Defining Primary Care
Since its introduction in 1961, the term primary care1 has been defined in various ways, often using one or more of the following categories to describe what primary care is or who provides it (Lee, 1992; Spitz, 1994). These categories include:
- The care provided by certain clinicians—Some proposed legislation, for example, lists the medical specialties of primary care as family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology. Some experts and groups have included nurse practitioners and physician assistants (OTA, 1986; Pew Health Professions Commission, 1994);
- A set of activities whose functions define the boundaries of primary care—such as curing or alleviating common illnesses and disabilities;
- A level of care or setting—an entry point to a system that includes secondary care (by community hospitals) and tertiary care (by medical centers and teaching hospitals) (Fry, 1980); ambulatory versus inpatient care;
- A set of attributes, as in the 1978 IOM definition—care that is accessible, comprehensive, coordinated, continuous, and accountable—or as defined by Starfield (1992)—care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness;
This chapter is based on the study committee's interim report, Defining Primary Care: An Interim Report (IOM, 1994b). The definition of primary care set forth here is the same as that in the interim report.
- A strategy for organizing the health care system as a whole—such as community-oriented primary care, which gives priority to and allocates resources to community-based health care and places less emphasis on hospital-based, technology-intensive, acute-care medicine (IOM, 1984).
No one category incorporates all the dimensions that people believe are denoted by the term, and this has resulted in a lack of clarity and consensus about the meaning of the term. A clue to the difficulty lies in an ambiguity of the word primary, as noted in a background paper prepared for this report by Safran (1994). If primary is understood in its sense of first in time or order, this leads to a relatively narrow concept of primary care as "first contact," the entry point, or ground floor of health care delivery. This meaning of primary can connote only a triage function in which patients are then passed on to a higher level of care. If, on the other hand, primary is understood in its sense of chief, principal, or main, then primary care is better understood as central and fundamental to health care. This latter idea of primary care supports the multidimensional view of primary care envisioned by this IOM committee.
This IOM committee thus reaffirms the importance of continuing to define primary care as multidimensional; it cannot be defined on the basis of a single dimension, as attractive as this might be for policymakers who formulate workforce policy and must decide who does or does not provide primary care. This exigency, faced by policymakers, has led to reliance on criteria based on, for example, residency training, care setting, or level of care (e.g., first contact). While fully acknowledging the need for a clearer sense of primary care to guide policymaking at the national and state level, the committee believes a careful but multidimensional view of primary care will permit a far richer discussion of organizational opportunities, professional development and satisfaction, health curricula reform, and improved health care than any single-dimension definition. Given this belief, the committee draws on an extensive literature that includes a number of key articles on primary care.
The notion of the primary physician providing continuing and comprehensive care was introduced very early. According to what became known as the Millis Commission report (1966), the primary physician
will serve as the primary medical resource and counselor to an individual or a family. When a patient needs hospitalization, the services of other medical specialists, or other medical or paramedical assistance, the primary physician will see that the necessary arrangements are made, giving such responsibility to others as is appropriate, and retaining his own continuing and comprehensive responsibility (Millis, 1966, p. 37).
The report also emphasized the need to focus ''not upon individual organs and systems but upon the whole man, who lives in a complex social setting. …" (Millis, 1966, p. 35).
From 1966 to the late 1970s variations and refinements of this concept appeared. In a classic monograph, Alpert and Charney (1973) described the three fundamental characteristics of primary medicine (defined as the personal health system of individuals and families, as distinguished from public health): Its clinicians (1) provide first-contact care (as compared to that based on referral), (2) assume responsibility for the patient over time regardless of the presence or absence of disease, and (3) serve as the "integrationist" (serve a coordinating role). They also believed that it was preferable that all family members be cared for by the same physician.
The First IOM Definition
In 1978, the IOM published a report entitled A Manpower Policy for Primary Health Care: Report of a Study (IOM, 1978). The second chapter, which had been released a year earlier as an interim report, defined the essence of primary care as it should and could be practiced: "accessible, comprehensive, coordinated and continual care delivered by accountable providers of personal health services." That definition has been widely quoted and used. It has also proved useful as a touchstone for guiding the assessment of primary care.
Distinguishing Public And Personal Health Services
Meanwhile, work by McKeown (McKeown and Lowe, 1966) and others led to a better understanding of socioeconomic, environmental, and behavioral factors affecting the health of individuals and populations. In a 1974 report, Canadian Minister of Health Marc Lalonde emphasized the importance of health promotion and disease prevention (Lalonde, 1974). Subsequently, the notion of primary care was expanded to the point where the World Health Organization conference at Alma-Ata defined primary health care as
essential health care … made universally accessible to individuals and families in the community … through their full participation and at a cost that the community and country can afford (WHO, 1978, p. 3).
This definition takes the notion of primary care beyond what this IOM committee intends. The committee therefore distinguishes between two terms: (1) primary health care as defined by WHO, which includes such public health measures as sanitation and ensuring clean water for populations; and (2) this committee's term primary care, which focuses on the delivery of personal health services. For this reason, this report addresses personal health services in a
context of family and community health and not population-based, public health services.
