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For several years now and with a growing messianic fervor, physicians and health care experts have been responding to the need to deliver more efficient and better primary care with one response: patient-centered medical homes.
Not long ago, I found myself doing the same with a friend who prides himself on being a well-informed patient. But instead of an overwhelmingly enthusiastic or even mildly interested response, my friend stared at me blankly.
“What in the world are you talking about?†he finally asked. “A hospice? A halfway house? Some kind of group home for patients?â€
I explained that a patient-centered medical home can be any primary care doctor’s office, but it is run with a different philosophy. Care is team-based, preventive and comprehensive, rather than one-on-one, fee-for-service or managed. Record keeping and sharing is seamless and electronic, rather than unwieldy and paper-based. Clinicians from the team are easily accessible in person, on the phone or via the Internet within 24 hours, rather than hidden behind labyrinthine automatic answering services and overbooked clinic schedules.
My friend suddenly became very interested.
Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.
Now, as dozens of pilot projects across the country are transforming traditional doctors’ offices into medical homes and putting this theory of practice to the test, one thing has become apparent: even this most promising of reforms is unlikely to take hold without the active involvement of patients.
The need to get patients involved was made startlingly clear last month when the American Academy of Family Physicians, a national medical society devoted to primary care, and TransforMED, a nonprofit consulting firm created by the society to help physicians turn their practices into medical homes, published the first report on their national demonstration project. Beginning in 2006, 36 traditional primary care offices began adopting the hallmarks of patient-centered medical home practices. They installed electronic medical record systems and reorganized deeply entrenched scheduling routines. Teams made up of nurses, medical managers, physician assistants and doctors, rather than a single physician authority figure, began working with patients. And care was focused not on single acute episodes of illness but on the patients’ comprehensive and ongoing management.
As the study progressed, the researchers found that the vast majority of doctors’ offices could successfully incorporate most of the changes into their practice, and early signs of the model’s success were promising. Quality of care and preventive health ratings revealed small improvements. Office staff became more streamlined, efficient and satisfied. Most notably, physicians were more content than ever before with their work, despite still having to deal with an unchanged fee-for-service or managed care reimbursement system. The doctors’ enthusiasm persisted even after the study closed, with many maintaining contact with one another through a listserv and twice-yearly self-organized meetings.
Yet despite these successes, there was also one unexpected early finding: the patients were unhappy.
Yes, they were getting into their doctors’ offices more quickly and were being followed more closely than ever before, but many patients reported feeling disoriented. Some felt displaced as they saw the old one-to-one doctor-patient interactions replaced with one-to-three or one-to-four relationships involving not only the doctor but also a whole host of other providers. As offices switched from paper-based to electronic medical records, other patients reacted to the distracted clinicians who seemed more focused on learning the new computer system than on listening to them. Satisfaction fell because, like my friend, few patients were cognizant of, much less involved in, the changes going on around them.
In working so hard to adopt changes on their patients’ behalf, clinicians had temporarily lost their focus on the patients themselves.
-- Pauline W. Chen, M.D.
This article was originally published in the New York Times, on July 15, 2010.