Patient Centered Medical Homes and Patient Portals

By Lesli Adams, MPA
Director, Oracle Healthcare Business Intelligence

In early March, Carolyn Clancy, MD, Director of AHRQ, posted in her Director Corner’s a nice motivational story about Patient Centered Medical Homes (PCMH) supporting Self Care and empowering patients.  Whether you are the 50 year old Type 2 Diabetic, the caregiver to an elderly relative with COPD, or a teenager struggling with Asthma, using a Patient Portal allows for the Patient Centered Medical Home to support your medical care when YOU need it.    But what needs to be a part of the PCMH?  NCQA (National Committee for Quality Assurance) has provided a brochure that outlines the 6 elements that identify a PCMH.

“PCMH Recognition is based on meeting specific elements included in six standard categories.

1. Enhance Access and Continuity: Accommodate patients’ needs with access and advice during and after hours, give patients and their families information about their medical home and provide patients with team-based care

2. Identify and Manage Patient Populations: Collect and use data for population management

3. Plan and Manage Care: Use evidence-based guidelines for preventive, acute and chronic care management, including medication management

4. Provide Self-Care Support and Community Resources: Assist patients and their families in self-care management with information, tools and resources

5. Track and Coordinate Care: Track and coordinate tests, referrals and transitions of care

6. Measure and Improve Performance: Use performance and patient experience data for continuous quality improvement?”

Does your patient portal provide all 6 critical elements?  Are you actively engaging the patients that need coordination of care the most?  Do you have the systems and TOO MUCH data but not information?  Perficient as a Platinum Partner of Oracle, has solutions that support the full life cycle of the patient’s PCMH experience; coupling historical results, monitoring trends, conformity to guidelines, and population based measures.

Oracle’s Endeca Information Discovery tool is the Industry’s Game Changer in discovering the blind spots in clinical care and variation to protocols.  Alerts for populations and individuals can be set and triggered if care deviates from targets.  Couple the “mining” of Endeca with a Patient Portal that serves up individualized content, you can now inform your patient that not only are they due for a refill of Albuterol, need to update their Family Care Plan, but also monitor the # of times they have used their rescue inhaler based on their input at the web portal.  Partnering Endeca with a Patient Portal solution brings the self-care together with clinical results and best practice.  For more information about Endeca, Patient Portals, and Population Health Management please contact .

More Information about the PCMH Recognition can be found at

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