Whether those tools are used effectively isn't measured. Practices are still learning, and clinicians are still figuring out the best way for their organizations to achieve goals of good patient outcomes, and they're still staffing up or rearranging the type of work that the physician's assistants should do to improve outcomes.
This is not surprising. You can have all the technological links in the world, and you can be certified, but if your practitioners don't use those tools to better communicate and connect with patients and their services at other sites, its promise is stillborn. Indeed, these softer skills are harder to quantify, but critical to the work. And aren't evaluated in the drive to achieve certification.
3. Principles pass the common sense test.
The principles of patient-centered care are still relatively new, especially to patients. And they aren't used to it. Patients are used to being on their own for healthcare outcomes, and the fact that a patient navigator is following up with them on needed care is unfamiliar. Old habits are hard to break.
It's common sense that acting on the principles of the PCMH, not just fulfilling the requirements to get the designation, should reduce healthcare costs and improve quality. If the PCMH designation leads to patients, payers and employers holding practices accountable for outcomes, it has promise.