The Advanced Practice Nurse and Patient-Centered Medical Home: Maintaining Patient Focus, Meeting the Institute for Healthcare Improvement Triple Aim Through the Electronic Health Record

Aileen Twomey
Aileen Teresa Twomey DNP, Seton Hall University



The Federal Government enacted the Heath Information Technology for Economic and Clinical Health Act (HITECH) in 2009, which incentivized providers to use electronic health records (EHR) for meaningful use (MU); the Patient-Centered Medical Home (PCMH) stems from the Act. Research by the National Council on Quality Assurance (NCQA) shows that primary care practices have a positive influence on the health of patients, families and communities. These positive influences are related to their ability to deliver first-contact access, and to develop long-term therapeutic relationships that focus on the person rather than the disease, improving patient health outcomes and reducing health care cost.

The project focuses on developing a standardized template to guide the primary care provider (PCP) to efficiently document in the EHR and according to the NCQA recommendations. The template includes specific recommendations to focus on during a primary care visit, which are in line with the PCMH model. Using the existing EHR software, a template was developed highlighting the elements identified by the NCQA to guide the provider to accurately document care plans he or she develops with the patient; to document identified patient barriers for those who have not met treatment goals; to make appropriate referrals and identify self-referrals; and to reconcile discrepancies in treatment when a patient transitions throughout the health care system, such as after hospitalization.