Comprehensive

First contact. One element of primary care is sometimes referred to as first contact. In a well-developed and functioning system, primary care is the usual and preferred route for entry into the health care system (although not necessarily in all circumstances). In the simplest model, the primary care clinician receives patients regardless of the disease or organ system involved and addresses a given patient's problem. This function may require sorting out a mixture of ill-defined symptoms, or it may call for fairly straightforward treatment. This simplest of models, however, should be flexible enough to allow patients to enter at various points or to skip given steps (e.g., authorizations) based on their needs and safety as well as on efficiency considerations. The model is not intended to describe a regimented or restrictive processing system, and indeed such a system would be antithetical to the committee's future vision of primary care.

First contact with a primary care clinician may lead to referrals to other resources—for example, to a nurse practitioner for diabetic counseling or to a cardiologist for subspecialty care. In some cases, self-referral by a patient may be appropriate—for example, for recurrent problems previously treated by another specialist or subspecialist or refractions for eyeglass prescriptions. Information about these encounters should be provided to the primary care clinician.

The descriptor first contact is not, however, a sufficient or unique attribute for defining primary care. It is not unique because some first contact events do not represent primary care—for example, those that occur through an occupational health service, an emergency room, or at a health fair booth for cholesterol screening. Such encounters can be integral to the patient's health care, and information gathered should be communicated to the primary care practice.

First contact is not adequate to define primary care. Insofar as it has come to imply the restriction of primary care to a triage function, it neglects the other characteristics of primary care included in this report, specifically, comprehensiveness.

A derivative term is gatekeeper. In many circles, the term gatekeeper has been used to describe the function of using the experience and judgment of the primary care clinician to determine whether diagnostic tests are necessary, whether a patient's problem can be handled by the primary care practice, or whether a person needs to be evaluated or treated by another specialist or subspecialist. The primary care clinician's important role in helping the patient to obtain appropriate care in a complex health system requires a high level of skill and judgment. This judgment involves both clinical and economic decisionmaking.

Patients may view gatekeeping with suspicion because they fear that efforts to control use of services and to manage costs may have subtle effects on clinicians and ultimately work to the detriment of their health. By contrast, many managers, benefits officers, and policymakers view gatekeeping with enthusiasm because they see it as a way of rationalizing, if not restricting, the use of health care resources. The term gatekeeper, therefore, has come to have a pejorative connotation when primary care is reduced to the function of managing costs and especially when it implies that the gate is kept closed most of the time. This committee categorically rejects the view that the primary care clinician acts mainly or exclusively as a gatekeeper.

The scope of primary care. Comprehensive care is intended to mean care of any health problem at a given stage of a person's life. It includes ongoing care of patients in various care settings (e.g., hospitals, nursing homes, clinicians' offices, community sites, schools, and homes). Ideally, the primary care clinician listens to the patient, makes diagnoses, manages, and screens for other health care problems. The clinician educates and communicates with the patient and others who may be involved including other specialists when appropriate. He or she assumes ongoing responsibility for maintaining contact with and care of the patient and assuring that the care provided is suitable.

The IOM definition refers to a large majority of personal health care needs. That phrase refers to the essential characteristic of primary care clinicians. Primary care clinicians receive all problems that people bring—unrestricted by problem or organ system—and have the appropriate training to manage a large majority of those problems, involve other health professionals for further evaluation or treatment when appropriate, and continue to act as advocates for their patients.

Primary care addresses a mixture of health problems along the spectrum of disease as they occur singly or in combination within a single individual. Ideally, primary care clinicians elicit the full range of patient concerns, whether physical or psychosocial, and are sensitive to the concerns and circumstances that accompany a patient's symptoms.

Not all patient problems represent deviations from normal health that require medical action. Thus, primary care clinicians have a special responsibility to be sensitive to those concerns that are appropriately labeled health problems and those that are not or that could be made worse by medical intervention.³

Some portion of patient problems—based on a particular individual's needs, on safety, or on efficiency considerations—may not be manageable by the primary care clinician. Some portion may require the expertise of other health professionals, other specialists, or subspecialists. The following categories of service are within the scope of primary care as defined by the committee:

1.

