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Primary Care and Patient Safety: Opportunities at the Interface
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Editor’s Note: Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.
Introduction
The Agency for Healthcare Research and Quality (AHRQ) recognizes that revitalizing the nation’s primary care system is foundational to achieving high-quality, safe, accessible, efficient healthcare for all Americans.1,2 AHRQ defines high-quality primary care as “the provision of whole-person, integrated, accessible, and equitable healthcare by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.”3 Setting a definition for primary care, and other important concepts in the essay, allows readers to build a common understanding about their structure, which provides a basis for exploration of their convergence. AHRQ, as one of the lead federal agencies in primary care research, funds research to understand how to implement this vision of primary care throughout the nation.
A strong body of evidence demonstrates that primary care can improve a patient’s overall health status.4 By providing a usual source of care, clinicians can help prevent, diagnose, and manage a wide range of patient conditions. Primary care can address acute problems, diagnose and manage chronic illness, deliver primary and secondary prevention, and provide trusted medical advice to improve health and well-being.
What makes primary care different from most other specialties is its role in coordinating and integrating a patient’s care across the healthcare system. Through primary care, patients can develop a long-standing relationship with their clinician and receive whole-person, comprehensive care. This relationship can enhance communication, manage clinical information, facilitate transitions in care, and engage patients and their families in care. The nature of relationship-based care provides the opportunity to potentially identify many, if not all, of patients’ determinants of health, from the health services themselves to the social and environmental factors that affect their health.
AHRQ is the lead federal agency for patient safety research. AHRQ’s broad definition of patient safety includes “prevention of diagnostic errors, medical errors, injury or other preventable harm to a patient during the process of healthcare, and reduction of risk of unnecessary harm associated with healthcare.” In addition to its role in managing most common patient conditions, primary care can prevent harms such as diagnostic delays, medication-related safety events, and avoidable hospital admissions and readmissions.5,6 Primary care, like other predominantly outpatient-based specialties, is vulnerable to safety issues in the ambulatory care setting. There is an opportunity to begin looking more closely at the alignment between the functions of primary care and patient safety as a component of quality care and at AHRQ’s approach to addressing both.
Primary Care, Quality of Care, and Patient Safety
Primary care plays an important role in avoiding and mitigating common safety issues such as diagnostic delays and errors; medication-related safety events; inadequate communication, including problems with care transitions or reporting and follow-up of laboratory and other diagnostic tests; unnecessary tests or procedures; and lack of access to care. For example, primary care providers can improve diagnostic safety through the use of relationship-based principles, e.g., promoting enhanced caring and listening. Strategies such as judicious application of technology, like clinical decision support tools, can be employed to reduce inappropriate medication use. Primary care practices can consider using systems engineering methods or lean workflow redesigns to improve communication processes and performance.
Quality healthcare is defined by the Institute of Medicine as the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.7 These six aims of quality are interdependent, and they share underlying drivers to achieve high-quality care. When one or more aims are not met, these interdependencies can also create negative outcomes. For example, if a patient receives the correct medications for a particular condition (effectiveness aim met), but they stop taking the medications because of side effects (patient-centered aim not met), their health may then be negatively affected (safety aim not met). A patient safety event can be the furthest downstream outcome of a series of events that starts with the intention of providing effective care. When optimally delivered, primary care, in its role of providing integrated and accessible healthcare services, can address each of the healthcare quality aims. Examining the functions and goals of primary care illustrates how they relate to these healthcare quality aims.
The functions of primary care have been described as the “4C’s”: first point of contact (access to care), continuity (long-term healing relationships, providing longitudinal care), comprehensiveness (whole-person care), and coordination (tracking all of a patient’s health issues across various settings).8 Others have since added patient-centeredness and cost-effectiveness, among others, to the 4C’s, describing 7C’s,9 9C’s,10 or even 10C’s.11 These models all identify functions that ultimately lead to improved access, equity, and quality care, at a lower cost for patients—similar to the six quality aims outlined by the Institute of Medicine—and all of the models have distinct implications for patient safety. (See table 1.)
