Dreaming of the ideal practice

February 10, 2011

The much talked about support for primary care should be a relief to a debilitated primary care workforce struggling to survive a toxic payment and policy environment.

Key Points

In spite of this skepticism, some primary care practices are transforming themselves along the lines of Patient-Centered Medical Homes-delivering care that improves outcomes and experience of care and reduces preventable emergency room and hospital use. The lessons learned from early success might help others succeed.

I have worked extensively to redesign my own primary care practice, and through my work with the Institute for Healthcare Improvement and the Ideal Medical Practices non-profit organization, I have assisted many other practices as they strive to improve. In this work, I have seen many efforts founder on policy, payment, measurement, or implementation issues. Meanwhile, costs continue to increase, an increasing number of people have difficulty obtaining care due to finances, and quality indicators for the United States lag behind the rest of the developed world.2

In this article, I discuss the exploration of high-quality primary care in my practice as well as others, the flaws with our current approaches to primary care measurement and quality improvement, and one way forward that better links primary care system redesign to the outcomes we desire.

Before I can discuss redesigning the delivery system, I must reiterate the obvious problem that in most clinical settings we're still punished financially when we pursue excellence in primary care. We must have new payment models that support both excellence in primary care and the goals of improving outcomes to reduce preventable emergency room, specialist, and hospital use.


In 2001, after years of working on primary care workflow redesign projects at an academic medical center and affiliated outpatient clinics and then with the Institute for Healthcare Improvement, I launched a prototype practice focused on exploring the roots of high-performing primary care in practice. The practice was organized around the principles of improved access, relationship, communication, and coordination.

Information technology allowed us to reduce overhead, providing the breathing room to implement the principles noted above.3 Anecdotal success of the model attracted significant interest from frontline clinicians, and together we created a community of common interest on the Internet.4

In 2005, a generous grant from the Physicians Foundation gave us the opportunity to explore dissemination of this approach and quality measurement in primary care.

Our project team invited practices to participate in conference calls every 2 to 3 weeks, use an online curriculum coupled with other online resources, and use an alternative approach to quality measurement better aligned with broad population improvement. Practice volunteers received coaching on changing their delivery system, access to a health coach, and use of a tool that starts practices on the path to supporting patient self-efficacy and improved outcomes.5

We wanted to avoid what we saw as mistakes inherent in the current approach to quality improvement and measurement in primary care. Practices with the best of intentions and efforts often fail to generalize excellence in disease management to excellence in primary care. Doing so is important because effective primary care is the foundation of high performing health systems, and disease management is not.6

The current measurement paradigm is dominated by the assumption that better disease management and health technology will solve our problems. Although good technology well implemented can enable better process and outcomes, disease management has a spotty history. Decades of funding and attention to disease management have failed to produce the needed population outcomes, patient experience improvement, and per capita cost reductions. Large population studies identify primary care as the foundation of high-performing health systems.7

Primary care is inherently different from the rest of the healthcare delivery system. It is the first point of access, has relationships over time, provides comprehensive services, and coordinates care through the rest of the health system.8

Attempts to measure primary care effectiveness by "percent guideline adherence for better disease management" or "how much of this list can your health information technology perform" misses the essence of primary care and therefore misses what we do that is likely to help us reach the goals of improved population health, experience of care while reigning in healthcare cost increases. Each of the line items in the lengthy Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH) rubric from the National Committee for Quality Assurance (NCQA) may be defensible but lacks importance relative to the basic attributes of primary care. Although correct on the technical side, the approach leaves out compassion and humanity, which are the intrinsic to good care even though they are difficult to measure.

An anecdote makes the point: I spoke with a physician policy-researcher who was evaluating medical home implementation. He visited many offices. Some had achieved NCQA PPC-PCMH Level III recognition but were cold, impersonal, and had problems with how they served their patients (waits and delays, etc.). He visited a low-tech practice that would receive no recognition from NCQA but found it to be very invested in its patients, knew them well, and treated them with dignity, respect, and real care. He said he'd take his elderly mom to the latter practice every time.