Acute care.⁴ (a) The primary care clinician evaluates a patient with a symptom or symptoms sufficient to prompt him or her to seek medical attention. Health concerns may range from an acute, relatively minor, self-limited illness, to a complex set of symptoms that could be life threatening, to a mental problem. The clinician arranges for further evaluation by specialists or subspecialists when appropriate. (b) The clinician manages acute problems or, when beyond the scope of the particular clinician, arranges for other management of the problem.

2.

Chronic care. A primary care clinician (a) serves as the principal provider of ongoing care for some patients who have one or more chronic diseases, including mental disorders, with appropriate consultations, and (b) collaborates in the care of other patients whose chronic illnesses are of such a nature that the principal provider of care ⁵ is another specialist or subspecialist. The primary care clinician manages intercurrent illnesses, provides preventive care (e.g., screening tests, immunization, counseling about life style), and incorporates knowledge of the family and the patient's community. An example would be managing the dermatitis, hypertension, or upper respiratory infection of a patient who is under the care of a rheumatologist for rheumatoid arthritis.⁶

3.

Prevention and early detection. The primary care clinician provides periodic health assessments for all patients, including screening, counseling, risk assessment, and patient education. Periodic health assessments are a natural part of primary care. Primary care must reflect an understanding of risk factors associated with these illnesses, including genetic risks, and of the early stages of disease that may be difficult to detect at their outset.

4.

Coordination of referrals. The clinician coordinates referrals to and from other clinicians and provides advice and education to patients who are referred for further evaluation or treatment.

Coordinated

Coordination ensures the provision of a combination of health services and information that meets a patient's needs and specifically means the connection

The terms generalist and primary care clinician are both sometimes used to describe specialists who provide a broad spectrum of care within their own specialty, for example, generalist orthopedist, primary care ophthalmologist, or generalist obstetrician. The committee emphasizes, however, that general care of an organ such as the eye or of an organ system does not constitute primary care as the committee defines it. within and across those services and settings—putting them in the right order and appropriately using resources of the community. The goal is to focus on interactions with patient and family and their health concerns, clarify clinical care decisions, advise hospitalized patients and their families, and help patients and their families cope with the social and emotional implications of disease or illness.

The primary care clinician will often be the principal clinician of inpatient care for certain conditions that require hospitalization (e.g., pneumonia). He or she follows hospitalized patients, even those whose principal clinician may be another specialist or a subspecialist. The primary care clinician brings knowledge of a patient and family history and social perspectives to bear on that episode of care. He or she may also manage other aspects of the patient's care during hospitalization, for example, by continuing to manage the diabetes of a patient who is hospitalized for a hip fracture. The primary care clinician also coordinates a patient's transition between health care settings—for example, hospital and home, home and nursing home, or between clinicians' offices.

Teams. An individual may need a set of activities that entail an array of services. The sorts of tasks required are varied and require efficient management of both care and available resources. The emphasis in this report on primary care teams acknowledges that we need not depend on a single person to organize and provide all expertise and care. Much primary care is rendered by single clinicians, but increasingly teams are managing the health problems presented to primary care practices.

A team is a group of people organized for a particular purpose. It may be organized to subdivide tasks, increase accessibility, extend the expertise of a health professional by drawing on several disciplines, or delegate tasks that do not require a clinician's level of training. The organization of health services for a defined population can be greatly facilitated by using teams with a mix of practitioners who together are best suited to meet the range of needs of a given patient or of a population. A pediatric practice may, for instance, have a group of pediatricians, a pediatric nurse practitioner, and a receptionist who work together giving general pediatric care. Other multidisciplinary groups might be organized for the care of those with particular problems, for instance, children who have been abused. Yet another case in point is a geriatric practice team that includes a social worker, dietitian, physical therapist, geriatric nurse practitioner, and geriatrician. Team composition may vary by specialty, subspecialty, clinician interest, expertise, and resource availability. The population served by a team may vary by gender, age, health concerns, and social problems.