Table 1. Functions of primary care, how they map to the six aims of quality, and the potential impact on patient safety
Editor’s note: This table is adapted from the “Six Aims of Quality Healthcare” framework, as cited in Crossing the Quality Chasm: A New Health System for the 21st Century).7 The reader may notice duplicative criteria under some elements of the framework. This duplication is purposefully intended by the authors, because multiple factors that influence quality healthcare may affect patient outcomes.
| Six Aims of Quality Healthcare (as cited in Crossing the Quality Chasm: A New Health System for the 21st Century and reflected on the AHRQ website)7,12 | Functions of Primary Care That Meet the Six Aims of Quality Healthcare | Ultimate Potential Implications for Patient Safety if Quality Healthcare Aim Is not Achieved |
| “Healthcare Should Be Safe” – Avoiding harm to patients from the care that is intended to help them. |
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(Editor’s note: Although access to care traditionally has not been considered a patient safety issue, the authors of this piece feel strongly that access can create a cascade of healthcare-related issues, ultimately affecting patient safety.) |
| Healthcare Should Be Effective – Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding underuse, overuse, and misuse) |
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| Healthcare Should Be Patient-Centered – Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. |
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| Healthcare Should Be Timely – Facilitating access to care; reducing waits and harmful delays for those who receive and those who give care |
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| Healthcare Should Be Efficient – Avoiding waste, including waste of equipment, supplies, ideas, and energy. Avoiding misuse of scarce workforce and other resources as well as missed opportunity costs. |
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| Healthcare Should Be Equitable – Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, or socioeconomic status |
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A Closer Focus on Access and its Impact on Patient Safety
In addition to enhancing diagnostic safety, preventing medication-related patient safety events, and thoughtful design of care processes, primary care helps ensure patients can access care when needed to prevent harm. Ideally, primary care is the patient’s first contact with the healthcare system for health concerns or health maintenance activities. This encounter establishes a relationship from which the other functions can occur (i.e., continuity of care). Access is often affected by elements that are frequently beyond the control of the provider, including insurance status and geographic location.16,17 Some of the rising demand for emergent and urgent care services can be attributed to access barriers to primary care, and to the fact that many of the patients seen in emergency departments could be treated in alternative, and more optimal, healthcare settings.18,19 Although patients may get appropriate short-term care for their chronic conditions (or ambulatory-sensitive conditions) in these alternative settings, care can quickly become disjointed, making continuity difficult to achieve and leading to patient safety events like diagnostic delays and medication-related harms.
There are three components to improving access to comprehensive, quality healthcare services: adequacy of insurance coverage, availability of health services, and timeliness of care. The remainder of the discussion focuses on interventions that target the availability of health services and timeliness of care components, both of which align with the functions of primary care. For this discussion, the term “health services” includes providing a usual and ongoing source of care to the patient and providing comprehensive services in the context of the community and family.20 Timeliness is the ability to provide care at the right time, reducing delays and potential harms caused by those delays.
Primary Care Workforce Innovations to Expand Access
In the context of primary care provider shortages, especially in rural and underserved communities, increasing access can be achieved by increasing and sustaining the primary care workforce, expanding the use of team-based care, liberalizing the scope of practice for advanced-practice nurses and physician assistants, and incorporating community health workers who are embedded in primary care clinics within communities that have low rates of primary care access. The deployment of health support staff directly within the community—typically staff who are embedded within the community—can help address individual barriers to primary care access and strengthen care. By working directly with patients, community health workers can establish customized, patient-centered solutions. These solutions may include initial screenings for symptoms of chronic health conditions, such as high blood pressure, or education about the benefits of preventive services, such as vaccinations and wellness visits.21,22
Integration of Primary Care Into Community Programs
Another approach is the incorporation of primary care services into existing health-related programs that serve populations with access challenges. For example, behavioral health programs that address substance misuse and mental health conditions might also be equipped to provide primary care. Conversely, an alternative model integrates behavioral health services into primary care practices while primary care providers prescribe medications for patients with substance use disorders. Research has found that integrating these services improves mental health outcomes and increases use of preventive services among patient populations.23
Increased Use of Telehealth Services
Increased use of telehealth services to reduce some of the barriers to primary care represents a third possible approach, which has been reinforced by the COVID‑19 pandemic. In particular, use of telehealth services can eliminate the need for travel to a primary care facility, and may benefit individuals with access barriers such as caring for a child or elderly relative at home. However, there are challenges associated with comprehensive access to telehealth services. To avoid introducing new patient safety issues, care must be taken to understand which visits can safely be conducted via telehealth.24 Communication and relationship building with patients, both critical functions of safe primary care, may also be more difficult via telehealth.25 Technical considerations, such as the availability of broadband internet service, access to a computer or smart device, and technology use among older adults may limit the effectiveness of this approach for some patients and may exacerbate disparities.26
Health Equity and Access to Healthcare
Determinants of health that exist outside the influence of providers often play a more prominent role in safe, high-quality care than the health services themselves. In her seminal work, Dr. Barbara Starfield described this phenomenon, which is supported by recent research27: “The health of individuals or populations is predestined by genetic structure heavily modified by the social and physical environment, by behaviors that are culturally or socially determined, and by the nature of the healthcare provided.”28 For example, take a patient who has hypertension that is controlled and who has good access to care and to medications: The patient’s health is maintained and overall quality of care is achieved in this context. In contrast, consider a patient with hypertension who lacks access to care or to medications: The patient’s health is in jeopardy, and there is high potential for resultant harm in this context. For patients to have equitable access to healthcare and avoid harms, we must make equity determinants of health just as important and integrated into patient care as we do the health services themselves.