There are, however, vital and important linkages that must be developed between primary care and public health programs, which are addressed in Chapter 5 and Appendix F of this report. The committee notes the increasing intersections and changing connections between public health and personal health care delivery. Two examples are childhood immunization and tuberculosis outreach services that are now provided in the public health sector to individuals and communities.
The 1984 Report On Community-Oriented Primary Care
Abramson and Kark (1983) pioneered an emphasis on communities and their connections with health practitioners. They viewed community-oriented primary care (COPC) as "a strategy whereby elements of primary health care and of community medicine are systematically developed and brought together in a coordinated practice" (p. 22) to facilitate community diagnosis, health surveillance, monitoring, and evaluation. They pointed out that such an approach requires knowledge of the demographic, socioeconomic, and cultural characteristics of communities.
A study completed by the IOM in 1984 addressed COPC. That report described community-oriented primary care operationally as
the provision of primary care services to a defined community, coupled with systematic efforts to identify and address the major health problems of that community through effective modifications in both the primary care services and other appropriate community health programs (IOM, 1984, p. 2).
According to that report, primary care practitioners strive to deliver to their active patients (the "numerator" in a COPC context) effective and appropriate health services. The word community as used by the COPC committee meant any group of people that the practice or program might reasonably expect to cover, the denominator in this COPC context. That is, the study directed its attention toward communities that included both users and nonusers of primary care services and did not mean the community defined solely in terms of the practice's active patients.
An operational COPC model must satisfy three criteria. There must be (1) a primary care practice, (2) an involved and definable community, and (3) a set of activities that systematically address the major health issues of the community. In its case studies at that time, the IOM COPC committee found no fully developed example of COPC. However, efforts to implement COPC continue in many countries, including the United States, with varying degrees of success. In the meantime, broad-scale changes in health delivery have refocused attention on the delivery of personal health care services in this country.
Changes In Health Care Delivery Today
The health care system, health policy, and health professional curricula in the United States are undergoing a period of rapid change. These shifts, particularly those that involve integrated delivery systems (Shortell et al., 1994), could not have been reflected in the Millis Commission report, Alpert and Charney's 1973 monograph, or the earlier IOM reports. The development of integrated delivery systems means that primary care cannot be defined or assessed in isolation from the overall system of which it is a part. Such systems involve physicians and other clinicians and the facilities they use to deliver a full array of services, for a given price, to a defined population, in settings that are most appropriate to patients' needs. The committee's first task in considering the future of primary care was to reexamine the 1978 IOM definition and other definitions in light of the current and anticipated health care environment. In doing so, the committee supported the essential features of the earlier definition but also believed that a new definition was needed to reflect the dramatic health system changes that have occurred in the past 18 years and to anticipate and to guide future change. After release of its recent interim report (IOM, 1994b), the committee invited public comment on its definition at conferences, in a published article (Vanselow et al., 1995), and in a public hearing that specifically requested comment on its definition. After considering all comments and letters that the committee received, it concluded that the new definition was well accepted, and it was adopted for this report. The definition is described below.
The New Definition And An Explanation Of Terms
The definition of primary care adopted by the IOM Committee on the Future of Primary Care follows:
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
Each term in the definition is summarized in Box 2-1 and is explained in the text following the box.
Although the new definition is based on the 1978 IOM definition, it recognizes three additional important perspectives for primary care: (1) the patient and family, (2) the community, and (3) the integrated delivery system. The 1978 IOM report addressed the first perspective, and the 1984 COPC report addressed the second. In recognizing the increasing importance to primary care of the integrated delivery system, this report addresses all three. The new definition thus stresses the importance of the patient-clinician relationship (a) as understood
Box 2-1 Definition of Primary Care
in the context of the patient's family and community, and (b) as facilitated and augmented by health care teams and integrated delivery systems.
Figure 2-1 illustrates this committee's view that the patient-clinician relationship is central to primary care. The patient and primary care clinician interact with one another as appropriate and also with others in the community and the health care delivery system. The shaded areas in the figure are fields this committee newly emphasizes in this report. On the patient side, the family and community provide the context in which to understand and assist the patient. On the health care delivery side, the team and integrated delivery system provide the means for extending and improving the delivery of primary care. One challenge that faces health care clinicians, policymakers, and administrators is how to foster and maintain such patient-clinician relationships in a complex, integrated delivery system. A correlative challenge is how to realize the potential benefits of
these organizations and the interdependent work of health professionals in improving patients' health. The committee addresses these issues in Chapter 5 of this report.
Recommendation 2.1 To Adopt the Committee's Definition
This committee has defined primary care as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. The committee recommends the adoption of this definition by all parties involved in the delivery and financing of primary
care and by institutions responsible for the education and training of primary care clinicians.