As indicated in Figure 2-1, the committee views the team as an extension of the patient-clinician relationship, not as an alternative to it. Although primary care can be delivered by teams, exemplary primary care requires that one or more members of that team develop a close one-on-one relationship with the patient.

Interaction with Communities

The effective coordination of health care services requires an intimate knowledge of the communities in which those services are delivered. Such coordination requires:

• knowledge of other health care agencies, resources, and institutions within the community (e.g., the availability of classes teaching cardiopulmonary resuscitation or of smoking cessation support groups);
• an understanding of the financial concerns of patients and communities;
• an understanding of the cultural, nutritional, and belief systems of patients and communities that may assist or hinder effective health care delivery;
• an understanding of day-to-day lifestyle patterns of patients and in communities that may enhance or diminish coordination efforts (e.g., work, transportation, school, child care); and
• effective information systems.

Continuous

The term continuous means ''uninterrupted in time, without cessation; being in immediate connection or spatial relationship" (Random House, 1983). In this report, continuity is a characteristic that refers to care over time by a single individual or team of health professionals ("clinician continuity") and to effective and timely communication of health information (about events, risks, advice, and patient preferences) ("record continuity"). It applies to both space and time. It combines events and information about events occurring in disparate settings, at different levels of care, and over time, preferably throughout a person's life span. Continuity encompasses patient and clinician knowledge of one another and the effective and timely communication of health information that should occur among patients, their families, other specialists, and primary care clinicians.

Clinician continuity, when achieved, is an effective way to provide continuity in primary care. The patient record is essential, but it does not substitute for clinician continuity. Information such as family, sexual, or emotional problems is often intentionally excluded from the record because of concern that the information might not be kept confidential. Knowledge of a patient's usual ways of dealing with symptoms such as pain is another example of how care can be dramatically altered by sustained personal relationships between clinicians and patients. A patient's story is dynamic, not static, and a primary care clinician who knows a patient understands when it is appropriate to use or disregard medical information in the patient's record because it is outdated, irrelevant, or wrong.

Given our propensity in the United States for moving from place to place, for changing employers and health insurance plans, and for changing household composition, such a goal of clinician continuity is not likely to be perfectly realized. At an earlier time in our nation's history, a general practitioner might care for a couple, deliver their babies, and see those children grow, marry, and have children of their own. Physicians knew their patients and their families, and record keeping was modest. Now the amount and complexity of information that must be recorded about patients is steadily increasing. If continuity is to be an element of primary care, it will likely be achieved by ensuring that relevant, accurate information is available to all clinicians, even when the relevance of data is not immediately apparent; this reflects the goal of record continuity.

Increasingly sophisticated clinical (as opposed to financial) information systems are being developed rapidly, and the progress of computer technology has led to efforts to aggregate health data from many sources such as hospitals, offices, pharmacies, and laboratories. Such data aggregation has tremendous potential for ensuring the continuity of medical information. Two IOM reports, The Computer-Based Patient Record: An Essential Technology for Health Care (1991) and Health Data in the Information Age: Use, Disclosure, and Privacy (1994c), have explored the benefits and risks of computer-based patient records and community-level information databases. Meeting the need for continuity of care is a significant element of computer-based patient records. Continuity can apply to an integrated delivery system, a primary care practice or team, and a single primary care clinician. Although the ideal may be an individual seeing the same clinician at each visit, there may be tradeoffs between continuity and access. Continuity of clinician may be more important for some people and in some circumstances than others. For a patient with hypertension who makes appointments at regular intervals, for example, it is particularly helpful to both the clinician and the patient to ensure continuity over a succession of visits so that progress and the need to adjust medications can be assessed. Continuity can also be a major source of satisfaction both to patients and clinicians, as it fosters the long-term relationships that represent, for many clinicians, a significant reward of medical practice.