Access to care is a cornerstone of high-quality, equitable primary care.29 Researchers believe that inequity in access to primary care is one reason for inequity in health outcomes between people who are White, people who are Black, and other minorities. As far back as the Heckler Report,30 data has indicated that preventable, manageable health conditions (e.g., diabetes, hypertension) make up the majority of deaths among minority racial and ethnic groups.31
Identifying the areas in which primary care has the most impact—for example, access—and then developing targeted programs and interventions to address the needs in these areas can lead to improved care. It can also foster efficiencies with provider resources—most importantly, providers’ time. Given its role in leading both patient safety and primary care research, AHRQ is ideally situated to continue to support research at the interface of primary care and patient safety to ensure broader access, higher quality, and safe primary care.
AHRQ Resources That Support Safety in Primary Care
- Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
- Toolkit for Engaging Patients to Improve Diagnostic Safety
- Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit
- Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings
- Primary Care-Based Efforts to Reduce Potentially Preventable Readmissions
- Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care
- TeamSTEPPS for Office-Based Care Version
Authors
Sarah E. Mossburg, RN, PhD
Senior Researcher
AIR
Crystal City, VA
Paul Dowell, PharmD, PhD
Senior Researcher
AIR
Columbia, MD
Patrick O’Malley, MD, MPH
Director
National Center for Excellence in Primary Care Research
AHRQ
Rockville, MD
Bob McNellis, PA, MPH
Senior Advisor for Disease Prevention
National Institutes of Health
Office of Disease Prevention
Emily Chew, MPH
Health Scientist Administrator
Agency for Healthcare Research and Quality
Center for Quality Improvement and Patient Safety
References
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2. Meyers D, Miller T, Genevro J, et al. EvidenceNOW: balancing primary care implementation and implementation research. Ann Fam Med. 2018;16(Suppl 1):S5-S11. Accessed August 11, 2022. https://doi.org/10.1370/afm.2196
3. National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. National Academies Press; 2021. Accessed March 4, 2022. https://doi.org/10.17226/25983
4. Starfield B, Shi L, Machinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457‑502. Accessed March 4, 2022. https://doi.org/10.1111/j.1468-0009.2005.00409.x
5. Agency for Healthcare Research and Quality Patient Safety Network. Patient safety in primary care. 2020. Accessed March 10, 2022. https://psnet.ahrq.gov/perspective/patient-safety-primary-care
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7. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press; 2001. Accessed March 4, 2022. https://doi.org/10.17226/10027
8. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. 2nd ed. Oxford University Press, Incorporated; 1998.
9. Bazemore A, Grunert T. Sailing the 7C’s: Starfield revisited as a foundation of family medicine residency redesign. Fam Med. 2021;53(7):506-515. doi:10.22454/FamMed.2021.383659
10. Doer T. The nine C’s of successful accountable primary care delivery. The Health Care Blog. Posted February 4, 2013. Accessed March 10, 2022. https://thehealthcareblog.com/blog/2013/02/04/the-nine-c%E2%80%99s-of-successful-accountable-primary-care-delive/
11. Kroenke K. The many C’s of primary care. J Gen Intern Med. 2004 Jun;19(6):708-709. doi:10.1111/j.1525-1497.2004.40401.x
12. Agency for Healthcare Research and Quality. Six Domains of Health Care Quality. Page last reviewed November 2018. Accessed August 10, 2022. https://www.ahrq.gov/talkingquality/measures/six-domains.html
13. Montero A, Kearney A, Hamel L, Brodie M. Americans’ challenges with health care costs. Kaiser Family Foundation. Published July 14, 2022. Accessed August 10, 2022. https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/
14. Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care. BMJ Qual Saf. 2018;27(3):199-206. https://doi.org/10.1136/bmjqs-2017-006917
15. Burman A. (2021). Laying ghost networks to rest: combatting deceptive health plan provider directories. Yale Law Policy Rev. 2021;40(1):78-148.
