Strengthening the PCMH and specialty care management through teamwork enabled by emerging healthcare technology

September 7, 2018

PCMH House Graphic

By Adam Darkins, AristaMD CSO, September 2018

A key innovation to support improved specialty care management, eConsults bridge the gap in electronic health record (EHR) systems toimprove provider communications and care coordination in support of the patient-centered medical home (PCMH) model.


Patient demographics and disease trends are driving the evolution of healthcare toward an increasingly patient-focused system centered on primary care.

In this environment, primary care physicians (PCPs) play a pivotal role in the team management of patients with complex chronic conditions. They are adept at balancing traditional disease-based approaches with individual patient and caregiver preferences.

Long-term relationships with their patients and community service providers across the continuum of care uniquely position PCPs to effectively individualize care, thereby increasing both patient and provider satisfaction, while enhancing the quality and cost-effectiveness of appropriate care.

Such holistic, patient-centered care requires consistent, coordinated, and team-based medical practice rooted in evidence-based medicine, as embodied in the patient-centered medical home (PCMH) model.

PCMH is focused on providing access to high quality, comprehensive, patient-centric, and coordinated care. Policy-makers, payers, and health systems have recognized the value of PCPs as quarterbacks for inter-disciplinary care teams across the broader healthcare system, including specialty care management, hospitals, home health care, and community services.

Coordination is especially critical during transitions between sites of care, such as when patients are discharged from the hospital to their home or a rehabilitation center. During this vulnerable transition, clear and open communication among patients and families, the medical home, and members of the broader care team are essential for positive patient health outcomes.

Assessing our information infrastructure

Ensuring that the right care is provided to the right patient, in the right place and at the right time requires ongoing input from the entire care team. Ideally, an electronic health record (EHR), essentially a digital version of a patient’s paper chart, can offer real-time information available instantly and securely to authorized users including clinical data such as patient medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results.

The visionaries of EHR development foresee the technology as an information-rich exchange between the primary care team and specialists across the continuum of care. However, in their current state of maturation, EHRs are often ill adapted for use across the continuum of care.

Most EHRs evolved from legacy systems dedicated to distinct silos of care within individual practices or hospitals. In addition to a lack of interoperability, poor alignment with clinical workflows can make the EHR a cause of frustration for many physicians, rather than help.

The challenges of referrals and specialty care management

Determining the course of specialty care management requires primary and specialty physicians to each evaluate a patient’s case including complaints, symptoms, and medical history.

In some cases, specialist input is needed to assure a PCP that specialist care is not required, and that proper care management can remain in the primary care setting. Likewise, a specialist consultation can effectively verify cases for which advanced care is needed.

Unfortunately, making effective referrals for specialty care management is a challenging task for PCPs today. With aging baby boomers seeking care, referral rates from PCPs to specialist physicians have more than doubled since 1999[1] while a shortage of specialists, especially in rural areas, results in a tight supply of specialist consultation and long wait times for specialty care visits.

Under this pressure, it’s not surprising many PCPs and specialists are dissatisfied with the current referral process that can often lack complete medical workups, are sent to the wrong specialist, or are inappropriate for specialist attention.

Long delays for PCPs to receive results from specialist visits decrease a PCP’s ability to proactively manage the patients’ care. Most importantly, referral issues may delay necessary patient treatment and decrease satisfaction with the care process.

Recognizing these shortcomings, the National Committee for Quality Assurance (NCQA) called for more effective referrals in their 2017 PCMH metrics.2 Moreover, in medical home pilot programs, primary practices have a financial incentive to track referrals and to provide decision support to guide compliance with referral best practice.3


Electronic consultations (eConsults) are an asynchronous telehealth modality, also referred to as store-and-forward technology, ecoming an indispensable tool for streamlining and enhancing communication and care coordination within the PCMH model.

By effectively reducing variations in referral practice, increasing access to specialist care consultation, reducing wait times for specialist visits, and increasing clinician satisfaction, eConsults fill the current gap in existing EHR technology by aligning electronic communications with existing clinical workflows.

Decision-making by the PCP is accelerated with rapid specialist input. Referral best practice compliance increases, and PCPs are better able to maintain ongoing management of their patients within primary care, rather than transferring them into specialist oversight.4

eConsults facilitate an essential element of the PCMH model, the ‘huddle.’ Team huddles, guided by pre-visit planning, have been reported to assist in role delegation, improve the consistency of information collected from patients, and foster effective communication among team-members.

When a patient’s care is co-managed by a specialist physician, the specialist would ideally participate in the huddle – a process that presents logistical, practical, and medico-legal hurdles. However, with eConsults there is a viable scenario for structured involvement of the specialist physician in a virtual huddle.

Effective implementation of eConsult technology is driving high levels of provider satisfaction, especially in safety-net systems and integrated healthcare systems3 such as Kaiser Permanente and the Department of Veterans Affairs.

NCQA has created a recognition program to highlight the application of PCMH principles. Practices that exhibit the use of teamwork and technology to deliver coordinated and patient-centered primary care are rewarded. Medical specialty boards use the NAQC listing to maintain board certification while Medicare and private insurers use NCQA Recognition to select providers for quality-based incentive payments.

Among the NCQA recognized leaders in PCMH teamwork and technology are AristaMD eConsult platform users Vista Community Clinics and North County Health Services in California, and Albany Family Medicine and Ellis Medicine in New York.

In conclusion

As more health systems look toward creating PCMH models to better manage the health of their patient population, eConsults systems will be instrumental in improving team-based care coordination and communication, supporting effective specialty care management and referrals.

Learn more about how PCMH-certified and AristaMD partner North County Health Services (NCHS) streamlined their referral process by leveraging eConsults.

Healthcare IT News: Patient-Centered Medical Home Model Saved BCBS of MI $626M

  1. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163-170.
  2. Quality Measures Crosswalk for PCMH 2017. NCQA PCMH 2017 Recognition Credit: CC 04C QI 02A.
  3. Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med. 2010;25(6):584-592.
  4. Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consultations (e-consults) to improve access to specialty care: A systematic review and narrative synthesis. J Telemed Telecare. 2015;21(6):323-330.