Guest post: The Ambulatory Practice of the Future

This is a guest post by David Stievater, a health care consultant working at the intersection of provider, payer, patient and technology trends.

Many policy makers and health care industry participants believe that improving provision of primary care holds the key to lowering costs and improving  outcomes.  But a new report from the Dartmouth Atlas Project suggests that tackling primary care will involve a lot more than just giving patients better access to a family physician, internist or pediatrician.  According to the study (Regional and Racial Variation in Primary Care and the Quality of Care among Medicare Beneficiaries), “neither a greater supply of primary care physicians in an area nor a regular visit to a primary care clinician is, by itself, a guarantee that a patient will get recommended care or experience better outcomes.”

So what is the answer?  The Dartmouth study and a recent CIMIT forum in Boston give a glimpse into what it will take to truly transform primary care.

The Center for Integration of Medicine & Innovative Technology (CIMIT) is a non-profit consortium of Boston teaching hospitals and engineering schools.  It holds weekly public forums to promote the exchange of ideas and information to improve patient care.  The CIMIT Forum reopened on September 14, 2010 by covering The Ambulatory Practice of the Future (APF), recently launched at Massachusetts General Hospital.

Moderator Ron Newbower, PhD, Chief Technology Officer and Strategic Director, CIMIT opened the forum by suggesting that “our existing health care system is not a system”, but rather “increasingly fragmented” with “tight islands of specialization supported by islands of technology” (ICUs, cath labs, imaging centers and so on).  The Dartmouth study authors echo this view, and conclude in their report that “Primary care is most effective when it is embedded in a high-functioning system (emphasis mine), where care is coordinated, where physicians communicate with one another about their patients, and where feedback is available about performance that allows physicians and local hospitals to continually improve.”

The APF – launched July 2010 with patients recruited from among MGH employees – is a live experiment intended to consider the nature of the health care system in its totality.  The focus is on patient health and wellness, not sickness, and creating a culture of collaboration and transparency.  The APF patient portal, iHealthSpace, provides a more robust tool for patients and caregivers to communicate with each other.  As with other similar ambulatory care pilots (e.g., Patient Centered Medical Home), the APF vision emphasizes a team approach to continuous care.  Roles among the care team (MD, RN, NP, MA, care coordinator, greeter, medical secretary) are clearly defined and the APF physical layout is designed to facilitate collaboration.

The APF is juggling multiple objectives, including patient care, business goals and ongoing learning.  The APF, while set up as a laboratory with a “prototyping room” for learning and further innovation, is a still a functioning living practice serving many patients.  David Judge, MD, Medical Director of APF and CIMIT Co-program Leader for Clinical Systems Innovation, reiterated at the forum that the APF is “absolutely on the hook to measure utilization of services allocated and the cost of this new model” while working to improve individual and population outcomes.  The APF is measuring results, in part, against a matched cohort of patients who are getting their care in traditional practice settings.

Anyone interested in the transformation of the ambulatory care setting should check out both the APF online tour and the Dartmouth report.

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September 16, 2010

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