¿Existe diferencia en la satisfacción del cliente al recibir atención médica en consultorios con apoyo de las TIC’s en relación a los consultorios sin ese apoyo?
1.- Tipo de estudio: Cualitativo
Dado que la pregunta inicial pretende conocer la satisfacción del cliente al recibir consulta médica en consultorios con apoyo de TIC’s en relación a aquellos pacientes que la recibieron en consultorios que no cuentan con este tipo de apoyo tecnológico, no se pretende medir estadísticamente el grado de satisfacción o la cantidad de pacientes satisfechos en relación a los no satisfechos, si no conocer el impacto que el uso de estas tecnologías tienen o no en el cliente.
2.- La variable a estudiar es la satisfacción del cliente ante el uso de las TIC’s en el consultorio mientras se le atiende en la consulta medica. Esto se determinara de acuerdo a tablas para medir la satisfacción del cliente como la mencionada por Ivan Thompson en su artículo “La satisfacción del cliente”.
Alberto G. Alexander, Director del Centro para la Excelencia Empresarial, de la Pontifica Universidad Católica del Perú, nos dice: “Si las empresas no miden como se siente el cliente con relación a su desempeño como proveedores de productos y/o servicios, nunca podrán iniciar acciones concretas para aumentar su eficacia, mantener a sus actuales clientes contentos, y captar nuevos…” (Medición de la satisfacción del cliente: Camino a la eficacia http://www.promonegocios.net/mercadotecnia/satisfaccion-cliente.htm)
En la primera década del siglo XXI, es importante que los modelos de atención médica primaria se enfoquen en modelos centrados en las necesidades y expectativas del paciente, lo que hace del paciente el centro de la atención medica primaria y no los modelos administrativos obsoleto que sitúan a los administradores en el ápice de la estructura y las necesidades del paciente son la ultima prioridad de estos modelos.
Citando a Jonathan Shoustack, PhD, MPH, es su artículo, Primary care: The Next Renaissance, (http://www.annals.org/cgi/reprint/138/3/268.pdf), “ la información y el intercambio de información son la llave para una excelente atención primaria, que asista el proceso de la toma de decisiones, dirija la atención preventiva y curativa, la educación del paciente para proveerlo de la información que requiere para el manejo de su salud y para la toma de decisiones sobre su cuidado…” continuando con el articulo del citado Dr. Shoustack, rescatamos el siguiente párrafo que a nuestro parecer identifica claramente el propósito de la investigación propuesta: “Más que procedimientos basados en la especialidad, la información es el meollo del proceso de atención medica primaria, y los sistemas de información son la “tecnología” del proveedor de servicios de atención medica primaria” (traducción libre de Ramón Murrieta).
Cierto es que el uso de las tecnologías de información y comunicación (TIC’S) permitirán que el clínico mantenga una comunicación más cercana con los pacientes de su consultorio, al permitirle mostrar graficas, fotografías y modelos anatómicos que faciliten la explicación de un padecimiento o de un modelo terapéutico.
miércoles, 23 de abril de 2008
Primary Care: The Next Renaissance
Jonathan Showstack, PhD, MPH; Nicole Lurie, MD, MSPH; Eric B. Larson, MD, MPH; Arlyss Anderson Rothman, PhD, MHS, FNP; and
Susan Hassmiller, PhD, RN
Three decades ago, a renaissance helped create the foundations of
primary care as we know it today. In recent years, however, new
challenges have confronted primary care. We believe that the
current challenges can be overcome and may, in fact, present an
opportunity for a new renaissance of primary care to address the
needs of our population.
In this paper, we suggest seven core principles and a set of
actions that will support a renaissance in, and a positive future
for, primary care. The seven principles are 1) Health care must be
organized to serve the needs of patients; 2) the goal of primary
care systems should be the delivery of the highest-quality care as
documented by measurable outcomes; 3) information and information
systems are the backbone of the primary care process; 4)
current health care systems must be reconstructed; 5) the health
care financing system must support excellent primary care practice;
6) primary care education must be revitalized, with an emphasis
on new delivery models and training in sites that deliver
excellent primary care; and 7) the value of primary care practice
must be continually improved, documented, and communicated.
At the start of the 21st century, a vital, patient-centered
primary care system has much to offer a rapidly changing population
with increasingly diverse needs and expectations. If we
keep the needs of persons and patients clearly in sight and design
systems to meet those needs, primary care will thrive and our
patients will be well served.
Ann Intern Med. 2003;138:268-272. www.annals.org
For author affiliations, see end of text.
Three decades ago, a renaissance in primary care helped
create the foundations of the field as we know it today.
While primary care has developed as a vital intellectual and
applied concept, the changes that had been hoped for in
the medical care system to support the goals of comprehensive,
continuous, patient-centered, and outcomesoriented
care have not occurred. In fact, the dominance of
specialty care is increasing, interest in primary care as a
career has waned; and changes in reimbursement and
health care organization, such as the advent of managed
care, have been relatively negative for primary care. We
believe passionately in the basic principles of primary care
and are deeply concerned about its future.
