Editor’s note: Jack Westfall, MD, MPH, is a retired professor from the University of Colorado School of Medicine and Former Director of the Robert Graham Center. We spoke with him about the role of primary care in the health and well-being of individuals, the hallmarks of high quality primary care and opportunities of primary care providers to enhance or promote patient safety.

Sarah Mossburg: Please tell us just a little bit about yourself and your current role.

Jack Westfall: My name is Jack Westfall. I’m a family physician and the former director of the Robert Graham Center for Policy Research. The goal of the Graham Center is to create and curate evidence to inform policies that support primary care and family medicine. In that role, I took a broad view, a 30,000-foot view of family medicine and primary care, scope of practice, workforce, and health equity. Where are the hot spots and the cold spots around the country in terms of access? We spent a lot of time thinking about the four Cs of primary care: contact, continuity, comprehensiveness, care coordination. Some people have added other Cs in there. Some people sometimes will spell quality with a “C” because we care a lot about quality. We recognize it’s not the way you spell it, but it is an effective way to remember what our research is about and what primary care is about.

SM: That’s great and that actually leads right into where we want to start. I’d love to hear a little bit about your thoughts on the role of primary care and the health and well-being of individuals.

JW: I firmly believe that primary care is the seat of delivering medical care to most of the people, most of the time. With that, providers have a really unique opportunity to be with patients during some of the most trying times. Sometimes, those are good times, like during pregnancy, prenatal care, and deliveries. Sometimes, that’s during the most trying times in terms of illness, suffering, and dying. But all the time, primary care is about developing a relationship with a patient, with a family, and with the community, not just from an individual clinician standpoint, me as the doctor making a relationship, but also really promoting the relationship between my practice and the patient, family, and community. So, it’s not just individual physicians anymore. Primary care is a team sport, and more and more people recognize and aspire to that. It’s really me as a family doctor working with my nurse, my medical assistant, my behavioral health clinician, and my social worker, along with possibly community health workers, to help build a relationship with the patient, the family, and the community to deliver high-quality care.

High-quality care, what the heck’s that? Well, high-quality care is both doing the things that a patient needs and not doing the things that a patient doesn’t need. We want to provide high-quality care related to preventive services, immunizations, and health promotion. We want to avoid overprescribing, complicating people’s lives, sending them out to do things they don’t need to do, and avoid unnecessary tests or treatments that might lead to worse outcomes.

I think more and more people are recognizing the need for primary care practices and clinicians to occasionally look out over the windowsill, open the door, and look at what’s going on in the community related to public health and community health organizations. What’s going on in the neighborhoods related to education, employment, transportation, and housing, those issues that we refer to as social determinants of health, has become very important in what a primary care practice does.

SM: Thank you. That’s a really interesting perspective on the relationship and the team aspect of care. You spoke about some examples of high-quality care, and I’m wondering if you have any thoughts on ways that we know when people are receiving high-quality primary care. What are some of the things that are hallmarks of that?

JW: How do we measure high quality? There have been lots of groups who have tried to do this, and there are organizations that have primary care clinicians and others trying to record dozens, if not hundreds, of quality metrics. Measuring quality is a crucial element of what the Graham Center does. Oftentimes, quality metrics and measures are taken out of context, so they’re isolated into one condition, one specific disease, or one specific preventive service. You want to achieve 90% of a metric in a patient population, for instance, colorectal cancer screening, or among people with chronic obstructive pulmonary disease (COPD), you want a high percentage of them to have a flu shot or pneumonia shot: Those are quality measures. What that fails to do is take into context the entirety of the person whom you’re looking at. When you look at an individual measures, primary care practices sometimes look like they have lower quality metrics; they’re 70% or 80% rather than 90%. But when you actually look at outcomes, we know that primary care is the only aspect of modern medicine that’s associated with better outcomes. This sort of dichotomy exists between the overall quality measures and the individual quality measures.

But sometimes, patients are more complex than a single guideline, and that’s where we start seeing measurement across metrics and across individual measures. So now, we’ve been thinking about the four Cs and how they relate to quality. We now know that continuity as a measure is associated with better outcomes, and comprehensiveness as a measure is associated with higher rates of guideline-concordant preventive services on a number of services. So rather than trying to measure 100 things, we wonder how to determine a parsimonious group of measures that are proxies for individual measures but serve as a primary-care-centric, whole-person measure of the entire relationship.