Sometimes, however, patients have an acute illness or injury and would prefer quick access to a clinician who might be known to them as a member of a team or practice or might even be a complete stranger at an urgent care center or emergency room. Balancing the competing values of continuity and access represents one of primary care's important challenges and one for which integrated delivery systems may offer some solution.

Comment: Who Is a Primary Care Clinician?

The committee acknowledges that the use of a functional definition of primary care does not provide a definitive answer to those who must count primary care clinicians and develop policies regarding payment for primary care services. Because the definition is normative, the committee hopes that the functions of primary care will increasingly be adopted. The committee preferred not to use the definition to differentiate among clinicians, despite the interest of many that it do so. If pushed to differentiate among clinicians, however, the committee would use as a reference its knowledge of how clinicians are currently trained and what they generally do in their practices. From this perspective, it seems clear that those trained in family medicine, general internal medicine, general pediatrics, many nurse practitioners, and physician assistants are trained in and are generally most likely to practice primary care.

Some physicians in other specialties may also be practicing primary care. For example, obstetrician-gynecologists undoubtedly deliver some primary care, but others are surgically oriented, are not currently trained in primary care, and do not consider themselves primary care clinicians (Leader and Perales, 1995). Subspecialists, particularly in internal medicine, may provide primary care for a subset of their patients with chronic conditions and they may well provide a majority of those patients' care. Specialists in emergency medicine may provide first-contact care, but this care is not usually integrated. It is certainly not continuous, and this care does not comprise the full spectrum of primary care. General dentists may provide general dental care, but they do not provide the full range of health care needs. If other medical specialties and health care disciplines are to provide primary care as defined by this committee, training would have to be modified as described in Chapter 7.

Quality of Care

Primary care practices are accountable for the quality of care they provide.

A 1990 IOM report, Medicare: A Strategy for Quality Assurance, defined quality of care in the following way:

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM, 1990, p. 21).

Focusing on outcomes requires clinicians to take their patients' preferences and values into account as together they make health care decisions. The phrase current professional knowledge in the above definition underscores the need for health professionals to stay abreast of the knowledge base of their professions and to take responsibility for explaining to their patients the processes and expected outcomes of care. High standards for licensure, certification, and recertification for all individuals and institutions that provide health care must be maintained. In accordance with this definition, primary care practices must be able to address three fundamental quality-of-care issues in their assessments of quality and in the steps they take to improve it (IOM, 1990):

1.

Use of unnecessary or inappropriate care. This makes patients vulnerable to harmful side effects. It also wastes money and resources that could be put to more productive use.

2.

Underuse of needed, effective, and appropriate care. This is related to accessibility—that is, whether people get the proper preventive, diagnostic, or therapeutic services; whether they delay seeking care; and whether they receive appropriate recommendations and referrals for care. People may face geographic, administrative, cultural, attitudinal, or other barriers that limit their abilities to seek or receive such care. Within managed care environments, efforts to restrict access to some services may result in underuse of care.

3.

Shortcomings in technical and interpersonal aspects of care. Technical quality refers to the ways health care is delivered—e.g., skill and knowledge in making correct diagnoses and prescribing appropriate medications. Professional competence is critical to high quality care, and inferior care results when health care professionals are not competent in their clinical areas. Interpersonal aspects of care are of particular importance in primary care. They include listening, answering questions, providing information, and eliciting and including patient (and family) preferences in decisionmaking. Interpersonal skills are also essential to primary care clinicians in their roles as coordinators, as members of a collaborative team, and with other health professionals.

Quality Measurement

Quality assessment involves more than the measurement of a single clinician's performance. The performance of systems—including primary care and entire integrated delivery systems—must also be measured and improved.