16. Agency for Healthcare Research and Quality. 2019 National Healthcare Quality & Disparities Report. AHRQ Pub. No. 20(21)-0045-EF. Published 2020. Accessed March 10, 2022. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr.pdf
17. Kirby JB, Yabroff KR. Rural-urban differences in access to primary care: beyond the usual source of care provider. Am J Prev Med. 2020;58(1):89-96. doi:10.1016/j.amepre.2019.08.026
18. Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med. 2017;24(9):1137-1149. doi:10.1111/acem.13220
19. Hefner JL, Wexler R, McAlearney AS. Primary care access barriers as reported by nonurgent emergency department users: implications for the US primary care infrastructure. Am J Med Qual. 2015;30(2):135-140. doi:10.1177/1062860614521278
20. National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. National Academies Press; 2021. Accessed March 4, 2022. https://doi.org/10.17226/25983
21. Community Preventive Services Task Force. TFFRS – Diabetes prevention: Interventions engaging community health workers. Community Preventive Services Task Force Finding and Rationale Statement; ratified August 2016. Accessed March 10, 2022. https://www.thecommunityguide.org/content/tffrs-diabetes-prevention-interventions-engaging-community-health-workers
22. Community Preventive Services Task Force. TFFRS – Heart disease and stroke prevention: interventions engaging community health workers. Community Preventive Services Task Force Finding and Rationale Statement; ratified March 2015. Accessed March 10, 2022. https://www.thecommunityguide.org/content/tffrs-heart-disease-stroke-prevention-interventions-engaging-community-health-workers
23. Gerrity M. Integrating Primary Care into Behavioral Health Settings: What Works for Individuals with Serious Mental Illness. Milbank Memorial Fund; December 17, 2014. Accessed March 4, 2022. https://www.milbank.org/publications/integrating-primary-care-into-behavioral-health-settings-what-works-for-individuals-with-serious-mental-illness
24. Jabbarpour Y, Jetty A, Westfall M, Westfall J. Not Telehealth: Which primary care visits need in-person care? J Am Board Fam Med. 2021;35(Suppl):S162-S169. Accessed March 10, 2022. https://www.jabfm.org/content/jabfp/34/Supplement/S162.full.pdf
25. AHRQ PSNet. In conversation with… Joel Willis, DO, PA, MA, MPhil and Neal Sikka, MD. Posted May 14, 2020. Accessed May 17, 2022. https://psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
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29. National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. National Academies Press; 2021. Accessed March 4, 2022. https://doi.org/10.17226/25983
30. US Department of Health and Human Services. Report of the Secretary’s Task Force on Black and Minority Health. Vol. 1, Executive Summary; August 1985.
31. Centers for Disease Control and Prevention. Leading Causes of Death – Males – by Race and Hispanic Origin – United States, 2017. Page last reviewed September 27, 2019. Accessed March 10, 2022. https://www.cdc.gov/healthequity/lcod/men/2017/byraceandhispanic/index.htm
Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC. Previously, as an Associate Professor at George Washington University, and at the University of Texas Dell Medical School, and School of Public Health, she developed a curriculum in Community Oriented Quality Improvement, to train the next generation of healthcare providers how to integrate population health into primary care to achieve the quintuple aim of better health outcomes, better patient experience, better provider experience, lower health care costs, and decreased health disparities. We spoke with her about her ongoing work in low-income communities to improve access to primary care and its impact on patient safety.
Kendall Hall: Could you just tell us a little bit about yourself and describe your current role, please?
