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BACKGROUND: The patient-centered medical home (PCMH) shows promise for improving care and reducing costs. We sought to reduce the uncertainty regarding the time and cost of PCMH transformation by quantifying the direct costs of transforming 57 practices in a medical group to National Committee for Quality Assurance (NCQA)-recognized Level III PCMHs. METHODS: We conducted structured interviews with corporate leaders, and with physicians, practice administrators, and office managers from a representative sample of practices regarding time spent on PCMH transformation and NCQA application, and related purchases. We then developed and sent a survey to all primary care practices (practice-level response rate: initial recognition-44.6%, renewal-35.7%). Direct costs were estimated as time spent multiplied by average hourly wage for the relevant job category, plus observed expenditures. RESULTS: We estimated HealthTexas' corporate costs for initial NCQA recognition (2010-2012) at $1,508,503; for renewal (2014-2016), $346,617; the Care Coordination resource costs an additional ongoing $390,790/year. A hypothetical 5-physician HealthTexas practice spent another estimated 239.5 hours ($10,669) obtaining, and 110.5 hours ($4,957) renewing, recognition. CONCLUSION: Centralized PCMH support reduces the burden on practices; however, overall time and cost remains substantial, and should be weighed against the mixed evidence regarding PCMH's impact on quality and costs of care.

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Health information technology shows promise for improving chronic disease care. This study assessed the impact of a diabetes management form (DMF), accessible within an electronic health record. From 2007 to 2009, 2108 diabetes patients were seen in 20 primary care practices; 1103 visits involved use of the DMF in 2008. The primary outcome was "optimal care": HbA1c ≤8%, low-density lipoprotein (LDL) cholesterol <100 mg/dL, blood pressure <130/80 mm Hg, not smoking, and aspirin prescription in patients ≥40 years. After adjusting for number of visits, age, sex, and insulin use, DMF-exposed patients showed less improvement in attaining "optimal care" (estimated difference-in-difference [DID] = -2.06 percentage points; P < .001), LDL cholesterol (DID = -2.30; P = .023), blood pressure (DID = -3.05; P < .001), and total cholesterol (DID = -0.47; P = .004) targets. Documented microalbumin tests, aspirin prescription, and eye and foot exams increased more. Thus, DMF use was associated with smaller gains in achieving evidence-based targets, but greater improvement in documented delivery of care.

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OBJECTIVE: To assess the impact of electronic health record (EHR) implementation on primary care diabetes care. DATA SOURCES: Charts were abstracted semi-annually for 14,051 diabetes patients seen in 34 primary care practices in a large, fee-for-service network from January 1, 2005 to December 31, 2010. The study sample was limited to patients aged 40 years or older. STUDY DESIGN: A naturalistic experiment in which GE Centricity Physician Office-EMR 2005 was rolled out over a staggered 3-year schedule. DATA COLLECTION: Chart audits were conducted using the AMA/Physician Consortium Adult Diabetes Measure set. The primary outcome was the HealthPartners' "optimal care" measure: HbA1c ≤ 8 percent; LDL cholesterol < 100 mg/dl; blood pressure < 130/80 mmHg; not smoking; and documented aspirin use in patients ≥ 40 years of age. PRINCIPAL FINDINGS: After adjusting for patient age, sex, and insulin use, patients exposed to the EHR were significantly more likely to receive "optimal care" when compared with unexposed patients (p < .001), with an estimated difference of 9.20 percent (95% CI: 6.08, 12.33) in the final year between exposed patients and patients never exposed. Components of the optimal care bundle showing positive improvement after adjustment were systolic blood pressure <80 mmHg, diastolic blood pressure <130 mmHg, aspirin prescription, and smoking cessation. Among patients exposed to EHR, all process and outcome measures except HbA1c and lipid control showed significant improvement. CONCLUSION: Implementation of a commercially available EHR in primary care practice may improve diabetes care and clinical outcomes.

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As ambulatory care practices face increasing pressure to implement electronic health records (EHRs), there is a growing need to determine the essential elements of a successful implementation strategy. HealthTexas Provider Network is in the process of implementing an EHR system comprising GE Centricity Physician Office-EMR 2005, Clinical Content Consultants (now part of GE), and Kryptiq Secure Messaging throughout all 88 practices in the Dallas-Fort Worth area and is hoping to extend the system to other practices affiliated with Baylor Health Care System as well. We describe the preimplementation clinical process redesign and quality improvement training that has been conducted networkwide in preparation for the introduction of the EHR, as well as the specific steps taken to prepare and train clinic staff for the integration of the EHR into daily workflows. The first pilot site, Family Medical Center at North Garland, implemented the system in May 2006. Based on both the positive aspects of this experience and the challenges we encountered, we identified 20 essential elements for successful implementation in the areas of site selection, implementation strategy, staff education and preparation, team project management, content, hardware and software, and workflow process. Broadly, we determined that 1) a pilot site's understanding of and willingness to work within the fluid nature of the implementation process during what is essentially a testing phase is a key ingredient in achieving success at the pilot site and in improving the process for later sites; 2) input from and representation of viewpoints of all types of EHR users during preimplementation decision making enables customization of the system and sufficient preplanning to ensure minimal workflow disruptions during and after implementation; and 3) a high level of technical and training support during the early days of implementation is invaluable.