The concept of the pediatric patient-centered medical home (PCMH) as a theory has been evolving since it was initially conceived more than 40 years ago. When the American Academy of Pediatrics’ (AAP) Council on Pediatric Practice first wrote about this model, “medical home” was defined solely as the central location of a pediatric patient’s medical records.1 Approximately two decades later, the AAP published its inaugural policy statement on this topic. Through this policy statement, the medical home was defined as a place where care for pediatric patients would be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.1
Although the premise of creating a comprehensive environment where a patient could have care completely managed by one team is laudable, practical realities have prevented this framework from being adopted en masse. Fortunately, for providers and practices that have implemented this model, clinical results have been positive. One study has shown that patients receiving care from practices with robust care coordination and chronic-condition management support services have fewer emergency department visits and hospital admissions.2 Furthermore, studies have also shown that families served by a PCMH are more likely to experience fewer missed work days.3
Care coordination and chronic-condition management are two of the six domains assessed as part of the Medical Home Index (MHI). The MHI is a survey tool used to assess a practice’s state of being when determining how close it is to being a certifiable medical home. Similar in nature to the PCMH is the chronic care model (CCM). The foundation of the CCM is built on the premises of a strong community, efficient health care systems, and provider support for the patient.4
Although the lack of access to providers, especially in rural communities,5 may inhibit the adoption of the PCMH or CCM models, technology has evolved to the point where many of the gaps in care can be bridged. mHealth, defined by the National Institutes of Health (NIH) as the use of mobile and wireless devices to improve health outcomes, health care services, and health research, can be one specific example of how technology can address these issues. One early study has shown that patients who use mHealth tools are more likely to adhere to self-monitoring requirements and in turn have significantly improved outcomes.6 A rapidly evolving and scalable mHealth technology that has the ability to address these issues are self-management mobile applications, or apps. It has been estimated that there are currently more than 40,000 health care-related apps available.7 Furthermore, use of these apps is growing, as more than 50% of smartphone users surveyed responded that they have used their device to gather health information, and almost 20% of this population has at least one health care app on their device.8
Technology has become a viable solution in supporting the PCMH and CCM theories. These individual theories complement one another by building off of specific elements integral to the success of each. Table 1 shows the similarities between the theoretical constructs of the PCMH, by way of the MHI survey, and CCM key principles.
Patient-Centered Medical Home and Chronic Care Model Key Principles
Note that both concepts look to aid patients by maximizing the efficiency of the health system through coordinating care and community resources. Furthermore, each theory looks to maximize decision-making opportunities through data management. Through increased education efforts, providers can enable patients to more effectively self-manage their chronic conditions. Conversely, engaged patients can provide more complete information on the impact of their treatment plan to their provider. Ultimately, this is mutually beneficial to both groups as patients work in synergy with their providers toward achieving desired outcomes.
Providers operating within the PCMH model are still limited by the amount of time the patient spends with the care team. This is where technology can have the biggest impact within the PCMH construct. Studies have shown that technology projects can support specific elements of the chronic care model, especially as they relate to decision support, self-management, and clinical information systems.9
Apps are one technology that can readily address these items. It has been shown that patients are inclined to use apps to communicate with their physician or provider team, educate themselves on their condition or course of treatment, and monitor their progress or compliance as related to their care plan.6 Current literature provides insight on functionality that should be included in pediatric apps focused on education and self-management.
Theory and Practice
Although apps present an opportunity to continually educate and reinforce positive self-management habits, it should be noted that not all apps are created equally. Presently, apps can be developed by numerous entities throughout the health care and technology ecosystems. This disparate creation process has led to a lack of interoperability amongst apps, as well as the inability to share data that are collected.10 There is also a variety of desired outcomes where each development group focuses only on what is pertinent to them.
To guard against patients using underdeveloped tools, providers should recommend apps that include specific functionalities. One way to manage chronic disease is to engage a patient in self-management behaviors that mitigate the impact of his conditions.11 Five key processes included in self-management are assisted decision-making, goal-setting, tracking, knowledge assessment, and learning.9 The pediatric self-management framework suggests that innovative interventions should target these modifiable elements and can influence patient outcomes.12
One example of an app that was developed with these key processes in mind is the patient self-management app, Tools4U, created by Nationwide Children’s Hospital. Figure 1 depicts a screenshot of the default home page constructed within the app framework. The app is infinitely scalable so that the hospital can develop numerous clinical “modules” yet have patients download only a single app. Clinical modules are designed and then assigned by NCH care teams. NCH care teams consist of a multi-disciplinary group of licensed dependent and independent providers. Physicians, nurse practitioners, nurses, dietitians, and social workers are examples of stakeholders who have been involved with the creation of the clinical content. Each service line looking to utilize this tool for its patients must identify how it will be incorporated into the continuum of care so that it maximizes the usability of the app and the patient experience.
A screenshot of the default home page constructed within the app framework of the patient self-management app, Tools4U, created by Nationwide Children’s Hospital.
Image courtesy of Michael R. Slaper, MHSA.