Freya Spielberg: Absolutely, so my name is Freya Spielberg, and I am a family medicine physician, a researcher, and an educator, and for most of my career I’ve combined all three of those components. In my research, I've worked on identifying new strategies to deliver services to address health disparities. As an educator, I've developed a new curriculum, Community-Oriented Quality Improvement, to teach medical students, health providers, and MPH [Master of Public Health] students how to improve health outcomes among underserved populations. In my current roles, I am an Associate Professor at the Dell Medical School at The University of Texas at Austin as well as the CEO [Chief Executive Officer] of a social enterprise called Urgent Wellness, which I created to implement some of the more innovative models in low-income housing projects to address health disparities and improve health outcomes. I am also the Medical Director for Primary Care of Bluebonnet Trails, where I've been integrating primary care into mental health care. Bluebonnet Trails is a large safety net mental healthcare organization, and in the past year I've had some experience seeing the benefit of bringing primary care to people who are receiving mental healthcare services, but who do not have access to primary care. Finally, in June I'll be starting a new job as the Chair of Family Medicine at a large FQHC [Federally Qualified Health Center] teaching consortium in Phoenix, including District Medical Group, Valleywise Health, and Creighton Medical School.
KH: Can you describe how your work in the community setting intersects with patient safety?
FS: I think about patient safety very broadly. Health disparities that result from limited education, low health literacy, poor access to care, and social determinants [of health] create barriers to care that result in poor health outcomes that I would say are patient safety issues. A narrow view of patient safety is if you, for example, give the wrong medicines to someone and they have a bad reaction. But I think if the goal is really to achieve the quintuple aim of improving health outcomes, improving patient experience, improving provider experience, lowering healthcare costs, and addressing health disparities, what we need to do is to think more broadly about patient safety and fix the healthcare system. If we address those barriers to patient care that result in health disparities, we will improve the health of populations that currently have poor health outcomes.
The way I engage in community health comes from a model of care called Community-Oriented Primary Care. Prior to my role here, I'd been the Director of Community-Oriented Primary Care at George Washington University and evolved a curriculum that teaches a methodology that starts with understanding what the specific patient barriers to care are. That's critical in any setting where you're trying to address patient safety issues. In Community-Oriented Primary Care and Community-Oriented Quality Improvement (COQI), what we do is start with qualitative interviews of patients to understand what their real barriers are. What's leading to poor outcomes? What are their preferences? What's going to be acceptable? And then we look at assets in the community. There are always many, many social programs, social services, and individual resources that can be tapped into and that could improve health outcomes in the community, but we have to understand what is out there. Then, of course, we have to understand what the best practices are in the literature and make sure that we are designing an intervention that is evidence-based to address those barriers and key causes of morbidity and mortality identified by the patients and the stakeholders. Then we implement, evaluate, and determine the return on investment and the impact on the quintuple aim. If effective, we scale up and provide training. If ineffective, we start over and redesign the next COQI test of change improvement cycle.
KH: What would you say are some your biggest lessons learned from that engagement? What are the pressing interventions?
FS: What you find is that we need to design new models of care. The new model of care that I designed initially with Urgent Wellness was really to address some of the main barriers to care: health literacy, access, and social determinants [of health]. In that model, we placed a wellness program inside a low-income public housing community, partnered with the public housing authority to turn an apartment into a clinic, and started by going door to door and doing holistic assessments of health needs, mental health needs, substance use, social service needs, etc. We assessed what community preferences would be for different types of services to address some of the barriers. With that data, we decided the most impactful model would be to have community health workers develop long-term relationships with individuals, to provide education, early screening, and the link to needed health and social services.
One of the important care-seeking behaviors that we found is that both in Washington, DC, and in Austin low-income housing projects, about half of the individuals hadn’t accessed primary care in the past year, even though they had insurance. A similar number had been to the ER [emergency room] one or more times. When you go to the ER, or to urgent care, you don't get your preventive health or chronic disease management needs met, leading to poorer health and potential disparities. People don't know that they're not getting what they need; they think they've been to the doctor. That's a health literacy issue that needs to be addressed. We had community health workers work with medical providers to come up with a care plan that they went over with patients, noting that here are the healthcare services that would benefit you, here are health behaviors that, if you worked on changing them, would improve your health outcomes, here are social services that might help improve your life. They would review all the different needs and then they would negotiate with the patient on what they wanted to prioritize, so it was a very patient-driven model. Then they would work with the patient longitudinally. If they needed primary care, which we always encourage if they haven’t had it, the community health worker would work with them to help them figure out how to schedule the appointment, get the transportation there, find childcare, and overcome the barriers that get in the way of people having appointments. During COVID-19, developing telemedicine literacy was a huge focus, and ultimately resulted in better access to care, as it prevented the need for transportation, childcare, and even leaving work sites—the most common barriers to following through for primary care.