However, patient-centered outcomes matter as well. What patients don’t care about is getting screened for a disease. They care about whether or not they have the disease and whether or not it is treatable and curable. So, a patient-centered measure is not the rate of screening; it’s the rate with which the patient suffered. As we think about that relational aspect of primary care, we’re in a unique position to take advantage of the patient-centered outcomes that matter and measure those as well.

SM: What are some of the other barriers that you see to providing quality primary care?

JW: The electronic health record (EHR) is a great tool for being able to ascertain people’s status on all sorts of quality measures. Have they met or not met certain measures, and was it in a timely manner? For example, a great way to think about using an EHR is to create registries of patients with diabetes, who need testing periodically, or a reminder to get a flu shot and a pneumonia shot and all the other various quality metrics. The issue is, as a family doctor, I wasn’t trained in how to write code for the EHR to create a registry. There are ways to do that, but it typically costs a lot, and it costs money for me to pay to an EHR company. I have to hire a nonbillable person in my practice who is paid out of the billable services, and the quality metrics aren’t necessarily revenue generating. If I increase the testing and if I increase the number of visits I have with patients, that creates revenue. But it also interferes with the number of patients I can take care of. If I see patients five times a year, rather than three times a year, then I can’t see as many patients. If I can do some of that by disease registries, emails, letters, other communications, or group visits, that doesn’t generate revenue. So, the payment model for primary care is a real barrier to doing many of these nonbillable services, and many of the quality measures rely on nonbillable activities. If I see a patient in the exam room and I have a nice checklist of all the quality metrics they need I can refer patients to for example, a mammogram, a pap smear, cancer screening, and A1C testing, that’s terrific. The patient may or may not have the time to do all of those things in the next two weeks before those referrals expire. I might have to see them again in the office, and the patient says they got two of those things done but didn’t get the third and the fourth one done. Then, I have to repeat that process again. There’s a whole lot of other people and groups within the practice who could be doing those activities, but their time isn’t billable.

The community culture around medical care matters, and if people don’t understand the complexities of medical care, for instance colorectal cancer screening or hypertension treatment, they don’t even know to come into the practice for that care. They may only come into the practice when they have a broken bone or a sore throat with an acute illness. So, getting in those other quality metrics is difficult because there’s not a community-wide understanding of those conditions. One of the things that we did in Colorado was to translate that complex medical jargon related to national guidelines around preventive care and treatments into locally relevant actionable messages and materials so that it wasn’t just the doctors and the nurses from the practice saying you should get colorectal cancer screening. The community had an understanding that testing to prevent colon cancer was important. You notice that I changed the language there from “colorectal cancer” to “colon cancer.” In our practice and in my medical training, it’s “colorectal cancer” screening. When we actually worked with a group of community members, they said “colon cancer” screening. We don’t use the word “rectal” at the dinner table, so can we just call it colon cancer? And what do you mean by screening? What is that? They said, “Oh you mean like take a test?” So, they changed the language from “colorectal cancer screening” to “testing to prevent colon cancer.” Suddenly, it was a conversation that could happen at the dinner table, at the bowling alley, or at the livestock sale barn, and the culture in the community changed. People were coming in saying, “I’m here to get tested to prevent colon cancer.” We can then partner with our patients to engage them in improving quality, and quality metrics, because they want to do it and because they understand it.

SM: It sounds like the payment model creates a transactional model for care. Is that potentially accurate to say?

JW: Yes, I appreciate that you said that. Right now, the payment model supports transactional healthcare. Transactional healthcare is when a patient comes in for a visit; you have a transaction, there’s a payment, and there’s an outcome. Boom. Relational healthcare is what we’re aiming for, and we want to build the relational aspects of these encounters. They include, certainly, what happens in the exam room, but also what happens in the waiting room and what happens out in the community. So practices and clinicians and physicians have relationships and not just a list of transactions.

SM: That’s great. Thank you. We’ve had a really rich discussion around primary care and quality. I’d like to transition into discussing patient safety and thinking a little bit more about avoidance of harm. And I’d love to hear your thoughts around primary care and patient safety, and how those two things come together.

JW: Patient safety is always forefront in primary care practices. We are always thinking about how to ensure that anything we do for patients may help them and decrease the chance of them suffering from something we do or don’t do. Over the last 25 years since the IOM report “Crossing the Quality Chasm,” patient safety has been a major part of healthcare. It’s been a major part of graduate medical education, continuing medical education, licensure and practice, and trying to minimize untoward, unanticipated, or unexpected results. There’s lots of ways to do this and many places where this can happen. For instance, medications. We want to make sure that we prescribe the right medicine, to the right person, for the right condition, at the right time. We don’t want to prescribe a medication for which this patient has an allergy. How do we make sure we do that? There are checks and balances in the system: My staff asks about medication allergies and I ask about medication allergies so that when I prescribe medicine, I have an understanding of the situation. The pharmacist also weighs in on this and asks about any medication allergies so that there’s checks and balances because maybe I forgot that the patient had an allergy and, for some reason, it didn’t get documented in the medical record. The checks and balances are really important.