Greater attention will need to be focused on the failures of systems of care in which well-trained and well-meaning clinicians work. A shift in focus is occurring—from reviewing records of individual patients and compiling assessments of care by individual clinicians to monitoring the performance of health plans and populations, and this has other implications for quality measurement. Although individual record review will undoubtedly continue to be necessary in some instances (e.g., surgical complications, adverse drug reactions), the creation of reliable, uniform data systems and the collection of consistent data from a variety of sources means that quality assessment may become less dependent on review of individual cases. This change in perspective from individual patients and clinicians to the performance of health plans might also result in less attention being paid to changes in the patient-clinician relationship. As policymakers shift attention toward systems of care, integration, and team approaches to health care delivery, it will be especially important to understand the relative risks and benefits to health outcomes and patient satisfaction of promoting or disrupting personal relationships.

The appropriate unit of assessment. To assess important attributes of primary care such as continuity, coordination, and the outcomes of and satisfaction with primary care, the most appropriate unit of analysis is the episode of care whose beginning and ending points are determined, in principle, by the individual. An episode of care refers to all the care provided for a patient for a discrete illness. A particular episode of care begins when a patient brings a problem to the attention of a clinician (or when a clinician brings a problem to the attention of a patient), and that patient accepts the continuing care that may be offered (should it be needed). Multiple episodes (sometimes referred to as comorbidity) may occur at the same time for a given patient. Because the beginning and ending points of an episode of care are defined in practice by a patient, the use of episodes of care to assess quality explicitly incorporates the patient's perspective whether those episodes last for a visit or two, for a year, or over a patient's lifetime. This means that structures for accountability and especially for measuring outcomes of care need to be able to define and measure episodes of care. In particular, an assessment of the outcome of care—both what is measured and the results of the assessment—may be quite different after a single visit than after an episode of care.

Patient Satisfaction

An emphasis on satisfaction and information highlights the importance of patients' and society's preferences and values and implies that they should be elicited (or acknowledged) and taken into account in health care decisionmaking (IOM, 1990). Knowledge about patient and family experiences in the health care system can be derived from patient reports—interviews and surveys of patients about their care. Patient reports on satisfaction can tell much about patient experiences in terms of access to and coordination of care, interpersonal and technical aspects of care, and understanding of instructions and follow-up advice.

Efficiency

In common parlance, efficiency is related to the organization and delivery of services so that waste and cost are minimized. Underuse of needed services (such as tests, therapies, or assistance) or overuse of services that result in unwarranted interventions or exposure to harm can hurt patients and waste resources—the time of patients and clinicians, money, and access for other patients. Tests that must be repeated because results are lost or wrong are examples of inefficiency that are quality of care problems. Good primary care presupposes a careful effort to manage care to ensure the efficient use of resources including the effective use of other health and social services.

Ethical Behavior

A critical part of accountability in primary care concerns the ethical behavior and decisionmaking by primary health care clinicians in relation to their patients, the community, and the health systems in which they practice. Primary care clinicians are responsible for care that respects and protects the dignity of patients and ensures that an individual's presenting complaint is addressed. Although the issues are not unique to primary care, clinicians must be competent in managing events with significant ethical overtones. These may include informed consent, advance directives, avoidance of conflicts of interest in financial arrangements, care of family members when goals are in conflict, reproductive decisionmaking, genetic counseling, privacy and confidentiality, and equitable distribution of resources. Clinicians are accountable first and foremost to their patients. They are also accountable to the health care systems in which they practice, and this may contribute to tension, especially when they must advocate for a patient's use of resources. Primary care clinicians are always ethically accountable for their advice, consultations, and actions, especially when they have financial or other incentives to use or not use certain resources.

Accountability of Patients

Use of the term partnership is intended to convey the idea that both clinicians and patients have responsibilities. Clinicians are accountable as described above; patients are responsible for helping to sustain the relationship, for conveying complete and timely information to the primary care clinician, for undertaking reasonable preventive care, for making healthy lifestyle choices, for seeking care as appropriate, and for participating in the management and treatment plan.

Patients are responsible for their own health to the extent that they are capable—that is, to the extent that they have the knowledge and skills that allow them to participate in improving their health. Patients must also be responsible in their use of resources when they need health care.