In addition, community health workers supported individuals with behavior changes that would help them improve their health. For a behavior change, for example, if someone needed to increase their exercise and [people] were not walking because of safety concerns, the community health workers started neighborhood walking groups. They made options available to help improve access to what was needed to improve health. One of the most sought-after interventions to improve nutrition was cooking classes; however, COVID-19 made that difficult to implement. For chronic diseases like hypertension or diabetes, what we found was that a high percentage of people didn't know that they had these conditions because they hadn't been to the doctor. A big step was just educating people that, in fact, they have high blood pressure and how they can take of themselves, training them to do chronic disease management. As part of this education, the community health worker would give a patient a blood pressure monitor so they could take their own blood pressure at different times during the day and see for themselves that it is high. This helped them overcome personal health barriers, so they’d be ready to get treatment.
KH: What sorts of successes were you seeing with this model? Could you also please talk a little bit about your challenges? I imagine this could be quite difficult to get off the ground.
The goal of this model was to have frequent interactions until someone's chronic disease was controlled and to help individuals overcome barriers to control. For example, I had another patient with HIV and, all of a sudden, their viral loads spiked. If you just saw that in a clinic setting, often providers would say, oh, you're not adhering to medicines or we need to change the medicine. But when the community health workers dug into it, it turned out that that individual had housing instability, they'd been kicked out of their grandmother's home and all of their meds were at grandma's house so they didn't have access to them. The community health worker was able to go to grandma's house, get the meds, bring them to the patient, and get the patient back into care. That's the kind of thing that, if you don't have an on-the-ground community health worker working with the patients, it is difficult to address. I think that this model of care is just critical to improving health outcomes among low-income populations or populations that just have significant barriers to care.
One of the big challenges is, how do you pay for the community health workers? Right now, there's a lot of data in the literature showing the impact of community health workers, both on improving health outcomes and lowering healthcare costs. They’ve been used for transitions in care, for chronic disease management, substance use, mental health, all sorts of things. A lot of those projects are grant-funded, and so figuring out how to really integrate community health workers into the collaborative care team and figuring out how to pay for them are the challenges for scaling up this kind of model of care. In DC, Urgent Wellness works with a large Medicaid managed care organization, AmeriHealth, and we contracted with them so that we could get reimbursed for the community health worker activities. This was really the first time that we've had the ability to provide this kind of care outside of a grant. If we're not going to reimburse, it's just not going to happen. I do think that in ACO [accountable care organization] and pay-for-quality models of care, there's a greater likelihood that these kinds of programs will be integrated. However, it'll take a change in the culture because we’re so used to the idea that care is provided within the walls of the clinic.
KH: Who are the community health workers? Do they get better traction with the people in these communities if they are from the community?
FS: When you're picking community health workers, what we found is the most successful model is when we actually trained people from the community. We went into the low-income housing communities and looked for people with an interest in healthcare or even a CNA [certified nursing assistant]. We proactively recruited people that had gone through CNA training and who lived in the housing complex, put them through a community health worker training, and then we put them through a training of our particular model of care. Those people have just been so effective. Not only do they make the program more effective because they're members of the team, and anything that is designed they can give the community perspective on. They know what's going on. I can't tell you the vast array of design issues that you wouldn’t have even thought about that they are able to help guide. But then, they also live in the communities. It's convenient for them, so they don't disappear, and people begin to trust them. They become the first person that someone calls when they have an issue. There are just so many stories of people that didn't have food, that didn't have rent, that had disabilities that weren’t being addressed, where the community health worker was able to step in, understand, and bring resources to bear for it. Additionally, when patients come to the community health worker with a sore throat or a cold and they are used to going to the ER for care, the community health worker can help them find same-day outpatient care in clinic or telemedicine settings.
In a scaled-up model, I do think that having a physician medical director and a nurse or [someone at the] nurse practitioner level to supervise large numbers of community health workers is the other important piece of the model. You need someone to help when they have medical issues that come up, and to help guide continuous quality improvement. These community health workers should become critical components of the integrated collaborative care team to help provide seamless handoffs, and to decrease inappropriate costly ER visits.
KH: I think that's the fascinating part of all of this is that you truly are re-envisioning healthcare. And what does patient safety mean, in that context?
FS: If you think about it, preventable hospitalization is a patient safety issue. Improve diabetes management, improve congestive heart failure management, and you decrease rates of avoidable hospitalizations.
KH: But in your model, the focal point is beyond those patients that are already getting care in the clinics.