The committee has recommended that health policymakers, professional groups and academic health centers adopt this definition for use in all relevant activities within their scope of responsibility. The committee believes that the adoption of a common definition will lead to greater clarity in health care delivery and program planning and in policy debate. If those involved in service, education, financing, and research in primary care use the same starting point in discussions, then substantive differences can be better understood and resolved and the field moved forward. Consistent with this objective, this report uses the committee's definition as a reference for framing its discussion about the content of primary care and research priorities.
By the term patient, this committee means an individual who interacts with a clinician either because of disease or illness or for health promotion and disease prevention. In primary care systems not all people are patients. People are usually patients at one time or another, but most of the time they are simply individuals going about their lives. They may need advice, information, or periodic physical examinations for preventive care. Wherever the term patient is used in this report, it is intended to mean individuals who seek care, whether or not they are ill at a given time.
Use of the term families in this report acknowledges the care-giving roles, the concerns of family members, and the impact of family dynamics on health and illness. The phrase context of family and community in the definition refers to an understanding of the circumstances and facts that surround a patient, such as the patient's living conditions, family dynamics, work situation, and cultural background. This committee uses the term family broadly to include a unit of individuals in a household and not necessarily a traditional nuclear family. Often a family member is a care giver—a parent caring for a child or an adult child caring for a parent. Unless clinicians can understand the nature of these relationships, they can miss opportunities to provide effective care of individual health care needs.
The community refers to the population potentially served, whether its members are patients or not. Community can refer to a social group residing in a defined geopolitical boundary (a city, county, or state), or to neighbors who share values, religion, experiences, language, culture, or ethnic heritage. The use of the term community draws attention to the different perspectives that need to be addressed. On the one hand, primary care needs to be concerned with the care that primary care clinicians deliver to individuals. This more traditional and familiar area of primary care addresses the care and outcomes of individual patients. In its broadest sense, primary care must also be linked to the larger community and environment in which people work and live. This also requires that primary care clinicians know the major causes of mortality and morbidity for the community served and that they be aware of what may be happening in the community—such as occupational dangers, patterns of childhood injuries, patterns of lead poisoning or other environmental hazards, homicides, issues of domestic violence, and epidemics. Health care needs and objectives may not be the same for individuals and communities or for different individuals or different communities. Individuals have particular health care needs; the community has a broader perspective that emphasizes improving health status2 and reforming the way care is delivered. An integrated delivery system has the potential for melding both perspectives.
Prevention of illness and promotion of healthful lifestyles are critical components of good health. The benefit gained from these elements and from broader
public health activities as compared to medical care can vary. For example, 10-to 24-year-olds are likely to gain much more in improved health and rates of survival by preventing injuries and damage due to violence, motor vehicle accidents, or substance abuse than they are from direct, episodic, medical care (IOM, 1994a).
Many barriers to better health are related to socioeconomic status, education, and cultural and behavioral components. At times these factors extend far beyond health care or health promotion and disease prevention in their usual sense. Primary care clinicians are not "responsible" for the environment, jobs, housing, or violence. Primary care clinicians do, however, need to be knowledgeable about the context of their patients' lives and problems and need to be knowledgeable about the resources in their communities. Health promotion activities within the primary care setting should (a) incorporate information about the needs of the community and its health problems, (b) provide information to the community and those involved in its public health efforts, and (c) help to coordinate the public health, social services, mental health services, and other appropriate services needed by patients.
The term clinician refers to an individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients. A clinician has direct contact with patients and may be a physician, nurse practitioner, or physician assistant. For most families, this clinician is a physician. Additionally, primary care clinicians might turn to a variety of other individuals—both with and without health care training—for their assistance and skill in particular areas. Examples of individuals other than primary care clinicians who can contribute to primary care are dentists, pharmacists, physical therapists, nutritionists, and social workers. Among many cultural groups, traditional healers may also provide primary care, for instance, the promotoras for Latino communities.
This committee has chosen to use the term clinician in contrast to other familiar terms such as provider. Provider is commonly used not only to refer to individuals who deliver care but also to denote facilities or organizations that provide health care, such as hospitals or health plans. In medical centers, clinician refers to someone with direct patient care responsibilities; in using the term clinician, then, this report underscores the importance of a relationship between a patient and an individual who uses judgment, science, and legal authority to diagnose and manage patient problems.
The term sustained partnership refers to the relationship established between
the patient and clinician with the mutual expectation of continuation over time. It is predicated on the development of mutual trust, respect, and responsibility. A bond to someone you trust may be healing in and of itself. This relationship is essential when guiding patients through the health system. As an ideal, primary care occurs within the context of a personal relationship between a patient and clinician that extends beyond an episode of illness. Such a relationship, developed over time, fosters a sense of trust and confidence. The partnership facilitates tailoring a specific intervention or specific advice to the needs and the circumstances of a particular person.
Although it denotes participation by both clinician and patient, the term partnership does not necessarily imply equal roles for clinicians and patients. The term partnership means that the patient and clinician agree on goals and the ways to reach them. It also implies that the patient's values and preferences are taken into account. In some cases patients desire and should have a large role in identifying health problems to be addressed or deciding how they should be addressed. In other cases a patient may prefer a relatively small role and may delegate most decisionmaking to a clinician.
