From the Editor
The focus of this issue could not happen at a better time. A thorough update and understanding of the Institute for Healthcare Improvement's (IHI's) Experience in Office Practice Redesign is critical for the attainment of patient-centered care. Patient-centered care is not just patient satisfaction but an entire approach to focusing on the patient's needs/interaction with the primary care health professional team. This issue of the journal provides us with the critical elements for success.
The articles in this issue also compel us to consider their relationship to the latest fad in healthcare delivery—the Medical Home. Financial success of the Medical Home is predicated on financial incentives that not only provide an encouragement for excellent practices to continue their already successful practice approach but also show a clear path of encouragement to health professional teams that have opportunities for improvement. Proponents of the Medical Home have understandably seen it as a way to increase payment to primary care physicians or healthcare professionals. To the extent that policy makers have expressed any interest in the way primary care health professionals run their practice, they have focused on a problematic combination of a simplistic examination of the cost side of the equation together with a significant increase in office paper work/process aspects of quality. I would like to convince the proponents of the Medical Home to focus their efforts on a patient-centered approach linking patient-derived concerns (their perception of care and their empowerment and all relevant costs). The office redesign experiences described here by the Institute for Healthcare Improvement combined with a recent series of articles about technologies to support patient-centered care (Moore & Wasson, 2006) and payment for this care (Goldfield et al., 2008) provide a useful foundation on which to build a durable Medical Home.
To be successful, the Medical Home needs to operate on the following principles:
- Patient-centered care is not just patient satisfaction but an entire approach to focusing on the patient's needs/interaction with the primary care health professional team.
- A key by-product of this relentless focus on the patient's needs is information that is continuously fed back to the health professional team and patient/family/socioeconomic unit such as community that identifies opportunities for improvement in patient health empowerment/health status/satisfaction/concerns.
- Use person de-identified methodologies pertaining to cost and the previously mentioned aspects of quality that are transparent to all users (payers, patients/family/community, health professionals).
- Recognize that we already spend a tremendous amount of money on healthcare, and a significant portion of the increase in payment to primary care health professionals will need to come from savings that emerge from changes in the way primary care health professionals deliver care.
- Changes in primary care health professional practice that can fund a significant increase in payment to the primary care health professional team will need to particularly emerge from changes in the way health professionals order and patients use ancillaries (especially expensive ones such as computed tomography and magnetic resonance imaging), emergency departments, and potentially avoidable hospitalizations (especially readmissions).
- This change in practice pertaining to ancillaries, emergency department usage, and potentially avoidable hospitalizations must be communicated to all interested parties, particularly the health professional team, in a timely and detailed enough manner that provides all parties with a clear understanding of opportunities for improvement in these 3 areas critical to the financial success of the Medical Home.
- Clear understanding of savings in these 3 areas together with patient information as described earlier can occur only if the information is transparent and the methodologies used are clinically credible.
- Financial success of the Medical Home is predicated on financial incentives using the methodologies described earlier, which involve not only encouragement for excellent practices to continue their already successful practice approach but also a clear path of encouragement to health professional teams that have opportunities for improvement.
Most health professional teams that have opportunities for improvement in cost and quality outcomes are simply responding to the current perverse fee-for-service incentives that reward waste and pay little attention to patient needs.
This issue of the 10th anniversary of IHI's outstanding Office Practice Redesign conclusively demonstrates that this approach has come of age.
Simply put, without prime-time implementation of Office Practice Redesign, the Medical Home—something all of us want—will fail.
Norbert Goldfield, MD
Goldfield, N., Averill, R., Vertrees, J., Fuller, R., Mesces, D., Moore, G., et al. (2008). Reforming the primary care payment system: Eliminating E&M codes and creating financial incentives for an advanced medical home. Journal of Ambulatory Care Management, 31
Moore, L. G., & Wasson, J. H. (2006). An introduction to technology for patient-centered, collaborative care. Journal of Ambulatory Care Management, 29(3)