The information regarding the impact of self-management principles evident in today’s literature further support utilizing apps like Tools4U because of the evidence associated with improved outcomes. Specifically, assisted decision-making aids have been shown to increase patient knowledge, satisfaction, and the number of questions patients will ask of their providers.13 Health quizzes comprising a short series of questions can assist patients with assessment of their current knowledge and foster information-seeking behaviors. Additionally, patients can be assisted in decision-making through a troubleshooting function in which the patient answers a series of questions about a problem to receive recommendations for steps that can be taken to resolve it.
Furthermore, current literature also shows that when patients participate in goal selection, they are more likely to retain information.13 Thus, any challenge section should allow a patient to choose from a list of possible goals and then be prompted over the course of time to take specific actions that facilitate progress toward accomplishment of the desired outcome.
Journaling functionality should facilitate documentation of signs, symptoms, or patterns of behavior by the patient and maintain a historical record. This mode of tracking has been found to be an effective mechanism for assisting patients with self-management between visits.14 A medical content section and glossary can link the patient to a wide variety of related multimedia patient education resources where they can learn about their disease and treatments on demand. This is beneficial because learning is more effective when it is patient-driven.15
Overall, structured systems that support the provision of personalized feedback have been found to be effective in some chronic diseases.16 A provider access portal that illustrates information on usage on an individual patient level is critical. The historical information documented within the aforementioned journal section should be available for review by the provider and should provide insight into the patient’s experience in between visits.
Conclusions and Future Considerations
The technological evolution as it relates to health care will continue to significantly impact care delivery models going forward. Limiting factors for the incorporation of technology into the care delivery continuum will be slowed mostly by provider acceptance and federal regulations.
Anecdotally, angst amongst providers has focused on the increased access patients will have through technology. This fear is potentially substantiated by a survey indicating that approximately 8 out of 10 patients would like to communicate with their provider via email or other secured messaging avenues.17 Provider concern though is less about the increase in patient interaction more about operational challenges. Communication via email, texts, web-portal messages, etc. present reimbursement obstacles for providers who devote time to these types of activities. Although accountable care organizations (ACOs) continue to trial different reimbursement methods based on quality outcomes, and Medicare has even gone so far as to propose new G-Codes focused on reimbursing for non-face-to-face services,18 the reality remains that meaningful reimbursement does not follow for time spent in these areas. Add to that the concerns surrounding data security and the lack of standardized protocols for mHealth technologies19 and it is understandable why the provider community has yet to accept these tools as a mainstream delivery option of patient education and self-management services.
Even if physicians were able to fully implement technology solutions into their practices, issues with compliance with federal and state regulations will always remain. Recently, the U.S. Food and Drug Administration (FDA) released its long-awaited guidelines on how medical apps will be regulated. The FDA report, Mobile Medical Applications: Guidance for Industry and Food and Drug Administration Staff, released in September 2013, outlines how health care apps will be assessed going forward. The FDA guidance acknowledges that apps can be used by providers to diagnose medical conditions and to enable patients to educate themselves and manage their own health and wellness.
To ensure that medical apps that come to market are safe, the FDA has created a system that categorizes these tools into several categories. The FDA defines “mobile medical app” as an application that can be defined as a “device” according to the Federal Food, Drug, and Cosmetic Act.20 The FDA categorizes apps as either the focus of its regulatory oversight, or those upon which it intends to exercise enforcement discretion. The FDA further defines the first subset of apps as meeting the statutory definition of a device where the device can either be used as an accessory to a regulated medical device, or transform a mobile platform into a regulated medical device.21 In short, any app that can be categorized in either of those ways will undergo a full FDA evaluation. Conversely, the FDA acknowledges that it cannot police the entire mobile world and thus reserves the right to exercise enforcement for all other tools. Characteristics of apps that would fall into this category contain functionalities such as tracking (journaling) mechanisms, medical information (definitions and explanations), and algorithms to help patient self-manage their conditions. Although the FDA continues to evolve its evaluation processes, providers are still vulnerable when it comes to identifying quality apps on their own. Luckily, prior to the FDA releasing its final guidelines, multiple websites emerged focusing on providing peer review resources to providers for apps that are currently available. One such site, MedicalAppJournal.com, provides an opportunity for specialists to review apps tailored to patient populations they would serve; another, Happtique.com, has created a set of standards by which the company evaluates and recommends available apps.22
Ultimately, apps have the ability to enhance the patient-provider relationship. Providers, by way of this technology, can support elements of the PCMH and CCM models. Likewise, patients can become active, empowered partners in the patient-provider dyad. Although the benefits of apps continue to be studied and discussed, long-term acceptance as a certifiable clinical tool will depend on their ability to adhere to federal guidelines, their effectiveness at driving outcomes, and their integration into provider work-flow processes.
- Sia C, Tonniges TF, Osterhus E, Taba S. History of the medical home concept. Pediatrics. 2004;113(5 Suppl):1473–1478.