The committee that developed the 1978 IOM definition viewed the primary care clinician as a manager for a specific episode of care. The current IOM committee broadens that view considerably. It emphasizes the need for the primary care clinician not only to manage a given health concern and address issues of preventive health care, but also to act as an advocate for the patient in a larger health system so that the patient knows who is directing and coordinating his or her care.
This personal relationship is more important to some people in some circumstances than it is to others. Although in many circumstances patients may feel quite comfortable knowing that information is in their medical record where all those involved in their care can find it, patients often prefer (when they can) to see a particular clinician. Challenges remain, however, about how to structure a team so that personal relationships are supported, and these challenges are addressed later in this report.
Health Care Needs and Health Care Services
The term personal health care needs includes reference to physical, mental, emotional, and social concerns that involve the functioning of an individual. The term health care services refers to an array of services that are performed by health care professionals or under their direction, for the purpose of promoting, maintaining, or restoring health (Last, 1988). The term refers to all settings of care (e.g., hospitals, nursing homes, clinicians' offices, community sites, schools, and homes). Health care services address physical, mental and emotional, and social functioning. The last concept pertains to any health condition that impedes
an individual's ability to fulfill his or her social roles, such as ability to attend school, work at gainful employment, or perform as a parent.
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 Merriam-Webster, 1981; Random House, 1983). Integrated as used in this report describes health care that coordinates and combines into an effective whole all of the personal health care services a patient needs over an extended period of time—that is, the provision of comprehensive, coordinated, and continuous services. Those three terms from the 1978 IOM definition—comprehensive, coordinated, and continuous—are described below. When using the term integrated this committee refers to all the office visits and phone calls, tests, procedures, and encounters that individuals have, regardless of setting such as clinic, hospital emergency room, doctor's office, hospital admission, or rehabilitation unit. It refers to services and information about the services of all the clinicians and other health professionals—pharmacists, nurse midwives, physical therapists, and so forth—over an extended period of time.
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 that use 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 continues to provide primary care.
First contact. One element of primary care 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, and indeed such a system would be antithetical to the committee's future vision of primary care.
First contact with a primary care clinician may lead to referrals to other resources—for example, to a nurse practitioner for diabetic counseling or to a cardiologist for subspecialty care. In some cases, self-referral by a patient may be appropriate—for example, for recurrent problems previously treated by another specialist or subspecialist or refractions for eyeglass prescriptions. Information about these encounters should be provided to the primary care clinician.
The descriptor first contact is not, however, a sufficient or unique attribute for defining primary care. It is not unique because some first contact events do not represent primary care—for example, those that occur through an occupational health service, an emergency room, or at a health fair booth for cholesterol screening. Such encounters can be integral to the patient's health care, and information gathered should be communicated to the primary care practice.
First contact is not adequate to define primary care. Insofar as it has come to imply the restriction of primary care to a triage function, it neglects the other characteristics of primary care included in this report, specifically, comprehensiveness.
A derivative term is gatekeeper. In many circles, the term gatekeeper has been used to describe the function of using the experience and judgment of the primary care clinician to determine whether diagnostic tests are necessary, whether a patient's problem can be handled by the primary care practice, or whether a person needs to be evaluated or treated by another specialist or subspecialist. The primary care clinician's important role in helping the patient to obtain appropriate care in a complex health system requires a high level of skill and judgment. This judgment involves both clinical and economic decisionmaking.
Patients may view gatekeeping with suspicion because they fear that efforts to control use of services and to manage costs may have subtle effects on clinicians and ultimately work to the detriment of their health. By contrast, many managers, benefits officers, and policymakers view gatekeeping with enthusiasm because they see it as a way of rationalizing, if not restricting, the use of health care resources. The term gatekeeper, therefore, has come to have a pejorative connotation when primary care is reduced to the function of managing costs and especially when it implies that the gate is kept closed most of the time. This committee categorically rejects the view that the primary care clinician acts mainly or exclusively as a gatekeeper.
The scope of primary care. Comprehensive care is intended to mean care of any health problem at a given stage of a person's life. It includes ongoing care of patients in various care settings (e.g., hospitals, nursing homes, clinicians' offices, community sites, schools, and homes). Ideally, the primary care clinician listens to the patient, makes diagnoses, manages, and screens for other health care problems. The clinician educates and communicates with the patient and others who may be involved including other specialists when appropriate. He or she assumes ongoing responsibility for maintaining contact with and care of the patient and assuring that the care provided is suitable.
The IOM definition refers to a large majority of personal health care needs. That phrase refers to the essential characteristic of primary care clinicians. Primary care clinicians receive all problems that people bring—unrestricted by problem or organ system—and have the appropriate training to manage a large majority of those problems, involve other health professionals for further evaluation or treatment when appropriate, and continue to act as advocates for their patients.
Primary care addresses a mixture of health problems along the spectrum of disease as they occur singly or in combination within a single individual. Ideally, primary care clinicians elicit the full range of patient concerns, whether physical or psychosocial, and are sensitive to the concerns and circumstances that accompany a patient's symptoms.
