A key term used in this definition is integrated. It can be defined as “combining separate and diverse elements or units so as to provide a harmonious, interrelated whole” (see Webster, 1981; Random House, 1983). Integrated as used in this report is intended to connote multiple important concepts: the provision of comprehensive, coordinated, and continuous services that represent a “seamless” process of care. Those three terms from the 1978 IOM definition—comprehensive, coordinated, and continuous—are described below. The committee's use of the term integrated when describing personal health care services should not be confused with the widely used term as applied to horizontal and vertical integration in integrated delivery systems. To integrate primary care fully, however, primary care clinicians are likely to practice in teams and in such integrated delivery systems.

Some care settings are very small systems, for example, a solo clinician, nurse, one administrative person, and referrals as needed for specialty care. One can envision, however, the development of primary care networks using computers to link smaller systems of care into broader ones that are facilitated by information networks (IOM, 1991). Although such primary care networks might not include a full range of services, such developments would move small systems toward the sort of integration envisioned by the committee.

Integration might be fostered in other ways. An example would be linking specialist (e.g., dermatology, psychiatry) or subspecialist (e.g., gastroenterology, pulmonology, cardiology) services for a patient with a chronic illness with a primary care clinician (either within the subspecialty practice or elsewhere) who can continue to give primary care.


First Contact. One element of comprehensiveness is sometimes referred to as first contact. In a well-developed and functioning system, primary care is the usual and preferred route for entry into the health care system (although not necessarily in all circumstances). In the simplest model, the primary care clinician receives patients regardless of the disease or organ system involved and addresses a given patient's problem. This function may require sorting out a mixture of ill-defined symptoms, or it may call for fairly straightforward treatment. This simplest of models, however, should be flexible enough to allow patients to enter at various points or to skip given steps (e.g., authorizations) based on their needs and safety as well as on efficiency considerations. The model is not intended to describe a regimented or restrictive processing system,

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