Durham, N.C. — Duke's Family Medicine Center is considered a pioneer for its development of the "medical home" concept. The system uses health care teams and the latest information technology to keep patients from falling through the cracks.

Duke’s Marshall I. Pickens clinic is 57-year-old Johnny Odom’s medical home. Dr. Gloria Trujillo helps Odom navigate through a system of specialists who treat him for complications of heart failure, diabetes and glaucoma.

“Dr. T., she sets up everything for me,” Odom said.

Through the medical home concept, Trujillo has instant access to all of Odom's medical records. Without this kind of information, she would have to rely on what he could tell her her or contact his other doctors by phone.

In the past, Trujillo said, she played phone tag for days with specialists. Now, Trujillo can communicate regularly with specialists by e-mail.

Trujillo can also help Odom cancel unnecessary appointments.

In some cases, the clinic can also take care of things a specialist might do.

“It's cut down a lot on his visits. He also gets his foot care here, where before he used to see a podiatrist in town,” Trujillo said.

Electronic medical records have cut down on errors of handwritten prescriptions. “Prescriptions are immediately sent to the pharmacy,” Trujillo said.

Patients can use a Web portal to access their own records at home. They can also schedule their own appointments and manage their accounts.

Odom said the comprehensive care of the medical home concept is paying off.

“At this point, everything is going pretty nice,” Odom said.

The National Committee for Quality Assurance recognized the Marshal Pickens clinic as a "Level 3" medical home in response to its achievements in care.