Not all patient problems represent deviations from normal health that require medical action. Thus, primary care clinicians have a special responsibility to be sensitive to those concerns that are appropriately labeled health problems and those that are not or that could be made worse by medical intervention.3
Some portion of patient problems—based on a particular individual's needs, on safety, or on efficiency considerations—may not be manageable by the primary care clinician. Some portion may require the expertise of other health professionals, other specialists, or subspecialists. The following categories of service are within the scope of primary care as defined by the committee:
- Acute care.4 (a) The primary care clinician evaluates a patient with a symptom or symptoms sufficient to prompt him or her to seek medical attention. Health concerns may range from an acute, relatively minor, self-limited illness, to a complex set of symptoms that could be life threatening, to a mental problem. The clinician arranges for further evaluation by specialists or subspecialists when
- appropriate. (b) The clinician manages acute problems or, when beyond the scope of the particular clinician, arranges for other management of the problem.
- Chronic care. A primary care clinician (a) serves as the principal provider of ongoing care for some patients who have one or more chronic diseases, including mental disorders, with appropriate consultations, and (b) collaborates in the care of other patients whose chronic illnesses are of such a nature that the principal provider of care 5 is another specialist or subspecialist. The primary care clinician manages intercurrent illnesses, provides preventive care (e.g., screening tests, immunization, counseling about life style), and incorporates knowledge of the family and the patient's community. An example would be managing the dermatitis, hypertension, or upper respiratory infection of a patient who is under the care of a rheumatologist for rheumatoid arthritis.6
- Prevention and early detection. The primary care clinician provides periodic health assessments for all patients, including screening, counseling, risk assessment, and patient education. Periodic health assessments are a natural part of primary care. Primary care must reflect an understanding of risk factors associated with these illnesses, including genetic risks, and of the early stages of disease that may be difficult to detect at their outset.
- Coordination of referrals. The clinician coordinates referrals to and from other clinicians and provides advice and education to patients who are referred for further evaluation or treatment.
Coordination ensures the provision of a combination of health services and information that meets a patient's needs and specifically means the connection
The terms generalist and primary care clinician are both sometimes used to describe specialists who provide a broad spectrum of care within their own specialty, for example, generalist orthopedist, primary care ophthalmologist, or generalist obstetrician. The committee emphasizes, however, that general care of an organ such as the eye or of an organ system does not constitute primary care as the committee defines it.
within and across those services and settings—putting them in the right order and appropriately using resources of the community. The goal is to focus on interactions with patient and family and their health concerns, clarify clinical care decisions, advise hospitalized patients and their families, and help patients and their families cope with the social and emotional implications of disease or illness.
The primary care clinician will often be the principal clinician of inpatient care for certain conditions that require hospitalization (e.g., pneumonia). He or she follows hospitalized patients, even those whose principal clinician may be another specialist or a subspecialist. The primary care clinician brings knowledge of a patient and family history and social perspectives to bear on that episode of care. He or she may also manage other aspects of the patient's care during hospitalization, for example, by continuing to manage the diabetes of a patient who is hospitalized for a hip fracture. The primary care clinician also coordinates a patient's transition between health care settings—for example, hospital and home, home and nursing home, or between clinicians' offices.
Teams. An individual may need a set of activities that entail an array of services. The sorts of tasks required are varied and require efficient management of both care and available resources. The emphasis in this report on primary care teams acknowledges that we need not depend on a single person to organize and provide all expertise and care. Much primary care is rendered by single clinicians, but increasingly teams are managing the health problems presented to primary care practices.
A team is a group of people organized for a particular purpose. It may be organized to subdivide tasks, increase accessibility, extend the expertise of a health professional by drawing on several disciplines, or delegate tasks that do not require a clinician's level of training. The organization of health services for a defined population can be greatly facilitated by using teams with a mix of practitioners who together are best suited to meet the range of needs of a given patient or of a population. A pediatric practice may, for instance, have a group of pediatricians, a pediatric nurse practitioner, and a receptionist who work together giving general pediatric care. Other multidisciplinary groups might be organized for the care of those with particular problems, for instance, children who have been abused. Yet another case in point is a geriatric practice team that includes a social worker, dietitian, physical therapist, geriatric nurse practitioner, and geriatrician. Team composition may vary by specialty, subspecialty, clinician interest, expertise, and resource availability. The population served by a team may vary by gender, age, health concerns, and social problems.
As indicated in Figure 2-1, the committee views the team as an extension of the patient-clinician relationship, not as an alternative to it. Although primary care can be delivered by teams, exemplary primary care requires that one or more members of that team develop a close one-on-one relationship with the patient.