Then there’s testing: How do we make sure that our patients get the right tests and don’t get unnecessary tests? A lot of quality metrics have to do with tests: checking cholesterol, checking A1Cs for diabetes, and doing CT scans of the chest for lung cancer screening. There’s a lot of steps along the way where things can go wrong. For example, I have ordered the wrong test because I typed in the wrong thing. I’ve seen this in my own practice where I type in the code that I think is the correct test, and it’s a different test or it’s not quite the one I wanted; it was a second test. There’s other times when a patient gets a test, and whether it’s normal or abnormal, the results never make it back to me so that I can close the loop on the issue. I will talk to the patient, and we decided on a plan of action that included a blood test. We did the blood test, and the blood test had a result. I reviewed the result, and now I’m having a conversation with the patient about that result. There’s a lot of steps in there, and there have been times when somebody had an abnormal blood test that didn’t get reported back to the patient for months. During that time, the patient may have suffered worse illness. There are other times when the tests were all normal, and the patient didn’t get notified, and so maybe they were anxious or worried, or they went somewhere else and got the test again, doubling up on unnecessary testing.

One of the projects that we did with AHRQ was developing and strengthening a patient safety laboratory testing algorithm for patients in primary care practices. The goal was for practices to be able to work out the flow from the time the patient and clinician (1) had a shared decision about getting a test, (2) getting the blood test, (3) the laboratory doing the test, (4) the laboratory reporting the test result back to the practice, (5) the result reported back to the clinician, and (6) the result reported by the clinician back to the patient. So six steps. We asked the practices to look at each of those steps and think about where there were places that they can improve flow of information. It was very effective. We included patients in that study, where patients said “Hey, this is the way I’d like to get my results, even if they’re normal.” So, I think that patient safety in primary care is really crucial, and those are two examples about how patient safety fits into primary care.

SM: That’s great. I love that you brought in the example of engaging with patients as part of that process to provide safer care and that gets back to your thoughts around primary care being a relationship between not just the patient and the provider, but the entire team. I’m curious if you can think of any examples of changes that you’ve seen in primary care delivery over the years and what the implications are, either good or bad, for patient safety.

JW: I have a great example of this. I started practice and got an opportunity to join a practice in rural Colorado. We were still using paper records at the time. We hadn’t gotten to EHRs yet. I was seeing an adult male patient, and when I opened the chart there was a new chart on the right and then the old chart on the left. There was a stack of three-by-five cards, which had the patient’s name and their date of birth, and then it was a line with a date, a diagnosis, a treatment, and a cost. That was the entire medical record. We knew from the top of the card the person’s date of birth and their name, and then each line was a visit with a diagnosis and a treatment. Well, that was easy and that relied on the doctor having a relationship with that patient, their family, and their community. It relied on all of those relational aspects, but it was really just a transaction. On the card the medical record was just a transaction. We had no information about whether the person was allergic to penicillin, we don’t know if the patient got better, we don’t know on what basis the diagnosis was made, we don’t know if it was the correct diagnosis. There was nothing at the time around preventive care. This was a young person, but did they have a sports physical exam, and they had been checked for other conditions, skin exams, and all the things we do throughout our wellness exams.

So, the changes that we’ve had in medicine in terms of documenting history and the social determinants of health in the context of the patient and the family provides us a reminder to make sure we’re careful in how we diagnose and treat. It provides a record, so that if you saw the patient last week and they came back in because they weren’t better, I would know a little bit more about what the diagnosis and treatment was. If I saw one of the patients and only had that three-by-five card, I wouldn’t know what their throat looked like, or whether they had a fever, or what their response was. So the way that we have moved from a three-by-five card to a more science- and evidence-based practice has been fantastic. But we sometimes allow that to get in the way of the relationship and we rely on a checklist. We might just say check sore throat, runny nose, cough, fever. We don’t think about the actual human in front of us and their family and context of where they’re coming from or why have we’ve seen three similar cases from the third-grade class of Mrs. Jones in the last week and maybe there’s an outbreak of something. So suddenly, having more data may be good, but we have to be careful about how we curate it and take advantage of it. I think the move to electronic health records is a great example of this double-edged sword of a tool that can be beneficial, but also because of its design to capture billing data, has really taken away from the relational aspects of a clinician with their patient. It essentially is designed to support the transactional aspects rather than the relational aspects. So, the change from a three-by-five card to broader evidence-based charting and to EHRs is a good example of positive changes but is also a cautionary tale for utilizing the information derived to improve care not eliminate the relational aspects.

