The articles in this supplement demonstrate that it is possible for highly motivated, largely independent practices3 to implement most of the predominantly technological components of the PCMH.4 This implementation results in improved indicators of chronic disease care as assessed from medical records, but at the cost of reducing the quality of key attributes of primary care as rated by patients, at least over the 26 months of the NDP.4,6
The journey is likely not pointless. It is a good thing to improve 'indicators of chronic disease care as assessed from medical records,' especially if there is a link between better numbers in medical records and outcomes that patients really care about like better functionality and fewer hospitalizations. It is also very important to try new things and see what we can learn about improving our currently not-so-good outcomes.
The troubling nature of this work as pointed out in this editorial in the Annals of Family Medicine supplement on Medical Home is that the experts on measuring health care quality in practice seem to be off track, in pursuit of small bits of chart data while missing the big picture.
When patients say that their access to care is no better, that the relationship with their PCP is no better, that comprehensiveness of care and care coordination are not better, we have failed to improve on the fundamental attributes of primary care. Troubling in this journal is the indication that in fact these attributes got worse during the study.
As these attributes predict a high performing health system, I don't think it is too soon to predict that this whole bandwagon of micro-measurement & blizzard of reporting and data mining will amount to very little except to create and support ever-growing bureaucracies of measurement, data mining, and reporting.
In fact, as predicted by many PCPs and others working in the front lines of care, much of this top-down labor intensive overly bureaucratic approach to improvement is not only stifling, it seems almost gamed to support large organizations at the expense of solo and small practices. The current approach is overly complex, burdensome, and largely tangential to the real work we do that helps people.
Adding a set of patient experience metrics to the current burdensome tangential approach is nice, but doesn't solve the underlying problem of focus on too many things, diverting attention from what is important, distracting us from work we should be doing for our patients instead of jumping through hoops for external reporting requirements. Measurement is good and just, but let's focus on the right work and the right amount of measurement. Things have gone way too far.
Our nation would be well served if it would take one small step to support truly innovative approaches to primary care - approaches that work even in solo and small practice and demonstrate and improvement not only in chart reviewed data but in patient experience of care and most importantly lead to results that patients would stand up for: reduced hospitalization and emergency room utilization.
We need pilots of other approaches, approaches not run through massive bureaucracies or expensive consultancies but accessible through simple on line support that honors adult learning theory and the exigencies of practice in the front lines. Give volunteer practices a lifeline - some breathing room to get off the hamster wheel and a simple set of resources that open their eyes to how they perform on the key metrics of primary care: access, relationship, comprehensiveness, coordination. Track hospital and ED use for preventable conditions. Simple, clean, actionable, accountable, and totally lined up with effective primary care and the outcomes we all want.
The burgeoning recognition of effective primary care as the foundation of high performing health systems deserves or wholehearted support. Mindless pursuit of minutia and further diversion of front line time and resources to chase data rainbows does not. Let us pursue meaningful data, let us pursue improved patient experience of care especially as it is linked to the very outcomes we want and need: improved meaningful outcomes like fewer people landing in the hospital due to preventable illness and complications.