Primary Care: The Next Renaissance

Three decades ago, a renaissance in primary care helped create the foundations of the field as we know it today. While primary care has developed as a vital intellectual and applied concept, the changes that had been hoped for in the medical care system to support the goals of comprehensive, continuous, patient-centered, and outcomes-oriented care have not occurred. In fact, the dominance of specialty care is increasing, interest in primary care as a career has waned; and changes in reimbursement and health care organization, such as the advent of managed care, have been relatively negative for primary care. We believe passionately in the basic principles of primary care and are deeply concerned about its future. The current state and direction of primary care are discussed in this supplement of Annals (1-4). In this paper, we suggest seven core principles (Table 1) to support a renaissance in primary care and a set of actions (Table 2) to address this crisis and enable primary care to play a substantial role in achieving the goals of high-quality, patient-centered, efficient, and user-friendly care for individuals and populations. Table 1. Seven Core Principles in Support of a Renaissance of Primary Care Table 2. Reconstructing Primary Care Core Principles Seven core principles should guide the next renaissance of primary care: 1) Health care must be organized to serve the needs of patients; 2) the goal of primary care systems should be the delivery of the highest-quality care as documented by measurable outcomes; 3) information and information systems are the backbone of the primary care process; 4) current health care systems must be reconstructed; 5) the health care financing system must support excellent primary care practice; 6) primary care education must be revitalized, with an emphasis on new delivery models and training in sites that deliver excellent primary care; and 7) the value of primary care practice must be continually improved, documented, and communicated. Principle 1: Health Care Must Be Organized To Serve the Needs of Patients Health care should achieve optimal health and medical outcomes within available resources and respect and respond to a patient's needs, values, and preferences. Patient-centered care (5) includes the patient as an active participant in the clinical decision-making process and incorporates an understanding of the patient's preferences and needs. Such care is user-friendly to both patients and clinicians, with everything from the design of information systems to the hours of operation structured to create a partnership between patient and clinician. Patient-centered care is a core principle of primary care and is supported by the goals of comprehensiveness and continuity. Much of the current organization of medical care, however, is structured to accommodate incentives in the reimbursement system and the preferences of clinicians, often with patients' needs included only as an afterthought. Responding to patients' needs and desires must be a fundamental objective of future health care systems. Principle 2: The Goal of Primary Care Systems Should Be the Delivery of the Highest-Quality Care as Documented by Measurable Outcomes The central goal of primary care systems should be the delivery of high-quality care that leads to the best possible outcomes. We agree with conclusions of the Institute of Medicine's recent analysis of the quality of health care, Crossing the Quality Chasm (6); it is time to create systems that are safe and effective. The definition of quality could, and should, be based in large part on definable outcomes. Accomplishing this goal requires research to establish appropriate indicators of primary care quality and the development of methods to identify, collect, and evaluate the most relevant information. While a true, outcomes-based system may be some years away, what is known today about processes and practices that lead to good outcomes can help guide the redesign of primary care systems. Systems of care need to be accountable to consumers, clinicians, and payers, and this accountability must include the measurement of individual and population outcomes. The concept of accountability has not fully evolved, and today's systems of oversight, such as the Health Plan Employer Data and Information Set measures (7), are oriented more toward overall system outcomes than toward assuring individual outcomes. As accountability becomes more clearly defined and operationalized, it should become part of, and assist in, routine quality-improvement efforts. This will require patient- and outcomes-oriented information systems with adequate mechanisms to protect confidentiality. Principle 3: Information and Information Systems Are the Backbone of the Primary Care Process Information and the exchange of information are key to excellent primary care to assist in the clinical decision-making process, track the preventive and acute care provided, educate patients, assess outcomes, and provide patients with the information they need to manage their health and make decisions about their care. The effective provision of primary care requires processing large amounts of knowledge, ranging from an individual's risk factors and health status to the likelihood that a particular diagnostic procedure or therapy will be optimal for a patient. More so than for procedure-based specialists, information is at the core of the primary care process, and information systems are primary care's technology. Today's health care information systems were designed primarily in response to administrative needs, with reimbursement at the top of the list (8). While these encounter-based systems may serve their narrow administrative purposes well, they rarely collect information that allows management of a patient's needs over time or an assessment of the effects of clinical processes on patient outcomes. Encounter-based systems encourage discontinuity for patients, poor communications among clinicians, and underuse of the information that is available, and they often produce less than optimal care. Even in academic medical centers, where the most advanced clinical technologies are developed and used, patients often cannot be tracked from the inpatient to the outpatient setting or among different types of clinicians, nor can patients and clinicians access and share information. A Personal Health Information and Choice system is needed. This system would be an essential component of patient-centered and accountable health care and would, almost by definition, enhance the role of primary care clinicians. Containing information about a person's health, risk profile, and recent preventive and clinical care, this system would be patient centered in both the information that it contains and the ability to access that information. Persons, whether they are active patients or not, would be able to interact with the system, communicate with their clinician, review their medical records (a recently established requirement [9]), view results of tests and therapies, and add information about their current health status. Decision-support tools would help both patients and clinicians to identify clinical choices and probable outcomes in a manner that is both understandable and useful, and the system would include links with community resources and Internet sites to enhance the short amount of time available for patient education in a routine visit. The system would also link closely with emerging efforts to rebuild the information technology components of the public health infrastructure and maximize the opportunities to develop robust connections between the personal health services delivery system and public health. The knowledge and technology to create and implement such systems are available today. The political will to devote the necessary resources to this effort is needed now. We believe that the development and implementation of patient-centered health information systems should be among the highest priorities for the future use of resources in health and health care. Principle 4: Current Health Care Systems Must Be Reconstructed Health care organization is an oxymoron. In reality, we have an extremely complex and fragmented set of clinicians, facilities, and services that have been created on the basis of requirements for reimbursement and the needs of clinicians. Patient needs and outcomes and clinician accountability usually have been secondary considerations in the design of systems of care. While not necessarily the worst offender in this regard, primary care has generally played a very passive role in the design and implementation of health care systems. For example, rather than taking the lead in developing organizations that are devoted to health maintenance, and in which primary care has a central role, primary care clinicians were relatively passive when assigned the role of gatekeeper by managed care organizations. We can imagine a new and better type of health care system that is designed to address patient and population needs and preferences. Such a system would be participant controlled, outcomes oriented, structured to address the needs of the system's population, and focused on the ongoing relationship between a patient and his or her primary clinician. Care models would be based on the functions that are necessary to achieve desired outcomes. Quality of care would be measured through active and ongoing assessment, ideally by an independent evaluator. The organization's integrated information systems would provide a real-time assessment of processes and outcomes so that quality issues could be resolved quickly, with key indicators of quality and outcomes published regularly. Such a system would be much closer to a true health maintenance organization. Health care systems need to be both flexible and agile, with a capacity for rapid change in response to new circumstances. In the futu