The current state and direction of primary care are
discussed in this supplement of Annals (1– 4). In this paper,
we suggest seven core principles (Table 1) to support
a renaissance in primary care and a set of actions (Table 2)
to address this crisis and enable primary care to play a
substantial role in achieving the goals of high-quality,
patient-centered, efficient, and user-friendly care for individuals
and populations.
CORE PRINCIPLES
Seven core principles should guide the next renaissance
of primary care: 1) Health care must be organized to
serve the needs of patients; 2) the goal of primary care
systems should be the delivery of the highest-quality care as
documented by measurable outcomes; 3) information and
information systems are the backbone of the primary care
process; 4) current health care systems must be reconstructed;
5) the health care financing system must support excellent
primary care practice; 6) primary care education must
be revitalized, with an emphasis on new delivery models
and training in sites that deliver excellent primary care; and
7) the value of primary care practice must be continually
improved, documented, and communicated.
Principle 1: Health Care Must Be Organized To Serve
the Needs of Patients
Health care should achieve optimal health and medical
outcomes within available resources and respect and respond
to a patient’s needs, values, and preferences. Patientcentered
care (5) includes the patient as an active participant
in the clinical decision-making process and
incorporates an understanding of the patient’s preferences
and needs. Such care is user-friendly to both patients and
clinicians, with everything from the design of information
systems to the hours of operation structured to create a
partnership between patient and clinician.
Patient-centered care is a core principle of primary
care and is supported by the goals of comprehensiveness
and continuity. Much of the current organization of medical
care, however, is structured to accommodate incentives
in the reimbursement system and the preferences of clinicians,
often with patients’ needs included only as an afterthought.
Responding to patients’ needs and desires must
be a fundamental objective of future health care systems.
Principle 2: The Goal of Primary Care Systems Should Be
the Delivery of the Highest-Quality Care as Documented
by Measurable Outcomes
The central goal of primary care systems should be the
delivery of high-quality care that leads to the best possible
outcomes. We agree with conclusions of the Institute of
Medicine’s recent analysis of the quality of health care,
Crossing the Quality Chasm (6); it is time to create systems
that are safe and effective. The definition of quality could,
and should, be based in large part on definable outcomes.
Accomplishing this goal requires research to establish appropriate
indicators of primary care quality and the development
of methods to identify, collect, and evaluate the
Future of Primary Care
268 © 2003 American College of Physicians–American Society of Internal Medicine
most relevant information. While a true, outcomes-based
system may be some years away, what is known today
about processes and practices that lead to good outcomes
can help guide the redesign of primary care systems.
Systems of care need to be accountable to consumers,
clinicians, and payers, and this accountability must include
the measurement of individual and population outcomes.
The concept of accountability has not fully evolved, and
today’s systems of oversight, such as the Health Plan Employer
Data and Information Set measures (7), are oriented
more toward overall system outcomes than toward assuring
individual outcomes. As accountability becomes more
clearly defined and operationalized, it should become part
of, and assist in, routine quality-improvement efforts. This
will require patient- and outcomes-oriented information
systems with adequate mechanisms to protect confidentiality.
Principle 3: Information and Information Systems Are the
Backbone of the Primary Care Process
Information and the exchange of information are key
to excellent primary care to assist in the clinical decisionmaking
process, track the preventive and acute care provided,
educate patients, assess outcomes, and provide patients
with the information they need to manage their
health and make decisions about their care. The effective
provision of primary care requires processing large amounts
of knowledge, ranging from an individual’s risk factors and
health status to the likelihood that a particular diagnostic
procedure or therapy will be optimal for a patient. More so
than for procedure-based specialists, information is at the
core of the primary care process, and information systems
are primary care’s “technology.”
Today’s health care information systems were designed
primarily in response to administrative needs, with reimbursement
at the top of the list (8). While these encounterbased
systems may serve their narrow administrative purposes
well, they rarely collect information that allows
management of a patient’s needs over time or an assessment
of the effects of clinical processes on patient outcomes.
Encounter-based systems encourage discontinuity
for patients, poor communications among clinicians, and
underuse of the information that is available, and they
often produce less than optimal care. Even in academic
medical centers, where the most advanced clinical technologies
are developed and used, patients often cannot be
tracked from the inpatient to the outpatient setting or
among different types of clinicians, nor can patients and
clinicians access and share information.
A “Personal Health Information and Choice” system is
needed. This system would be an essential component of
patient-centered and accountable health care and would,
almost by definition, enhance the role of primary care clinicians.
Containing information about a person’s health,
risk profile, and recent preventive and clinical care, this
system would be patient centered in both the information
that it contains and the ability to access that information.
Persons, whether they are active patients or not, would be
able to interact with the system, communicate with their
clinician, review their medical records (a recently established
requirement [9]), view results of tests and therapies,
and add information about their current health status.
Decision-support tools would help both patients and clinicians
to identify clinical choices and probable outcomes in
a manner that is both understandable and useful, and the
system would include links with community resources and
Internet sites to enhance the short amount of time available
for patient education in a routine visit. The system would
also link closely with emerging efforts to rebuild the information
technology components of the public health infrastructure
and maximize the opportunities to develop robust
connections between the personal health services
delivery system and public health.
