Providers can use the functions and capabilities of their electronic health (EHR) system to help deliver care as a health care home (HCH). A health care home, also known as a medical home, is an approach to health care in which a team of health professionals works in partnership with patients and families to provide the best care. In a HCH, patients and families are at the center of care.
Care coordination is an essential part of health care homes. A care coordinator will make sure that all providers—including specialists—will share needed information about patients’ health through patient tracking and care plans. Care coordinators can help patients manage their care.
To be certified as a health care home in Minnesota, the Minnesota Department of Health requires clinics to meet criteria related to the five following standards (Minnesota Statutes §256B.0751, subd.2, 01/11/2010):
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Access and communication : Facilitate consistent communication among the HCH, the patient and family (“participant”), and other providers to provide the participant with continuous access to their HCH.
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Participant registry and tracking participant care activity : Use an electronic, searchable registry that enables the HCH to identify gaps in patient care and manage health care services.
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Care coordination : Include care coordination that focuses on patient and family-centered care.
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Care Plan : Include a care plan for selected patients with a chronic or complex condition that involves the patient and the patient’s family in care planning.
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Performance reporting and quality improvement : Reflect continuous improvement in the quality of the patient’s experience, health outcomes, and cost-effectiveness of services.
As you plan your EHR selection, consider the capabilities and functions that support the health care home standards, including:
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Storing and retrieving patient information, both clinical and other pertinent information (i.e., cultural background, racial heritage, primary language, values, beliefs, and preferred method of communication).
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Leveraging communication and interoperability capabilities to facilitate care coordination between the patient, the patient’s family, other providers involved in the patient’s care and other organizations (pharmacies, testing labs, etc.).
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Using data to develop individualized care plans that guide and educate the patient and their family about the risks, benefits, and likely outcomes of available health care options.
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Demonstrating data reporting and analysis capabilities that enable performance reporting and tracking of key quality metrics.
If seeking an EHR that supports health care homes, use this tool to determine the functionality you want to include in your clinic’s request for proposals for an EHR that can support your HCH implementation.
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1.
Review the list of EHR features important to health care homes in the table below to see if it contains information you wish to seek from the vendors—adding, changing, and deleting as necessary. Retain, modify, or delete the italicized examples.
2.
Add your HCH functionality requirements to Section 4. How Product Meets Functionality
Requirements in your request for proposal (1.3 Request for Proposal).
3.
Examine the combined list and address any potential redundancies by deleting, editing, or combining items to meet your needs and the level of detail desired.
Indicate how your proposed system makes available the following features and functions.
Information supplied here will serve as a contractual obligation in any contract we enter into for this product. Describe availability as:
1 = Not available, no current plans to develop
2 = Not available, but will develop for additional fee
3 = Planned for future release ( specify date )
4 = Installed in one or more sites, but not available for general release until ( specify date )
5 = Installed in one or more sites, but not included in this proposal
6 = Installed in one or more sites
EHR Functionality
Availability
(1-6)
Describe How Product Performs
Function and Addresses
Minnesota’s HCH Standards
1. Record management a. Manage Patient Demographics. Capture and maintain demographic information, including designated HCH, racial or ethnic background. Where appropriate, data should be clinically relevant and reportable. b. Capture Data and Documentation from
External Clinical Sources. Incorporate clinical data and documentation from external sources.
2. Preferences, directives, consents, and authorizations
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EHR Functionality a. Manage Patient and Family
Preferences. Patient and family preferences regarding issues such as language, religion, spiritual practices, primary language, and preferred method of communication (e.g. phone, email, letter, etc.) and culture may be important to the delivery of care. Capture these so that they are available to provider at the point of care. b. Manage Patient Advance Directives.
Patient advance directives and provider
DNR orders are captured as well as the date and circumstances under which the directives were received, and the location of any paper records or legal documentation (e.g. the original) of advance directives as appropriate. c. Manage Consents and Authorizations.
Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
3. Care plans, treatment plans, guidelines, and protocols a. Manage Patient-Specific Care and
Treatment Plans. Care plans, guidelines, or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. Transfer of treatment and care plans may be implemented electronically, for example, using templates or by printing plans to paper.
