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In successfully reducing healthcare expenditures, patient goals must be met and savings differentiated from cost shifting. Although the Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program for chronically ill individuals has resulted in cost reduction for the VA, it is unknown whether cost reduction results from restricting services or shifting costs to Medicare and whether HBPC meets patient goals. Cost projection using a hierarchical condition category (HCC) model adapted to the VA was used to determine VA plus Medicare projected costs for 9,425 newly enrolled HBPC recipients. Projected annual costs were compared with observed annualized costs before and during HBPC. To assess patient perspectives of care, 31 veterans and caregivers were interviewed from three representative programs. During HBPC, Medicare costs were 10.8% lower than projected, VA plus Medicare costs were 11.7% lower than projected, and combined hospitalizations were 25.5% lower than during the period without HBPC. Patients reported high satisfaction with HBPC team access, education, and continuity of care, which they felt contributed to fewer exacerbations, emergency visits, and hospitalizations. HBPC improves access while reducing hospitalizations and total cost. Medicare is currently testing the HBPC approach through the Independence at Home demonstration.

PURPOSELittle is known about the effects of the electronic health record (EHR) on physician-patient encounters. The objectives of this study were to identify the factors that infl uence the manner by which physicians use the EHR with patients. METHODSThis ethnographic study included 4 qualitative components: 80 hours of participant observation in 4 primary care offi ces in the Pacifi c Northwest; individual interviews with 52 patients, 12 offi ce staff members, 23 physicians, and 1 nurse-practitioner; videotaped reviews of 29 clinical encounters; and 5 focusgroup interviews with physicians and computer advocates. The main outcome measures were factors that infl uence how physicians use the EHR. Researchers qualitatively derived these factors through serial reviews of data. RESULTSThis study identifi ed 14 factors that infl uence how EHRs are used and perceived in medical practice today. These factors were categorized into 4 thematic domains: (1) spatial-effect of the physical presence and location of EHRs on interactions between physicians and patients; (2) relational-perceptions of physicians and patients about the EHR and how those perceptions affected its use; (3) educational-issues of developing physicians' profi ciency with and improving patients' understandings about EHR use; and (4) structural-institutional and technological forces that infl uence how physicians perceived their use of EHR.CONCLUSIONS This study found that the introduction of EHRs into practice infl uences multiple cognitive and social dimensions of the clinical encounter. It brings into focus important questions that through further inquiry can determine how to make best use of the EHR to enhance therapeutic relationships. INTRODUCTIONT he electronic health record (EHR) is a new technology touted as a standard of practice for American medicine in the 21st century. 1,2 This technology brings the medical record and health information into the examination room through computer hardware and software, patient education materials, and Internet search capabilities. Several authorities endorse the transition to EHRs and promote a technologybased information infrastructure that eliminates handwritten clinical data within 10 years. 3,4 Numerous authors have discussed the theoretical benefi ts of computers in clinical practice, 1,[5][6][7] and differences exist when comparing the use of EHRs with paper charts. 7,8 Although these differences have not been found to affect patient satisfaction, 9-11 little else is known about the effects of this technology on physician-patient encounters.Studies examining clinical encounters with EHRs suggest that physicians using EHRs preferentially structure interviews around data-gathering demands rather than patients' own narratives. 12,13 Recent data, however, suggest that this pattern relates more to physician style than to EHR use alone.14 Physicians using EHRs also engage in a variety of computer-related The purpose of this work was to explore how EHRs affect the encounters between physicians and thei...

Objective-Recommendations for improving care include increased patient-clinician collaboration, patient empowerment, and greater relational continuity of care. All rely upon good

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