FS: Absolutely! The patients that are showing up to the ER, and ending up in the hospital, are those that aren’t getting care at the clinics because they're not plugged in. The other thing that we really, really, really need to do is redesign the technology and the processes for improving access to technology among people who experience poor health outcomes. There are two different aspects of that. One is, if you didn't have access to telehealth, your access to healthcare can be limited. This was particularly highlighted during COVID-19. It's totally possible to bring the technology to low-income communities and give them access, either by training them, providing the internet service, or providing the cell phone service.1 A lot of states will actually provide cell phone service so people at least have access to a smartphone, but we have to be sure that they know how to use it. A community health worker can work with the individual to show them how to get into patient portal, how to set up appointments, and how to connect to telehealth. Sometimes it might just take one training session to get someone up to speed, but the other people who have other disabilities may just need that community health worker to be that person in between to help link them. So, re-envisioning what the CNA does, basically training them to work in the community and to help get the vital signs and get the health history and get someone ready for a telemedicine visit in their homes. That could have a huge impact. The other thing that's really important, is that what we've learned during the epidemic is that even if people don't have access to telemedicine, don't have access to a laptop, or can't navigate the system, they can use the telephone. Many patients actually prefer to use a telephone than a full telehealth system because it is easier to do privately when they are taking a break from work or child care. In fact, as COVID-19 immunization rates increase, it is critical that telephone care continues to be made available to individuals who have barriers to attending in-person visits. Some states are going back to the requirement that telemedicine is done with video, and this will result in greater health disparities for individuals who have telemedicine literacy issues, or who prefer the privacy of a telephone call.
The other technological innovations that are necessary to really optimize medical care for the underserved, focus on the integration of data. Ideally, you would have a tool for the patient and the community health worker that pulls in data from all the different sources that the patient may have touched—the exchange of health information from the clinics, the hospitals, patient-reported outcomes, and from community health worker visit notes. When you have all that integrated data, the providers, the community health workers, and the patients can all be on the same page. But even more importantly, you can begin to build in decision support so that when a patient shows up at the ER, the community health worker is pinged and can help with transitions of care. Or when someone has diabetes that’s out of control with an elevated hemoglobin A1c, or when someone never got their colon cancer screening, the health worker can be pinged for their panel of patients and reach out to intervene. That's where we need to get to, to be able to really address poor health outcomes.
KH: It sounds like the community health workers are acting as case managers essentially to help patients navigate the system as well as track their health. Is it kind of a hybrid?
FS: In part! The important piece is the integration of activities. Normally in a clinic setting, care coordinators would assist with linkage to care, CNAs would get the patient’s medical history and vital signs, and nurses or health educators would provide behavior change counseling and chronic disease management. In a sense, what is needed is a community health worker that can provide first-line assessment and linkage to all of those services. Once the individual is linked to primary care, the in-clinic staff can further implement the care plan, while the community health workers can support adherence to the care plan in the community setting. The community health worker would assess the patient’s vital signs but also help the patient learn to do their own vitals. For example, one goal is that since hypertension is such a huge issue in these populations, everybody should have a home blood pressure [monitor] and know how to use it. The community health workers can teach them how to do that, collect the information on their vitals if they don't put it into the portal themselves, or if home remote monitoring is not available. You need that person out in the community doing that education, doing the home screening, reinforcing any behavior change, helping to overcome the barriers to linking care. They can help make those care referral connections. They can do motivational interviewing to reinforce provider-directed behavior change agreed upon with the patient. So, it's kind of a hybrid position that's right in the middle of the whole collaborative care team.
KH: I hear you talking about patient activation and having that community health worker get the patient motivated and able to advocate. Is there any need to have a readiness assessment for the community at large? Is there a chance that it's the community that just can't support this model of care?
FS: That’s an interesting question. I think that that makes a lot of sense as a natural step in the process of trying to scale up. If you do the stakeholder interviews, you'd understand the community assets, right? You’d understand barriers to implementing different parts of the model, so that is really part of the COQI methodology. But I like highlighting the need for that as the first step before you try to implement these kinds of new programs. On the individual level, understanding needs, barriers, preferences so that you can start designing the program, but then understanding the community-level readiness for the intervention that has come from that process is a critical step as well.
KH: I want to shift to talking about your work around bringing primary care into mental health, rather than having primary care integrate the mental health piece.