Interaction with Communities
The effective coordination of health care services requires an intimate knowledge of the communities in which those services are delivered. Such coordination requires:
- knowledge of other health care agencies, resources, and institutions within the community (e.g., the availability of classes teaching cardiopulmonary resuscitation or of smoking cessation support groups);
- an understanding of the financial concerns of patients and communities;
- an understanding of the cultural, nutritional, and belief systems of patients and communities that may assist or hinder effective health care delivery;
- an understanding of day-to-day lifestyle patterns of patients and in communities that may enhance or diminish coordination efforts (e.g., work, transportation, school, child care); and
- effective information systems.
The term continuous means ''uninterrupted in time, without cessation; being in immediate connection or spatial relationship" (Random House, 1983). In this report, continuity is a characteristic that refers to care over time by a single individual or team of health professionals ("clinician continuity") and to effective and timely communication of health information (about events, risks, advice, and patient preferences) ("record continuity"). It applies to both space and time. It combines events and information about events occurring in disparate settings, at different levels of care, and over time, preferably throughout a person's life span. Continuity encompasses patient and clinician knowledge of one another and the effective and timely communication of health information that should occur among patients, their families, other specialists, and primary care clinicians.
Clinician continuity, when achieved, is an effective way to provide continuity in primary care. The patient record is essential, but it does not substitute for clinician continuity. Information such as family, sexual, or emotional problems is often intentionally excluded from the record because of concern that the information might not be kept confidential. Knowledge of a patient's usual ways of dealing with symptoms such as pain is another example of how care can be dramatically altered by sustained personal relationships between clinicians and patients. A patient's story is dynamic, not static, and a primary care clinician who knows a patient understands when it is appropriate to use or disregard medical information in the patient's record because it is outdated, irrelevant, or wrong.
Given our propensity in the United States for moving from place to place, for changing employers and health insurance plans, and for changing household
composition, such a goal of clinician continuity is not likely to be perfectly realized. At an earlier time in our nation's history, a general practitioner might care for a couple, deliver their babies, and see those children grow, marry, and have children of their own. Physicians knew their patients and their families, and record keeping was modest. Now the amount and complexity of information that must be recorded about patients is steadily increasing. If continuity is to be an element of primary care, it will likely be achieved by ensuring that relevant, accurate information is available to all clinicians, even when the relevance of data is not immediately apparent; this reflects the goal of record continuity.
Increasingly sophisticated clinical (as opposed to financial) information systems are being developed rapidly, and the progress of computer technology has led to efforts to aggregate health data from many sources such as hospitals, offices, pharmacies, and laboratories. Such data aggregation has tremendous potential for ensuring the continuity of medical information. Two IOM reports, The Computer-Based Patient Record: An Essential Technology for Health Care (1991) and Health Data in the Information Age: Use, Disclosure, and Privacy (1994c), have explored the benefits and risks of computer-based patient records and community-level information databases. Meeting the need for continuity of care is a significant element of computer-based patient records. Continuity can apply to an integrated delivery system, a primary care practice or team, and a single primary care clinician. Although the ideal may be an individual seeing the same clinician at each visit, there may be tradeoffs between continuity and access. Continuity of clinician may be more important for some people and in some circumstances than others. For a patient with hypertension who makes appointments at regular intervals, for example, it is particularly helpful to both the clinician and the patient to ensure continuity over a succession of visits so that progress and the need to adjust medications can be assessed. Continuity can also be a major source of satisfaction both to patients and clinicians, as it fosters the long-term relationships that represent, for many clinicians, a significant reward of medical practice.
Sometimes, however, patients have an acute illness or injury and would prefer quick access to a clinician who might be known to them as a member of a team or practice or might even be a complete stranger at an urgent care center or emergency room. Balancing the competing values of continuity and access represents one of primary care's important challenges and one for which integrated delivery systems may offer some solution.
Comment: Who Is a Primary Care Clinician?
The committee acknowledges that the use of a functional definition of primary care does not provide a definitive answer to those who must count primary care clinicians and develop policies regarding payment for primary care services. Because the definition is normative, the committee hopes that the functions of
primary care will increasingly be adopted. The committee preferred not to use the definition to differentiate among clinicians, despite the interest of many that it do so. If pushed to differentiate among clinicians, however, the committee would use as a reference its knowledge of how clinicians are currently trained and what they generally do in their practices. From this perspective, it seems clear that those trained in family medicine, general internal medicine, general pediatrics, many nurse practitioners, and physician assistants are trained in and are generally most likely to practice primary care.
Some physicians in other specialties may also be practicing primary care. For example, obstetrician-gynecologists undoubtedly deliver some primary care, but others are surgically oriented, are not currently trained in primary care, and do not consider themselves primary care clinicians (Leader and Perales, 1995). Subspecialists, particularly in internal medicine, may provide primary care for a subset of their patients with chronic conditions and they may well provide a majority of those patients' care. Specialists in emergency medicine may provide first-contact care, but this care is not usually integrated. It is certainly not continuous, and this care does not comprise the full spectrum of primary care. General dentists may provide general dental care, but they do not provide the full range of health care needs. If other medical specialties and health care disciplines are to provide primary care as defined by this committee, training would have to be modified as described in Chapter 7.
