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Musings: Blog of the JAAPA Editorial Board

Musings

Blog of the JAAPA editorial board.

Monday, April 30, 2018

The patient-centered medical home (ain't what it used to be)

​Brian T. Maurer, PA-C

Since the advent of the widespread use of the electronic medical record (EMR) in clinical practice, we have been moving toward the concept of the medical home, a place that houses all of the salient medical data about an individual patient; in short, his or her entire medical history, ideally from conception through birth, growth, development, medical and surgical diagnoses and subsequent treatments, chronic conditions, current medications, lifestyle, sexual history, psychosocial issues, and general state of health—everything, as it were, from soup to nuts; the full Monty.

Advocates of the patient-centered medical home tout the desirability of having all of this information in a central repository, readily accessible, complete. Supposedly, such a system will drastically reduce duplication of services, reduce the likelihood of medical error, and subsequently cut the cost of medical care. Conceptually, it all sounds so good—too good, as the adage goes, to be true.

First, there is the expense for the initial outlay and implementation of the EMR system. Second, there is the need to periodically enter data updates at the point of care, something that requires additional time and effort for clinicians. Third, these systems actually limit patient access to providers—there are only so many hours in a day, and dotting “i’s” and crossing “t’s” can be quite tedious and time-consuming for the practicing clinician—with the upshot being that clinicians actually spend less time caring for the patient as more time is allotted to documenting the care of the patient.

This translates into a lack of timely access to medical care. The acutely ill patient is less inclined to wait 2 or 3 days for the first available appointment at the medical home. More likely than not, he or she will opt to visit one of the myriad urgent care centers, where care is readily available and easily accessible—which, of course, defeats the whole purpose of having a patient-centered medical home in the first place.

Presumably, documentation of these extracurricular medical encounters will eventually find its way back to the medical home—scattered sojourners tend to regroup at some point. And yet, it almost seems as though the entire system has become more fragmented, rather than less so.

An older friend of mine recently signed up with his primary care physician’s new concierge service. For $500/month, my friend enjoys carte blanche access to his physician, day or night; and should he fall ill, he can get a same-day appointment.

To my recollection, this is a throwback to the way my family accessed medical care when I was growing up. If one of us became ill, a call was placed to the family doctor; if necessary, we were given an appointment to be seen that day. Our family doctor knew all about us, despite the sparse notes he scribbled on the 5 by 7 cards in his tickler file. He practiced out of the same residential office for nearly 50 years.

These days, as nearly as I can surmise, those sorts of patient-centered medical homes are gone for good.

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The views expressed in this blog post are those of the author and may not reflect AAPA policies.