The House Before the Home

David-FinnThe Patient-Centered Medical Home (PCMH)

By David Finn, Health IT Officer at Symantec
Twitter: @DavidSFinn
LinkedIn Profile

I’ve been hearing and reading a lot about the Patient-Centered Medical Home (PCMH) again, recently. And I think that is good. It is a concept I believe in, personally, and a model my own provider is moving to. So, if I’m so happy why have I taken to the keyboard to write about this?

Well, I think we’re missing something here. It might be the cart before the horse thing with the cart being processes and people and the horse being the information and information technology. How do you coordinate care across the “medical neighborhood” if you don’t have a sound technology infrastructure or if your practice isn’t even connected to the medical neighborhood? Or maybe you don’t even have the information, yet. I prefer to think of it as the home before the house problem.

In other words, you can’t have a Patient-Centered Medical Home until you have a Patient-Centered Digital House (PCDH). I don’t think I need to tell you there is a difference between a house and a home. A house is a structure, nothing more, nothing less. To build a house requires a technical knowledge, materials and some money. There are well-built houses and badly built houses. A house serves as a place to keep your stuff and protect you from the elements. But a home is different.

You can live in a house that doesn’t feel like home. To be a home, it needs to feel like a place you belong. A place you feel secure. And even if you don’t own the house, the home is yours.

I live in Houston, where the slabs of homes slide and sink and rise on gumbo soil – – highly susceptible to excessive rain and drought. We get both excessive rain and drought in this part of Texas. So, I had a pretty good home until I realized the underpinnings of the house weren’t as sound as the home itself.

Humor me here and let’s call my home the PCMH and the bell-bottom piers I just installed around and, yes, in my home, the “sound infrastructure”. The house looks good and works fine after you move in. The doors open and close and can be locked. The pipes all line up and bring in clean water and the sewage runs off to wherever sewage runs to.

Then one day you realize that a few bricks have cracked and maybe a door or window doesn’t close properly. Now, you’ve got air coming in and going out that you don’t want coming in and going out. Let’s call that PHI. But let’s not call the OCR.

Then another corner slips a little more and now the back door doesn’t lock. Now, I’ve got people coming in that shouldn’t even be inside my home! Then a waste water line cracks partly because of tree roots trying to get any water they can during the drought – – and the water running out of that line is creating a wash out under my house and the living room starts sinking. You might call that bad data.

I’m not only no longer connected to the “medical neighborhood” anymore; no one wants to come into my PCMH – – including me. I get that piers and foundation watering systems are not as sexy as new televisions in the exam and waiting rooms for my PCMH. No one sees them and while we all benefit from them you only notice that nasty infrastructure stuff (like availability, confidentiality and integrity) when it isn’t there or doesn’t work. If you build the house right, turning it in to a home is much easier and it will last longer.

The Patient-Centered Digital House is one construction project where you may really want to consider where you use builder grade and what you upgrade on. It is faster, easier and cheaper to re-paint and re-carpet later than it is to rebuild the infrastructure or reconnect to the neighborhood or make sure the EHR you are using actually has the attributes you need to proactively manage a patient’s health (or a population’s health).

Let’s get the technical structure and foundation of the PCDH right first and then look at access and patient engagement, the patient experience including coordination of care across the medical neighborhood. If we all have well-built, protected Patient-Centered Digital Houses, it is much easier to turn those houses into secure, well functioning Patient Centered Medical Homes where we actually can and really do look out not only for ourselves but each other.