FS: I’ve just learned so much through my recent experiences as the Primary Care Medical Director for Bluebonnet Trails, an eight-county safety net mental health network. It has really changed my understanding around how we need to address health among people who have mental health needs. In my work in community clinic settings, we always had a behavioral health person integrated into the clinic. However, there was rarely enough staffing to be able to get everybody who needed mental healthcare services into behavioral healthcare. I thought that access to mental healthcare was the primary issue, not access to primary care. But then, when I started working in the mental health safety net clinic system, I realized that the vast majority of patients had not had primary care for some time. Almost all my patients have no insurance, and so getting them access to care is really, really challenging. I would have patients that had diabetes, COPD [chronic obstructive pulmonary disease], congestive heart failure, history of MI [myocardial infarction], and who hadn't had primary care and could only go to the emergency room. I strongly believe that to improve mental healthcare, you have to address primary healthcare needs. To improve primary health outcomes, you have to address mental healthcare needs. The best way to do that really is to integrate services—all mental healthcare should really integrate primary care and vice versa. What it comes down to is that people that have challenges and multiple social determinants of health have difficulty getting plugged into any kind of healthcare setting. You'll find that there are some people that get plugged into mental healthcare settings but won't go anywhere else. Similarly, some people get plugged into primary care settings but would never go to a mental healthcare organization. So you really need both of those models. Nationally, it'll be important to come up with payment models and programs that incentivize integrating primary care and mental healthcare, and vice versa. And then on the ground, we have our community health workers screen for depression, anxiety, and PTSD [post-traumatic stress disorder]. They just get that as part of their vital signs screens and if someone screens positive, we link them to a mental health provider. That's a direction that I think is really important.
KH: When you are talking about mental health, I assume you're including in that bucket patients with substance misuse?
FS: Absolutely. We screen for substance use and assess readiness for treatment as part of the mental health assessment. I do think that the more convenient a program can be made for a patient who has a chaotic life, the more likely they will be to get services. The other interesting thing that I've learned recently was from overseeing a student who has been helping to assess an integrative pain treatment program. We know we can’t use opioids for chronic pain without the risk of creating addiction and overdose, so what do you do? Integrative pain management programs are what's needed. There's one that's being done in Austin at People’s Community Clinic that brings together groups of people with chronic pain and they have a variety of interventions, mental health and acupuncture, a variety of integrative therapies. But in the qualitative work, at least so far, it seems that it's really the support group that is having a big impact in being able to get that needed social support, understanding they're not alone, sharing ideas about new coping mechanisms for living with pain and anxiety and stress. It seems to really have an impact. So we're going to have to also think about how group visits could play an important part of chronic disease management and substance use treatment. I think, as we have more and more data that this is what works, we will need to figure out the financial models, logistically how you make this happen, and how to do it virtually, is going to be key for some populations. That's another exciting direction that we are moving in.
KH: What do you think comes next for population health and training the next generation of health providers and collaborative care teams?
FS: If you don't have a good infrastructure to do population health, you will not be able to address poor health outcomes because you won't know that you have them. A lot of clinics now have data visualization software, but really, I believe what's needed on the collaborative care team is an MPH-level trained person to support providers in the design and assessment of rigorous Community-Oriented Quality Improvement interventions. Providers have excellent ideas, but the MPH training can drive the Community-Oriented Quality Improvement methods further and faster for the team. Obviously, you need a data system that will allow individual providers to know how they’re doing with their patient population for all the reportable quality outcomes. That's critical and it needs to be talked about as part of regular routine meetings so that the team understands what's necessary, what has to be prioritized, what's needed to change, and so that they can see the impact of changes that they make. So that's one key thing. The healthcare team of the future will be a collaborative care team, in-clinic or virtual, that will include community health workers and an MPH-level population health expert, as well as healthcare providers, nurse educators, behavioral health counselors, clinical pharmacists, and care coordinators. And then training the providers, that's really key. Providers that get MPHs as part of their education have a good understanding usually of population health, but they may not learn the Community-Oriented Quality Improvement methods that focus on making sure you understand, first and foremost, what the patient's needs and preferences are, the stakeholders’ needs and preferences, and community assets. I think, you know, the vast majority of medical providers come through trainings that don't really have a rigorous population health program. One of the things that I'm going to be doing as we grow the Urgent Wellness model of care, is to partner with Medical Schools and Family Medicine residency programs to introduce training in Community-Oriented Quality Improvement to medical students and residents, so that they get those skills and methods to bring with them when they go out into the world.
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.