4. Orders and referrals management a. Manage Referrals. Enable the origination, documentation, and tracking of referrals between care providers or health care organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
Availability
(1-6)
Describe How Product Performs
Function and Addresses
Minnesota’s HCH Standards
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EHR Functionality
5. Documentation of care, measurements, and results a. Manage Results. Present, annotate, and route current and historical test results to appropriate providers or patients for review. Provide the ability to filter and compare results.
6. Manage health information to provide decision support a. Performance and Accountability
Measures. Support regular reporting on health care provided to individuals and populations. These reports may include measures related to process, outcomes, costs of care, may be used in “pay for performance ” monitoring and adherence to best practice guidelines. b. Support for Identification of Potential
Problems and Trends. When personal health information is collected directly during a patient visit, input by the patient, or acquired from an external source (i.e., lab results), need to be able to identify potential problems and trends that may be patient-specific, given the individual ’s personal health profile, or changes warranting further assessment. c. Support for Patient and Family
Preferences. Decision support functions should permit consideration of patient/family preferences and concerns, such as with language, religion, culture, medication choice, invasive testing, and advance directives. Such preferences should be captured in a manner that allows for their integration with the health record and easy retrieval from the health record. Preferences may be specified across all treatment plans or specifically to a treatment plan.
7. Support for condition-based care and treatment plans, guidelines, protocols
Availability
(1-6)
Describe How Product Performs
Function and Addresses
Minnesota’s HCH Standards
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EHR Functionality a. Support for Standard Care Plans,
Guidelines, Protocols. Before they can be accessed upon request, standard care plans, protocols, and guidelines must be created. These documents may reside within the system or be provided through links to external sources, and can be modified and used on a site specific basis.
To facilitate retrospective decision support, variances from standard care plans, guidelines, and protocols can be identified and reported. b. Support for Context-Sensitive Care
Plans, Guidelines, Protocols. Identify and present the appropriate care plans, guidelines and/or protocols for management of patient-specific conditions that are identified in a patient clinical encounter. c. Support Consistent Health Care
Management of Patient Groups or
Populations. Populations or groups of patients that share diagnoses (i.e., diabetes or hypertension), problems, functional limitations, treatment, medication, and demographic characteristics (i.e., race, ethnicity, religion, and socio-economic status) that may impact care are identified for the clinician. The clinician is advised and assisted with management of these patients to optimize the clinician’s ability to provide appropriate care.
8. Patient knowledge access a. Patient Knowledge Access. An individual will be able to find reliable information to research a health question, follow up from a clinical visit, identify treatment options, or other health information needs. The information may be linked directly from entries in the health record, or may be accessed through other means such as keyword search. The information may be provided as part of the EHR system but may also include patient information from external databases or specific Web sites.
Availability
(1-6)
Describe How Product Performs
Function and Addresses
Minnesota’s HCH Standards
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EHR Functionality
9. Support for clinical communication a. Support for Inter-Provider
Communication. Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. The system should provide for both verbal and written communication.
These exchanges would include but not be limited to consults and referrals, as well as possible exchanges within the office as part of the provision and administration of patient care. b. Support for Provider - Pharmacy
Communication. Provide features to enable secure bi-directional communication of information electronically between practitioners and pharmacies or between practitioner and intended recipient of pharmacy orders. c. Support for Communications Between
Provider and Patient and/or the Patient
Representative. Providers are able to communicate with patients and others, capturing the nature and content of electronic communication, or the time and details of other communication.
10. Measurement, monitoring, and analysis a. Outcome Measures and Analysis.
Support the capture and subsequent export or retrieval of data necessary for reporting on patient outcome of care by population, facility, provider or community. b. Performance and Accountability
Measures. Support reporting on health care provided to individuals and populations. These reports may include measures related to process, outcomes, costs of care, may be used in
“pay for performance ” monitoring and adherence to best practice guidelines.
Availability
(1-6)
Describe How Product Performs
Function and Addresses
Minnesota’s HCH Standards
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Stratis Health
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Health Information Technology Services
952-854-3306
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info@stratishealth.org www.stratishealth.org
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