Every Physician Can be a Patient-Centered Medical Home
Clinical Support Services (CSS) offers a software system, EMRPath™, that allows any physician practice, large or small -- with or without an EMR, to take major steps toward becoming a patient-centered medical home (PCMH). EMRPath is a web-based, electronic medical record software program designed to include workflow management and decision support functionality for disease management purposes.
Built around a robust patient registry, EMRPath has an easy-to-use graphical user interface that allows users to enter, organize and manage clinical information obtained from administrative claims and clinical data. Each program is constructed in the S-O-A-P (subjective-objective-assessment-plan) Note format familiar to all clinicians. Included in each account is AlertPath™, a messaging system that alerts clinicians when a patient’s current health status falls outside of evidence-based care.
A reminder system is also embedded within the program that tags each patient record with an appropriate follow-up date. Case managers are notified daily of patients who require follow-up.
Users of EMRPath can provide their patients with PMR Smart™ – an online, patient-oriented personal medical record. PMR Smart gives access to objective clinical information (lab values, personal medication record, etc.) in a read-only format. PMR Smart can be configured to allow patient entry of home-based clinical monitoring values (i.e. blood pressure, weight, etc.).
For physicians who are not yet prepared for EMR functionality within their offices, CSS can provide clinical support using its VirtualClinic™ software tool. By faxing progress notes, lab reports and other data to our offices, CSS can assist physicians by providing them with a robust case management system that meets specific PCMH certification requirements.
Here’s how VirtualClinic and EMRPath line up with National Committee for Quality Assurance (NCQA) scoring for PCMH certification:
| Standard | Description | CSS Software |
|---|---|---|
| Standard 1 | Access and Communication | |
| Written standards for patient access and communication | Not Applicable | |
| Uses data to show it meets standards for patient access and communication | Not Applicable | |
| Standard 2 | Patient Tracking and Registry Functions | |
| Uses data system for basic patient information (mostly non-clinical data) | Not Applicable | |
| Has clinical data system with clinical data in searchable data fields | Yes | |
| Uses the clinical data system | Yes | |
| Uses paper or electronic-based charting tools to organize clinical information (PCMH must-pass element) | Yes | |
| Uses data to identify important diagnoses and conditions in practice** | Yes | |
| Generates lists of patients and reminds patients and clinicians of needed services (PCMH must-pass element) | Yes | |
| Standard 3 | Care Management | |
| Adopts and implements evidence based guidelines for 3 conditions (PCMH must-pass element) | Yes | |
| Generates reminders about preventative services for clinicians | Yes | |
| Uses non-physician staff to manage patient care | Yes | |
| Conducts care management, including care plans, assessing progress, addressing barriers | Yes | |
| Coordinates care / follow-up for patients who receive care in inpatient and outpatient facilities | Yes | |
| Standard 4 | Patient Self Management | |
| Assesses language preference and other communication barriers | Not Applicable | |
| Actively supports patient self-management | Yes | |
| Standard 5 | Electronic Prescribing | Optional |
| Standard 6 | Test Tracking | |
| Tracks tests and identifies abnormal results systematically (PCMH must-pass element) | Yes | |
| Uses electronic systems to order and retrieve tests and flag duplicate tests | No | |
| Standard 7 | Referral Tracking | |
| Tracks referrals using paper based or electronic system (PCMH must-pass element) | Yes | |
| Standard 8 | Performance Reporting and Improvement | |
| Measures clinical and/or service performance by physician or across the practice (PCMH must-pass element) | Yes | |
| Survey of patients’ care experience | Not Applicable | |
| Reports performance across the practice or by physician (PCMH must-pass element) | Yes | |
| Sets goals and takes action to improve performance | Not Applicable | |
| Produces reports using standard measures | Yes | |
| Transmits reports with standardized measures electronically to external entities | Yes | |
| Standard 9 | Advanced Electronic Communication | |
| Availability of interactive web site | Yes | |
| Electronic patient identification | Yes | |
| Electronic care management support | Yes |