PCMH | “Revitalizing” Primary Care

With all of the focus across the EHR marketplace spotlighting the need for Meaningful Use, NCQA’s Patient Centered Medical Home (PCMH) is a program that many organizations have yet to focus on. The program is designed to “revitalize” primary care and proactively treat clients for chronic conditions, focusing on 5 key areas:

  1. Comprehensive Care
  2. Patient-Centered Care
  3. Coordinated Care
  4. Accessible Services
  5. Quality and Safety

These are all subjective goals. What does comprehensive care even mean? How do you measure whether an organization qualifies as a PCMH?

The Agency for Healthcare Research and Quality outlines key reporting measures to demonstrate how well an organization is doing at achieving these overall goals and provides the certifications needed to reap great financial rewards from the federal government. The Agency for Healthcare Research and Quality has chosen measures like MU, NQF, and UDS to certify as PCMH compliant, and organizations can pick and choose at which measure they want to try and excel. However, even with this guidance, it is often not clear how to approach these reports. Galen has been working with organizations since before the HITECH act was passed, and we would like to summarize some of the challenges we have seen as we have helped clients navigate the fog of PCMH reporting.


  • Defining the Criteria: While requirements may be defined at a high level, some do not offer a clear definition of what each of their criteria actually means. For example, what is the definition of an ‘active patient’? One of the most common definitions we have seen organizations use is any patient that has been seen by their Primary Care Provider in the last 18 months.
  • Improving Clinical Workflows: Organizations will need to have buy-in from their Primary Care Providers that these investments will pay off both for their patients and their own wallets. They often need new staff and training on workflows relative to clinical data including problem management (ICD-9/10), medications, and orders.  This is imperative to assure that clinical data is being documented reliably and accurately in a consistent way by everyone.  The proper documentation of these workflows is also key, so that anyone can reference them at any time.
  • Reporting & Data Aggregation: Reporting is not limited specifically to EHR, as there are various data points that might be found in your Practice Management System. Aggregating data between an EHR and a PMS can be tricky depending on the architecture of the respective vendors, but here we will focus on Allscripts Enterprise EHR & Epic.
    • Allscripts provides a number of tools that can assist with PCMH reporting including their StimSet, Population Health Management, Analytics and CQS platforms. However, these do not always meet the standards of every organization, especially when they must aggregate data or use custom logic. Here at Galen, we can leverage custom reports querying the database directly to assist with any unique circumstances and build out custom databases for analytics across multiple systems.
    • Epic’s Reporting Workbench and Clarity applications provide organizations the ability to report on clinical documentation relating to patient outcomes, treatment methods and interventions.  These tools can report on improvements in care, implement a continuous improvement cycle and report out to stakeholders, accrediting bodies, and the patient population.  Galen can provide assistance in creating and configuring reporting solutions based on your organization’s needs.
  • Abstraction & Scanning During Active Roll-Out:  One organizational challenge that Galen has seen has been certifying for PCMH during the active implementation of your EHR software.  Abstraction & Scanning procedures need be thought out in advance and included per implementation.  For example, if your organization might want to report on Pap Smears and Mammograms, it is important to clearly define a chart structure where these specific documents are listed separately. This allows reports to be run against those items alone.
  • Patient Communication: Depending on the level of certification, the organization is expected to create an active communication channel with their patients.  Efforts using secured channels like patient portals are obviously important to plan for, but knowing and scripting the communication is also equally important. For example, if your organization has selected to meet the criteria for obesity, as it is an easy measure to report on, will you be able to script a communication that will be well-received from your patient population?

Galen Healthcare Solutions has experts in all areas of healthcare data management that can assist your organization during the PCMH certification process. We can help with both Allscripts & Epic application reporting and workflow requirements. Despite the chaos of this new healthcare landscape, this is an exciting time for Galen and our clients as the PCMH guidelines open the doors to some amazing innovations by our clients.

Contributions & Experience Provided By:

August Borie: Consultant, Professional Services

John Buckley: Senior Consultant, Professional Services

Logan Cate: Consultant, Technical Services

Sue D’Agostino: Clinical Consultant, Professional Services

Charlee Day: Epic Consultant, Professional Services

Christopher Libby: Associate Consultant, Technical Services

Julia Snapp: Epic Managing Consultant, Professional Services


Additional Resources:



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