The term accessible means "easy to approach, reach, enter, speak with or use" (Random House, 1983). It refers to the ease with which a patient can initiate an interaction for any problem with a clinician (e.g., by phone or at a treatment location). It includes efforts to eliminate barriers such as those posed by geography, administrative hurdles, financing, culture, and language.
Accessibility is also used to refer to the ability of a population to obtain care. For example, having public insurance coverage does not guarantee access to care if no local clinicians are willing to see individuals with that form of insurance. Accessibility is also a characteristic of an evolved system of which primary care is a basic unit. Potential enrollees of a health plan want to know whether they have "access" to other specialists or subspecialists, how to obtain that access, and where they would need to go to be seen on a weekend or holiday. Determining the level of accessibility that has been achieved is a judgment that is based on a community's needs and expectations as defined by members of the community and based on their experiences in obtaining the care they desire.
Clearly, no single clinician can be accessible at all times to all patients. Integrated delivery systems seek ways to ensure timely care, to meet patient expectations, and to use resources efficiently. Integrated delivery systems may establish policies regarding maximum waiting times for an urgent appointment,
periodic health examinations, coverage when a clinician is out of the office, getting patients into substance abuse treatment programs on a weekend, or handling an out-of-market-area health problem.
Primary care is a key to accessibility because it can provide an entry point to appropriate care. It is the place to which all health problems can be taken to be addressed. People do not have to know what organ systems are affected, what disease they have, or what kind of skills are needed for their care.
Accessibility also involves user friendliness. It refers to the information people have about a health system that will allow them to navigate the system appropriately. Health plan members need directions about where to call for certain information or how to get help in an emergency. Patients need to understand how to get information about self-care or community resources, about the use of computer technologies to obtain information, or about how to obtain their own medical record.
Administrative barriers to accessing health services deserve special attention. Even when individuals have a benefit package that provides coverage for a given service, administrative hurdles may sometimes be so burdensome, whether by intention or not, that the service is effectively denied. For example, the approval process for obtaining mental health care is, in some organizations, so intimidating or personally intrusive that individuals may be unable to get timely assistance or even any adequate care at all.
Accessibility can also be increased by the use of telecommunication and information management technologies. Clinicians in rural practices can use telecommunication to obtain subspecialist consultations in the reading of diagnostic tests for heart function and for reading slides of pathology specimens.
The term accountability in a general sense means the quality or state of being responsible or answerable. It also means "subject to the obligation to report, explain, or justify" (Random House, 1983). Like all clinicians, primary care clinicians are responsible for the care they provide, both legally and ethically. Primary care clinicians and the systems in which they operate are, in particular, answerable to their patients and communities, to legal authorities, and to their professional peers and colleagues. They can be held legally and morally responsible for meeting patients' needs in terms of the components of value—quality of care, patient satisfaction, efficient use of resources—and for ethical behavior. Primary care clinicians are also accountable to the systems in which they work.
Quality of Care
Primary care practices are accountable for the quality of care they provide.
A 1990 IOM report, Medicare: A Strategy for Quality Assurance, defined quality of care in the following way:
Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM, 1990, p. 21).
Focusing on outcomes requires clinicians to take their patients' preferences and values into account as together they make health care decisions. The phrase current professional knowledge in the above definition underscores the need for health professionals to stay abreast of the knowledge base of their professions and to take responsibility for explaining to their patients the processes and expected outcomes of care. High standards for licensure, certification, and recertification for all individuals and institutions that provide health care must be maintained. In accordance with this definition, primary care practices must be able to address three fundamental quality-of-care issues in their assessments of quality and in the steps they take to improve it (IOM, 1990):
- Use of unnecessary or inappropriate care. This makes patients vulnerable to harmful side effects. It also wastes money and resources that could be put to more productive use.
- Underuse of needed, effective, and appropriate care. This is related to accessibility—that is, whether people get the proper preventive, diagnostic, or therapeutic services; whether they delay seeking care; and whether they receive appropriate recommendations and referrals for care. People may face geographic, administrative, cultural, attitudinal, or other barriers that limit their abilities to seek or receive such care. Within managed care environments, efforts to restrict access to some services may result in underuse of care.
- Shortcomings in technical and interpersonal aspects of care. Technical quality refers to the ways health care is delivered—e.g., skill and knowledge in making correct diagnoses and prescribing appropriate medications. Professional competence is critical to high quality care, and inferior care results when health care professionals are not competent in their clinical areas. Interpersonal aspects of care are of particular importance in primary care. They include listening, answering questions, providing information, and eliciting and including patient (and family) preferences in decisionmaking. Interpersonal skills are also essential to primary care clinicians in their roles as coordinators, as members of a collaborative team, and with other health professionals.
Quality assessment involves more than the measurement of a single clinician's performance. The performance of systems—including primary care and entire integrated delivery systems—must also be measured and improved.
