BMJ  2005;330:E358-E359 (11 June), doi:10.1136/bmj.330.7504.E358

BMJ USA: Editorial

Editorial

Primary care needs a new model of office practice

Fewer in-person visits, more patient contacts

Primary care medical practice is well known for a brief office visit model of practice. However, this model no longer meets the needs and expectations of patients. Tools and methods are now available to revolutionize how primary care is delivered. New care models have the promise to be of higher quality, more efficient, and more satisfying for both patients and physicians. Now is the time to radically change how primary care is delivered throughout the world.

Until the last three decades, people generally went to their primary physicians only when they got sick. Respiratory infections, gastrointestinal maladies, and other common health problems were efficiently diagnosed and treated. Productivity in primary care has been defined by how many patients can be seen each day, and how many patients in a community the primary care physician can manage. While many primary care physicians do an amazing job seeing lots of patients every day, poor overall quality of care has been the dirty secret that has recently come to light.^1-3

Today, primary care physicians are expected to provide comprehensive and continuing care to patients and families, including modern preventive care and chronic illness management. They must adhere to the latest clinical guidelines, provide care based on the biopsychosocial model, and complete all the paperwork required by health plans. This is complex work, and physicians are the only professionals in society that try to do complex work in brief visits.

This mismatch between time available in the current model of care and expectations of primary care practice results in not only poor quality but also major stress and unhappiness among physicians.⁴ There are alternatives.

The typical primary care physician cares for 1500 to 3000 people in a community, depending on its demographics. Based on a target of 5000 fifteen-minute visits a year, a visit-dependent model of care allows a physician about an hour per year per patient! That is not enough time to provide good preventive care, let alone to treat illness. The first rule of a new model of quality care is not being dependent on visits.²

So what are the elements of a new model of primary care and what would the average day be like? The answers are emerging and the news is very exciting.

The future of primary care depends on leadership stepping up and promoting redesigned models for greater quality and satisfaction. The tools and methods are here. Let's get on with it.

Online care The internet is the greatest advance to civilization since the printing press, and it is free. The internet is changing almost every service industry, from banking to travel, and health care should be no different. While health information, good and bad, is abundant over the internet, actual patient care is not. That will change, and each primary care practice should have a robust interactive web site with resources for everything from preventive advice to the management of chronic illness. Ongoing important health problems such as smoking cessation, losing weight, and monitoring almost any chronic illness can be done on a new online platform of care. Office visits are then scheduled selectively and can be given more time, which would make primary care far more professional in its delivery. What percentage of current visits could be managed online? When the author began to give his e-mail address to all his patients, two thirds of health communication went online each week, and visit lengths doubled in time.⁵ Since 20 to 30 patient communications can be done per hour online, most of the day is spent seeing fewer patients in unhurried visits. No more running on a hamster wheel!⁶

Group visits Since chronic illness management and lifestyle modification dominate primary care, patients with similar problems can now be seen in groups. The dynamics of group visits are powerful, and peer support can help with tackling tough problems such as weight loss.⁷

Electronic health records and self management The age of health information technology is here, and having patient records on scattered pieces of paper is outdated. When the patient record is available over a secure Web site, the patient can access their record anytime and add important information. True patient-centered primary care happens when the patient becomes a partner in their own care and has ownership of their medical record.

Team practice Primary care today is no longer a single physician craft but a complex set of tasks best managed by a multidisciplinary team. Asthma care and obesity management are good examples. Online care and electronic health records allow the primary care team to work in a coordinated way with patients to achieve the best possible outcomes a system of care may provide.⁸

Finances The current financial model of fees for office visits retards innovation in primary care and must be modified. Visits are time consuming and expensive, and online care and group visits create efficiencies that should lower the cost of care for most patients. This is of great interest to whoever pays for the care, whether the patient, the government, or a health plan. Prepaid contracts for care or monthly user fees are emerging to reimburse primary care physicians for care not based on office visits. Primary care physicians should be open to and creative with reimbursement models that drive innovation.

What holds back primary care from such innovation? Donald Berwick, founder of the Institute for Healthcare Improvement, sees it as a lack of will and ambition.⁹ Primary care physicians are so busy doing clinical work that most do not have time to change. Primary care is also undervalued in many health systems and redesign has not been a priority. However, primary care is critical to any well run health system. The recent convergence of knowledge and technology provides an opportunity to fundamentally rethink and redesign how primary care is delivered. The future of primary care depends on leadership stepping up and promoting redesigned models for greater quality and satisfaction. The tools and methods are here. Let's get on with it.

Department of Family and Preventive Medicine University of California, San Diego Jscherger{at}ucsd.edu

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Competing interests: JES has accepted fees for speaking on the topics expressed in this editorial. He has also been reimbursed for attending conferences where this material has been presented.

References

1. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348: 2635-45.[Abstract/Free Full Text]
2. Institute of Medicine. Committee on Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st century. Institute of Medicine. Washington, DC: National Academy Press; 2001.
3. Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, et al. Patient safety: Adverse drug events in ambulatory care. N Engl J Med 2003;348: 1556-64.[Abstract/Free Full Text]
4. Edwards N, Kornacki MJ, Silversin J. Unhappy doctors: What are the causes and what can be done? BMJ 2002;324: 835-8.[Free Full Text]
5. Scherger JE. Online communication with patients: Making it work. Fam Pract Manag 2004;11(4): 73-4.[Medline]
6. Morrison I, Smith R. Hamster health care. BMJ 2000;321: 1541-42.[Free Full Text]
7. Bodenheimer T. Innovations in primary care in the United States. BMJ 2003:326: 796-9.[Free Full Text]
8. Lawrence, D. From chaos to care: The promise of team-based medicine. Cambridge, MA: Perseus Publishing; 2002.
9. Galvin R. A deficiency of will and ambition: A conversation with Donald Berwick. Health Affairs 2005; web exclusive, http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.1v3.

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