Top Tools, Workflows and Processes for a Patient-Centered Medical Home

Tuesday, February 4th, 2014
This post was written by Patricia Donovan

Online tools such as EHRs and registries facilitate care coordination in the patient-centered medical home.


Chart scrubbing, electronic medical records and disease registries form the framework of patient-centered care, according to respondents to the 2012 Patient-Centered Medical Home survey. The following tools, workflows and processes are enhancing patient-centered care delivery by responding organizations, as told in their own words:

  • Added patient advisory council, which has made great suggestions.
  • ‘Electronic medical record (EMR) lite’ with secure e-mail.
  • Extended hours obviating urgent care centers or ER visits.
  • Chart scrubbing: review of the charts of patients coming in for appointments so that the provider is made aware of everything that needs to happen at that visit so it can be taken care of proactively.
  • Microsystems.
  • Registry management.
  • Using lower level (education) workers in the process.
  • Patient profile to include all providers, specific care gaps, etc.
  • Discharge reconciliation registry.
  • Our EMR is the most effective; it supports everything else. Secondly, standardized written protocols/standing orders that allow the healthcare team to provide care that increases office efficiency and quality indicators.
  • It’s not about the tools, it’s about training the people to use the tools effectively and efficiently. ‘LEAN’-ing is not a cure; it’s another aspect of training.

Excerpted from: 33 Metrics for Care Transition Management

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