- Cooley WC, McAllister JW, Sherrieb K, Kuhlthau K. Improved outcomes associated with medical home implementation in pediatric primary care. Pediatrics. 2009;124(1):358–364. doi:10.1542/peds.2008-2600 [CrossRef]
- Palfrey JS, Sofis LA, Davidson EJ, et al. The Pediatric Alliance for Coordinated Care: evaluation of a medical home model. Pediatrics. 2004; 113(5 Suppl):1507–1516.
- Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002; 288(14):1775–1779. doi:10.1001/jama.288.14.1775 [CrossRef]
- Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001; 286(9):1041–1048. doi:10.1001/jama.286.9.1041 [CrossRef]
- Burke LE, Styn MA, Sereika SM, et al. Using mHealth technology to enhance self-monitoring for weight loss: a randomized trial. Am J Prev Med. 2012;43(1):20–26. doi:10.1016/j.amepre.2012.03.016 [CrossRef]
- Silow-Carroll S, Smith B. Clinical Management Apps: Creating Partnerships Between Providers and Patients. The Commonwealth Fund. Available at: http://www.commonwealthfund.org/media/Files/Publications/Issue%20Brief/2013/Nov/1713_SilowCarroll_clinical_mgmt_apps_ib_v2.pdf. Published November 6, 2013. Accessed November 12, 2013.
- Fox S, Duggan M. Mobile Health 2012. Pew Internet and American Life Project. Available at: http://www.pewinternet.org/~/media/Files/Reports/2012/PIP_MobileHealth2012_FINAL.pdf. Published November 8, 2012. Accessed November 22, 2013.
- Siminerio LM. The role of technology and the chronic care model. J Diabetes Sci Technol. 2010;4(2):470–475. doi:10.1177/193229681000400229 [CrossRef]
- Estrin D, Sim I. Health care delivery. Open mHealth architecture: an engine for health care innovation. Science. 2010;330(6005):759–760. doi:10.1126/science.1196187 [CrossRef]
- Bourbeau J. Clinical decision processes and patient engagement in self-management. Disease Management & Health Outcomes. 2008;16(5):327–333. doi:10.2165/0115677-200816050-00009 [CrossRef]
- Modi AC, Pai AL, Hommel KA, et al. Pediatric self-management: A framework for research, practice, and policy. Pediatrics. 2012;129(2):e473–e485. doi:10.1542/peds.2011-1635 [CrossRef]
- Woltmann EM, Wilkniss SM, Teachout A, McHugo GJ, Drake RE. Trial of an electronic decision support system to facilitate shared decision making in community mental health. Psychiatr Serv. 2011;62(1):54–60. doi:10.1176/appi.ps.62.1.54 [CrossRef]
- Piette JD, Rosland AM, Marinec NS, et al. Engagement with automated patient monitoring and self-management support calls: experience with a thousand chronically ill patients. Med Care. 2013;51(3):216–223. doi:10.1097/MLR.0b013e318277ebf8 [CrossRef]
- Zubialde JP, Eubank D, Fink LD. Cultivating engaged patients: a lesson from adult learning. Families, Systems & Health. 2007;25(4):355–366. doi:10.1037/1091-75184.108.40.2065 [CrossRef]
- Ceriello A, Barkai L, Christiansen JS, et al. Diabetes as a case study of chronic disease management with a personalized approach: the role of a structured feedback loop. Diabetes Res Clin Pract. 2012;98(1):5–10. doi:10.1016/j.diabres.2012.07.005 [CrossRef]
- Ricciardi L, Mostashari F, Murphy J, Daniel JG, Siminerio EP. A national action plan to support consumer engagement via e-health. Health Aff (Millwood). 2013;32(2):376–384. doi:10.1377/hlthaff.2012.1216 [CrossRef]
- Clark C. New G-Codes to Pay Doctors for Broad Array of Non-Face-to-Face Care. HealthLeaders Media. Available at: http://www.healthleadersmedia.com/print/QUA-298983/New-GCodes-to-Pay-Doctors-for-Broad-Array-of-NonFacetoFace-Care. Published December 5, 2013. Accessed December 16, 2013.
- Luxton DD, Kayl RA, Mishkind MC. mHealth data security: the need for HIPAA-compliant standardization. Telemed J E Health. 2013;18(4):284–288. doi:10.1089/tmj.2011.0180 [CrossRef]
- Blumenfeld BA, Garvin WA. An update on mHealth regulation in the United States. Journal MTM. 2013;2(3):1–3. doi:10.7309/jmtm.2.3.1 [CrossRef]
- U.S. Food and Drug Administration. Mobile Medical Applications: Guidance for Industry and Food and Drug Administration Staff. Washington, D.C.: U.S. Department of Health and Human Services. September23, 2013.
- Zanni GR. Medical apps worth having. Consult Pharm. 2013;28(5):322–324. doi:10.4140/TCP.n.2013.322 [CrossRef]
Patient-Centered Medical Home and Chronic Care Model Key Principles
|Patient-Centered Medical Home
||Chronic Care Model
||Clinical information systems
|Chronic care management
||Delivery system design