Principles of the Patient-Centered Medical Home and Preventive Services Delivery

This fascinating study supports the experience of many GPs that long term care from the one practice and from a usual GP within that practice results in better care, and in particular with better provision of preventive care.

Readers may care to compare the findings of this study with ours of 2005:
Preventive activities during consultations in general practice: Influences on performance
http://www.racgp.org.au/afp/200506/200506frank.pdf
whose results we reported as:

"Patient characteristics significantly associated with higher performance of preventive activities were male gender, middle age, having had fewer consultations during the preceding 2 years, and having more long term health problems.

Women GPs were significantly more likely to record patients’ allergies and weight, perform Pap tests and tetanus immunisation, but significantly less likely to record patients’ smoking status. Patients’ usual GPs performed significantly better for lipid screening but significantly worse for recording of smoking status (Table 1).

Consultation characteristics significantly associated with higher performance were longer consultation (but the reverse for influenza immunisation), and fewer other preventive activities being due at the consultation (Table 2).

When at least one problem was coded at the consultation, recording of allergies, smoking status and weight were significantly more likely performed, as was screening for hypertension when two or more problems were coded. The opposite held for Pap testing and lipid screening, which were significantly less likely to be performed when one problem was coded. Tetanus immunisation was significantly more likely to be performed when two or more problems were coded, but significantly less likely to be performed when one problem was coded.

The billing of a patient co-payment was associated with higher performance of recording of smoking status and weight, screening for hypertension and Pap testing, but with lower performance of lipid screening, influenza, and measles, mumps, rubella (MMR) immunisation.

Characteristics of preventive opportunities significantly associated with higher performance were a reminder being displayed, and being the first opportunity during the study to perform the activity. The opposite held for lipid screening, which was most likely to be performed at the second opportunity (Table 3). When the preventive activity had been due for longer, performance was significantly higher for MMR immunisation and for screening for hypertension, hyperlipidaemia and diabetes, but significantly lower for recording of smoking status and Pap testing."

Competing interests:   None declared

The article by Ferrante, et. al. in this issue argues that the “high touch” aspects of the Patient-Centered Medical Home are of greater importance to improved care quality than the “high tech” aspects that many researchers and policy makers focus on when seeking primary care practice improvements.[1] This finding fits with other recent work finding that the promise of health information technologies (HIT) is unevenly realized in typical practice settings.[2-5] Interestingly, some of the key findings from this study point towards ways in which the use of HIT could be supportive of, rather than detrimental to, relationship-centered care in a PCMH. For example, effective use of clinical decision support functions of HIT systems such as electronic medical records and electronic prescribing could encourage rather than stand in the way of the evidence-based approaches to care advocated here. For example, having patient-specific prescription drug insurance information available at the point of care could assist physicians and patients in making cost effective treatment decisions. One other area where better use of high tech resources could support the high touch care advocated here is in proactively identifying patients in need of preventive services. Since the authors find that more frequent attendance is associated with better preventive service guideline adherence, identifying those who do not come in to the office and addressing their barriers to care could lead to better population health outcomes. Of course, these are all new tasks for physicians and primary care practice teams and practices will need support if they are to take them on effectively. In any case, high touch and high tech should not be seen as opposing approaches to care. Rather HIT, like other technologies (including paper-based reminder systems for example), should be seen as a tool to support relationship-centered approaches. Keeping high touch objectives in mind while working to integrate HIT into primary care practices may lead to improvements in work processes that prioritize work based on evidence-based goals while allowing physicians and other members of the health care team to focus on maintaining a relationship-centered approach. Rather than choosing to focus on one or the other approach, high touch and high tech approaches will need to be closely coordinated if primary care practices are to meet the challenges of improving preventive service delivery and care quality.

References:
1. Ferrante JM, Balasubramanian BA, Hudson SV, Crabtree BF. Principles of the patient-centered medical home and preventive services delivery. Ann Fam Med. 2010;8(2):108-116.
2. Crosson J, Isaacson N, Lancaster D, et al. Variation in electronic prescribing implementation among twelve ambulatory practices. JGIM. 2008;23(4):364-371.
3. Grossman JM, Gerland A, Reed MC, Fahlman C. Physicians' experiences using commercial e-prescribing systems. Health affairs (Project Hope). 2007;26(3):w393-404.
4. Crosson JC, Ohman-Strickland PA, Hahn KA, et al. Electronic medical records and diabetes quality of care: results from a sample of family medicine practices. Ann Fam Med. 2007;5(3):209-215.
5. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. May 16 2006;144(10):742-752.

Competing interests:   None declared

Many studies have demonstrated that PCMH works and it is the kind of care I would want for my family and your family. It seems so obvious that if one has 5 chronic diseases and ten different doctors treating them, and none coordinating, then you're in real trouble. And yes, this paper shows that when the number of chronic diseases are greater [5.8 (2.8 to 8.8)<.001], PCMH works. But this paper shows the relationship counts: the soft stuff, the high touch, the care, the whole-person, the whole-community-orientation also lowers cost and increases the possibility the patient will get the right test done. Want lower hospital rates and overall cost of care? Well, here are a few secrets:

Care provided for you by some who knows you and cares for you is better than care from a total stranger.

Care that one has access to is better than care one does not have access to.

Care that is comprehensive is better than care that is episodic only.

Care that is integrated is better than disintegrated.

Care that is whole-family and whole-community-oriented is better than care that is oriented to the doctors' pay.

Care that is supported by clinic decision support is better than unsupported care.

Care that is based on a relationship is better than care that is faceless.

Care that is empowering of self-management is better than passive.

The kind of care you would want for yourself and your mother is better than the kind you would not wish on your enemy.

This paper is timely: on March 21, 2010, the NCQA standards advisory group meets. This information will have been seen by all of them and will be used!!

Competing interests:   None declared