Friday, March 4, 2011

Dreaming of the ideal (family) practice

Several months ago, I reviewed the many challenges associated with measuring quality in primary care practices:

Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.

Along similar lines, the February 10th issue of Medical Economics contains an insightful article by family physician and quality guru L. Gordon Moore, MD, titled "Dreaming of the ideal practice." Dr. Moore points out that improved information technology and adherence to disease management guidelines, while the cornerstone of "medical home" accreditation, isn't necessarily associated with better care from a patient's perspective. "Primary care is inherently different from the rest of the healthcare delivery system," Dr. Moore asserts. "It is the first point of access, has relationships over time, provides comprehensive services, and coordinates care through the rest of the health system." Therefore, he says, these are the very things that can and should be measured to define "quality":

first point of contact;
person-focused (as opposed to disease focused) care over time;
comprehensiveness of care; and
care coordination for people who need care beyond the capacity of the primary care setting.

While I wholeheartedly agree that these elements are essential for good primary care, they aren't incompatible with traditionally measured qualities, either. In other words, you can see a doctor who knows the most appropriate drugs to use to manage diabetes and congestive heart failure, and also happens to be great at focusing on the whole person and coordinating care with other health professionals. Rather, what Dr. Moore seems to be arguing is that the latter should come before the former in value, which would have been obvious to a previous generation of family physicians, but is a mildly revolutionary concept in an increasingly "pay for performance" health care world. I think he's on to something.