SM: I would be curious to hear your thoughts on unique opportunities that primary care providers have to enhance or promote patient safety that clinicians providing care in other care settings or specialties don’t necessarily have the opportunity to do.

JW: I think because in primary care we see most of the patients, for most of the problems, most of the time, we have both a high-level and detailed look at their care. So, I think we’re well positioned to lead patient safety efforts. I think when you say “patient safety,” oftentimes people hear “medical errors” and you’re going to point a finger at me or accuse me of making medical mistakes. I think there’s been a broad culture change over the last 20 years related to this, but I think there’s still the sort of visceral reaction to patient safety that prevents really robust conversations about the topic. I think primary care has an opportunity to lead the patient safety effort or to claim it as part of what we do. We don’t just provide high-quality care; we provide high-quality, safe care. I think if we could get primary care to claim that and really lead the discussion, it becomes less onerous and less judgmental, and provides an opportunity for broader conversations between primary care and specialties like hospitals, pharmacies, urgent care, and emergency rooms. The bulk of serious medical mistakes probably occur in acute settings where major decisions have to be made in that short amount of time. That doesn’t mean patient safety isn’t important in primary care. We did a large project years ago on patient safety in primary care that really focuses on how we make sure primary care leads this discussion or is part of the leadership of the discussion on behalf of our patients. That’s what it gets down to—that if we’re going to work on behalf of our patients, we should be leading the conversation about their safety, both in our own practice and when they go elsewhere for care.

SM: I agree that transitional point is especially vulnerable. For patients either when they’re transitioning away from primary care or coming back after an acute episode in the hospital, for example, I think that’s definitely a place where there’s a vulnerability for patients and that primary care has an opportunity to step in.

JW: Sarah, I think that’s exactly right. Primary care needs to lead the proactive sharing of information when we transition patients and refer them to specialists, to community organizations, to hospitals, or to emergency rooms. We need to lead the charge in making sure that those organizations have the information they need to practice safe care for our patients. Then, we equally need to demand from those organizations that they share information back with us in a timely manner and make sure those patients understand as they come back, that there is a transition, so that we can provide the best follow-up care from the emergency room, the hospital, or the specialist. Those transitions are important, and I think primary care can lead by example and demand from our colleagues better transitional information flow.

SM: You mentioned this just a moment ago, a project working on patient safety and primary care. I’d love to hear a little bit more about that.

JW: Yeah, this was called Applied Strategies for Interventions for Patient Safety (ASIPS), and it was out of the University of Colorado. It was an AHRQ-funded study looking at ambulatory patient safety. So how do we develop a taxonomy for patient safety, and how do we improve safe discussions around patient safety? We went into dozens of primary care practices, and we asked them to think about patient safety, near misses, and medical mistakes. We used all this different language and we had them report patient safety issues that they faced, and patient medical mistakes, and medical errors. It was fascinating. We had I think well over 1,000 submissions in a year or so about patient safety, patient medical mistakes, and near misses. We categorized all those as a group, and we put them into different categories. Part of it became some of the work that AHRQ continued, specifically the lab safety component of the study. Lab safety was one of the conditions for which we found a larger number of patient safety events like duplicating labs. That means the person had to get poked twice. That’s a needle going into the skin that’s painful, but it’s not a major life-threatening medical mistake. However, it certainly is annoying and not getting the medical records transitioned properly or having to repeat a whole series of testing is not optimal. So that study did some interventions to try to improve patient safety in those practices.

SM: So, we’ve had a really great discussion on this topic, and I very much appreciate your time. I’m curious if there’s anything else that I haven’t asked you about that you’d like to talk about today.

JW: I want to just reiterate the point that primary care and family physicians can lead the efforts on patient safety on behalf of our patients. I think claiming the relational aspects of primary care, and really demand that primary care clinicians and practices take a leadership role in patient safety efforts, whether that’s local in their practice, local in their hospital, or state, or national efforts to improve patient safety. We need to make sure that primary care clinicians and practices are there on the forefront on behalf of their patients.