Patient-Centered Medical Home Information Model

While the literature contains principles associated with the concept of a patient-centered medical home (PCMH), how these principles relate to the actual experiences of patients and clinicians within a PCMH is not well understood. This project developed a framework to link a set of core principles and attributes of a PCMH to the clinical activities and experiences, or “information flows,” of patients within a medical home. The framework is designed to organize the elements of a PCMH, understand their relationships, and examine these information flows within and beyond the PCMH. It is also intended to help clinicians and patients better understand what the principles mean in terms of attributes and individual experience. In addition, the framework can guide the technology development of PCMH information systems. 

The objectives of this project were to:

• Conduct a comprehensive literature review into the various interactions a patient has within a patient-centered medical home.  
• Convene an expert panel to obtain key stakeholder input on development of the PCMH information model. 
• Convene working groups and focus groups for the purpose of model validation. 
• Develop non-technical narrative and technical reports to describe the PCMH information model.

The project team constructed a framework of what a PCMH is and is not, focusing on 44 of the 59 possible attributes that are thought to improve quality, decrease cost, or differentiate the medical home. The core principles identified in the literature included: access, coordinated care, continuity of care, community linkages, information system support, payment alignment, patient-centered care, provider type, quality, scope of care, active care management, and “other.” In addition to the framework, nine patient scenarios were developed to provide examples of modeling within the framework.  

Following completion of the framework, the project team outlined gaps and areas needing additional work.  These include: the need to validate the framework with stakeholder groups; the need to test the approach in a variety of situations; and the need to study the range of outcomes when the framework is applied. Further definition and clarification of the principles and their attributes could lead to standardization that supports a common understanding and interpretation. Additional scenarios need to be developed and verified in order to address other combinations of attributes, patient characteristics, and their experiences.