for health and wellness activities take many forms. We wanted to see how companies are integrating incentives with health insurance benefits.

View the chart at:

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HealthSounds Podcast: Improving Physician Performance and Value-Based Reimbursement Levels
Dr. Paul Kaye, medical director at Taconic IPA and Susan Stuard, executive director of THINC, describe how the sharing of data across organizations is improving physician performance and value-based reimbursement levels. Along with the transformation to a PCMH came an acceptance of a model that coordinates care for an entire population, not just the patients showing up each day, explains Dr. Kaye. Although the 238 Taconic physicians at 11 sites have received Level III PPC®-PCMH™ recognition from the NCQA, Stuard explains that practice transformation doesn't stop there.

To listen to this HIN podcast, please visit:

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Use of Doctor-Patient E-Mail Improves Care Quality
Secure patient-physician e-mail messaging improves the effectiveness of care for patients with diabetes and hypertension, according to new research by Kaiser Permanente.

The study observed 35,423 patients with diabetes, hypertension or both, finding that use of secure patient-physician messaging in any two-month period was associated with statistically significant improvements in HEDIS care measurements.

Results included 2.0 to 6.5 percentage-point improvements in glycemic, cholesterol and blood pressure screening and control.

Kaiser Permanente previously found that 75 percent of all patient-physician e-mail encounters addressed ongoing medical problems or care plans. The leading reasons patients contact physicians are to discuss changes in a health condition, lab test results, a new condition, drug dosage adjustments or the need for a new prescription.

Kaiser Permanente physicians participating in the study reported that the use of secure e-mail messaging has been highly successful for diabetes patients, enabling them to follow medical instructions to the letter. Physicians also are encouraging patients to schedule an appointment if they raise issues via e-mail that are too complex or lengthy to address using that medium.

To learn more, please visit:

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HIN Survey of the Month: Reducing Avoidable Emergency Room Visits
Inappropriate and preventable use of the hospital ERs is a nationwide problem and a serious drain on healthcare resources. Many healthcare organizations have launched programs to reduce avoidable use of the hospital ER. Complete this month's survey on reducing avoidable ER visits by July 31, 2010 and we will e-mail you a copy of the compiled survey results in August.

Complete the survey by visiting:

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JUST PUBLISHED! 2010 Benchmarks in Health Risk Assessments Use
Aggregate data from health risk assessments (HRAs) provides a roadmap for healthcare organizations to deliver health promotion and disease management interventions to targeted individuals — with the goal of improving clinical and financial outcomes. This white paper captures key information regarding the use of HRAs from 116 healthcare organizations in response to the Healthcare Intelligence Network June 2010 HRAs e-survey.

To download this complimentary white paper, please visit:

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EDITOR'S PICK: Save 10% on This Week's Medical Home Resource

The Emerging Role of Nurse Practitioners in Expanding Access, Enhancing Revenue

With 32 million people becoming eligible for health coverage in the coming years and an already strained primary care system with a shortage of primary care physicians, physician practices, clinics, hospitals and other providers of care will continue to look to enhance the use of nurse practitioners in the delivery of primary care services. During The Emerging Role of Nurse Practitioners in Expanding Access, Enhancing Revenue, a 45-minute webinar on July 28, 2010, an industry expert examines how nurse practitioners are being utilized in the physician practice, hospital and clinic settings to increase access to care and coordinate care for patients with chronic conditions.

Use ordering code MHMP to save 10 percent on this resource by visiting:

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Contact HIN:
Guest Editor: Jackie Lyons,;
Publisher: Melanie Matthews,;

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