Greater attention will need to be focused on the failures of systems of care in which well-trained and well-meaning clinicians work. A shift in focus is occurring—from reviewing records of individual patients and compiling assessments of care by individual clinicians to monitoring the performance of health plans and populations, and this has other implications for quality measurement. Although individual record review will undoubtedly continue to be necessary in some instances (e.g., surgical complications, adverse drug reactions), the creation of reliable, uniform data systems and the collection of consistent data from a variety of sources means that quality assessment may become less dependent on review of individual cases. This change in perspective from individual patients and clinicians to the performance of health plans might also result in less attention being paid to changes in the patient-clinician relationship. As policymakers shift attention toward systems of care, integration, and team approaches to health care delivery, it will be especially important to understand the relative risks and benefits to health outcomes and patient satisfaction of promoting or disrupting personal relationships.
The appropriate unit of assessment. To assess important attributes of primary care such as continuity, coordination, and the outcomes of and satisfaction with primary care, the most appropriate unit of analysis is the episode of care whose beginning and ending points are determined, in principle, by the individual. An episode of care refers to all the care provided for a patient for a discrete illness. A particular episode of care begins when a patient brings a problem to the attention of a clinician (or when a clinician brings a problem to the attention of a patient), and that patient accepts the continuing care that may be offered (should it be needed). Multiple episodes (sometimes referred to as comorbidity) may occur at the same time for a given patient. Because the beginning and ending points of an episode of care are defined in practice by a patient, the use of episodes of care to assess quality explicitly incorporates the patient's perspective whether those episodes last for a visit or two, for a year, or over a patient's lifetime. This means that structures for accountability and especially for measuring outcomes of care need to be able to define and measure episodes of care. In particular, an assessment of the outcome of care—both what is measured and the results of the assessment—may be quite different after a single visit than after an episode of care.
An emphasis on satisfaction and information highlights the importance of patients' and society's preferences and values and implies that they should be elicited (or acknowledged) and taken into account in health care decisionmaking (IOM, 1990). Knowledge about patient and family experiences in the health care system can be derived from patient reports—interviews and surveys of patients
about their care. Patient reports on satisfaction can tell much about patient experiences in terms of access to and coordination of care, interpersonal and technical aspects of care, and understanding of instructions and follow-up advice.
In common parlance, efficiency is related to the organization and delivery of services so that waste and cost are minimized. Underuse of needed services (such as tests, therapies, or assistance) or overuse of services that result in unwarranted interventions or exposure to harm can hurt patients and waste resources—the time of patients and clinicians, money, and access for other patients. Tests that must be repeated because results are lost or wrong are examples of inefficiency that are quality of care problems. Good primary care presupposes a careful effort to manage care to ensure the efficient use of resources including the effective use of other health and social services.
A critical part of accountability in primary care concerns the ethical behavior and decisionmaking by primary health care clinicians in relation to their patients, the community, and the health systems in which they practice. Primary care clinicians are responsible for care that respects and protects the dignity of patients and ensures that an individual's presenting complaint is addressed. Although the issues are not unique to primary care, clinicians must be competent in managing events with significant ethical overtones. These may include informed consent, advance directives, avoidance of conflicts of interest in financial arrangements, care of family members when goals are in conflict, reproductive decisionmaking, genetic counseling, privacy and confidentiality, and equitable distribution of resources. Clinicians are accountable first and foremost to their patients. They are also accountable to the health care systems in which they practice, and this may contribute to tension, especially when they must advocate for a patient's use of resources. Primary care clinicians are always ethically accountable for their advice, consultations, and actions, especially when they have financial or other incentives to use or not use certain resources.
Accountability of Patients
Use of the term partnership is intended to convey the idea that both clinicians and patients have responsibilities. Clinicians are accountable as described above; patients are responsible for helping to sustain the relationship, for conveying complete and timely information to the primary care clinician, for undertaking reasonable preventive care, for making healthy lifestyle choices, for seeking care as appropriate, and for participating in the management and treatment plan.
Patients are responsible for their own health to the extent that they are capable—that is, to the extent that they have the knowledge and skills that allow them to participate in improving their health. Patients must also be responsible in their use of resources when they need health care.
Achieving The Goals Of Primary Care As Defined
The committee believes that these attributes of primary care are highly desirable and achievable over time. It also believes that the degree to which current primary care practices match these attributes varies considerably. However, the committee did not want to propose a limited definition of primary care that sets goals that might be more immediately achievable by most practices but does not present challenging goals for the future. Neither did the committee want to establish a commendable but ideal definition of primary care that would bear little relationship to current realities.
In the committee's judgment, all practices deserving the primary care label can aspire to many of the attributes in the near term; indeed, some may already be there. In the spirit of continuous quality improvement, however, the committee believes that all primary care activities must strive toward a fuller realization of these attributes. The pace of accomplishment will vary depending on a practice's starting point, its circumstances, and its resources.
The committee has already indicated its belief that the achievement of the desired attributes of primary care will be easier in some form of integrated delivery system serving a defined population than in isolated practices without a defined member population. A major advantage of integration lies in providing infrastructure support for personal health care services and for developing systems of accountability. Such arrangements often do not exist in many primary care settings and may be a long time in coming. In the meantime, every practice can move toward meeting the goals of primary care.
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