Health Care Homes - January 2011 Webinar

Presented by Paul Kleeberg, M.D., Stratis Health

Date: Thursday, January 20, 2011
Theme: How national goals, measures, incentives and meaningful use help us achieve HCH goals
Presentation slides: Meaningful Use Supporting Health Care Homes (PDF: 361KB/27 pages)

Background Information and Materials

Health care providers can use health information technology (HIT)—including electronic health record (EHR) systems, patient care registries, and personal health records (PHR)—to support patient care as a health care home (HCH). Providers should ensure that any HIT tool they chose allows them to meet federal meaningful use criteria and any other clinical or process needs they may have.

Patients can use a PHR to actively manage their own health care information. Learn more about PHRs at

In general, HIT can support HCH by storing and retrieving patient information (i.e., cultural background, racial heritage, primary language, values, beliefs and preferred method of communication); facilitating care coordination and communication between the patient, the patient’s family, other providers involved in the patient’s care and other organizations; developing individualized care plans that guide and educate the patient and their family about the risks, benefits, and likely outcomes of available health care options; and providing reporting and analysis capabilities for performance reporting and tracking of key quality metrics.

The five Minnesota HCH standards are listed below with information on how technology can be used to support them.

  • Access Standard: Facilitate consistent and ongoing communication among the HCH, the patient, and their family (“participant”), and provide the participant with continuous access to their HCH.

Technology may help the Minnesota HCH:

  • Provide continuous access to the participants’ medical record information, including the participant’s contact information, personal clinician’s or local trade area clinician’s name and contact information, and designated enrollment in a HCH; the participant’s racial or ethnic background, primary language, and preferred means of communication; the participant’s consents and restrictions for releasing medical information; and the participant’s diagnoses, allergies, medications related to chronic and complex conditions, and whether a care plan has been created for the participant.
  • Comply with applicable privacy and confidentiality laws.
  • Registry Standard: Use an electronic, searchable patient registry that enables the HCH to manage health care services, provide appropriate follow-up, and identify gaps in patient care.

Technology may help the Minnesota HCH:

  • Conduct systematic reviews of the HCH’s participant population to manage health care services, provide appropriate follow-up, and identify gaps in care.
  • Record participant name, age, gender, contact information, and identification number assigned by the heath care provider.
  • Issue a report that shows any gaps in care for groups of participants with a chronic or complex condition.
  • Care Coordination Standard: Provide care coordination focused on patient and family-centered care.

Technology may help the Minnesota HCH:

  • Document referrals for specialty care, whether and when the participant has been seen by a provider to whom a referral was made and the result of the referral; tests ordered, when test results have been received and communicated to the participant; admissions to hospitals or skilled nursing facilities, and the result of the admission; timely post discharge planning according to a protocol for participants discharged from hospitals, skilled nursing facilities, or other health care institutions; communication with participant’s pharmacy regarding use of medication and medication reconciliation; and other information such as links to external care plans.
  • Care Plan Standard: Have a care plan for selected patients with a chronic or complex condition that involves the patient and the patient’s family in care planning.

Technology may help the Minnesota HCH:

  • Document the use of evidence-based guidelines for medical services and procedures.
  • Document the participant’s care plan goals and action plan for preventive care; care of chronic illnesses; exacerbation of a known chronic condition; end-of-life care and health directives.
  • Continuous Improvement Standard: Reflect continuous improvement in the quality of the patient’s experience, health outcomes, and cost-effectiveness of services.

Technology may help the Minnesota HCH:

    • Measure, analyze, and track changes for quality indicators.
    • Collect health care homes evaluation data.
    • Participate in statewide quality reporting system by collecting outcomes for quality indicators, such as improvement in patient health; quality of patient experience; and measures related to cost-effectiveness of services.

Resources on Technology and HCH

Visioning and Strategic Planning, Including Health Care Homes (DOC - Stratis Health). This tool describes a vision for HIT in clinics, including the purpose of implementing an EHR, along with a conceptual model of an EHR and suggestions for strategic planning—including planning EHR adoption to support being a certified health care home in Minnesota.

HIT Goal Setting (DOC - Stratis Health). Each organization needs to evaluate what it wants out of HIT, and define its own goals. This tool provides an overview of goal setting and template for tracking goals.

Minnesota Health Care Homes Functionality (DOC - Stratis Health). Determine what functionality your clinic will want to include in its request for proposals for an EHR that can support your HCH implementation.

Minnesota Health Care Homes Standards Crosswalk to CCHIT Criteria by EHR Certification Year (PDF: 130KB/7 pages). This tool cross references the Minnesota Health Care Homes (HCH) Standards to the Certification Commission for Health Information Technology (CCHIT) Criteria and Health Level Seven (HL7) Messaging Standards by electronic health record (EHR) CCHIT certification year. Use this information to help plan for an EHR that will meet your organization's needs.

Free or Low Cost Patient Registries (PDF: 46KB/2 pages). Patient registries can help providers support care delivery as a health care home. This document provides a list of free or low cost standalone registries (June 2010).

Free or Low Cost Personal Health Records (PHRs) (PDF: 51KB/2 pages). PHRs can help providers support care delivery as a health care home. This document provides a list of free or low cost PHRs (June 2010).

Minnesota Health Care Home – Scenarios for Evaluating and Testing HIT (PDF: 38KB/4 pages). Use these three scenario scripts or create your own to make sure HIT products meet your needs as a Minnesota Health Care Home.

Updated Monday, April 07, 2014 at 11:04AM