The knowledge and technology to create and implement
such systems are available today. The political will to
Table 1. Seven Core Principles in Support of a Renaissance of
Primary Care
1. Health care must be organized to serve the needs of patients.
2. The goal of primary care systems should be the delivery of the
highest-quality care as documented by measurable outcomes.
3. Information and information systems are the backbone of the primary
care process.
4. Current health care systems must be reconstructed.
5. The health care financing system must support excellent primary care
practice.
6. Primary care education must be revitalized, with an emphasis on new
delivery models and training in sites that deliver excellent primary care.
7. The value of primary care practice must be continually improved,
documented, and communicated.
Table 2. Reconstructing Primary Care
Redesign primary care organization and finance
Undertake a national 5- to 10-year effort to create new and innovative
patient-centered primary care systems.
Design, implement, and evaluate a “Personal Health Information and
Choice” system that is patient centered and outcomes oriented.
Create new health care financing systems to support and encourage
patient-centered primary care services and systems.
Reform primary care education
Require that primary care clinicians receive their clinical training in
patient-centered, outcomes-oriented primary care settings that include
state-of-the-art information systems.
Revise graduate medical education funding to provide adequate support
and incentives for training in high-quality primary care settings.
Develop a common core curriculum and integrate training experiences
across different primary care specialties and practices.
Expand and disseminate knowledge about primary care
Create a Primary Care Institute within the National Institutes of Health to
perform, fund, and disseminate the results of research on primary care
organization and delivery, and establish Centers of Excellence in
Primary Care Practice to facilitate the development and evaluation of
new models of primary care practice and teaching.
Establish a clearinghouse to aggregate and disseminate the results of
primary care research and demonstration projects to the public,
clinicians, administrators, academicians, and policymakers.
Provide recognition to exemplary primary care practice, such as a “Glen
Cove Medallion Award.”
Primary Care: The Next Renaissance Future of Primary Care
www.annals.org 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 269
devote the necessary resources to this effort is needed now.
We believe that the development and implementation of
patient-centered health information systems should be
among the highest priorities for the future use of resources
in health and health care.
Principle 4: Current Health Care Systems Must Be
Reconstructed
Health care organization is an oxymoron. In reality,
we have an extremely complex and fragmented set of clinicians,
facilities, and services that have been created on the
basis of requirements for reimbursement and the needs of
clinicians. Patient needs and outcomes and clinician accountability
usually have been secondary considerations in
the design of systems of care. While not necessarily the
worst offender in this regard, primary care has generally
played a very passive role in the design and implementation
of health care systems. For example, rather than taking the
lead in developing organizations that are devoted to health
maintenance, and in which primary care has a central role,
primary care clinicians were relatively passive when assigned
the role of gatekeeper by managed care organizations.
We can imagine a new and better type of health care
system that is designed to address patient and population
needs and preferences. Such a system would be participant
controlled, outcomes oriented, structured to address the
needs of the system’s population, and focused on the ongoing
relationship between a patient and his or her primary
clinician. Care models would be based on the functions
that are necessary to achieve desired outcomes. Quality of
care would be measured through active and ongoing assessment,
ideally by an independent evaluator. The organization’s
integrated information systems would provide a realtime
assessment of processes and outcomes so that quality
issues could be resolved quickly, with key indicators of
quality and outcomes published regularly. Such a system
would be much closer to a true health maintenance organization.
Health care systems need to be both flexible and agile,
with a capacity for rapid change in response to new circumstances.
In the future, systems should be allowed to use
resources that produce the desired outcomes in that setting.
For example, while some (perhaps most) patients may prefer
a physician as their primary clinician, others may
choose a nurse practitioner, and some may want multiple
clinicians functioning in a team. The organizing principle
should be achieving the best outcomes possible within the
creative use of available resources, while allowing patient
choices and preferences to help guide the use of those resources.
Principle 5: The Health Care Financing System Must
Support Excellent Primary Care Practice
Patient-oriented and accountable health systems cannot
survive unless current payment practices are changed
radically. Such changes must, at a minimum, include adequate
reimbursement for basic primary care services, such
as performing a history and physical examination; counseling
patients about their health behaviors; and, possibly
most important, advocating for and guiding patients
through the health care system. The current financing system
is also often a barrier to continuous and comprehensive
care and contributes to quality-of-care problems associated
with both overuse and underuse of services (6).
The government and private payers have ignored the
negative effects of current financial systems on patients and
their clinical outcomes for far too long. There is little
doubt that the current financing system is adverse to the
goals of primary care. In many communities, primary care
practitioners have had to abandon practice because of inadequate
reimbursement and hospitals have abandoned
their sponsored primary care clinics because of continued
losses (10). The recent reduction in Medicare reimbursement
for physicians has arguably hurt primary care more
than other specialties (11).
Despite some movement toward prospective payment
systems, the financial disincentives toward primary care
have changed little in recent decades. These disincentives
were described and quantified over two decades ago (12),
and they still influence how medicine is practiced. Primary
care services remain undervalued in comparison with surgery
and other specialty services, with cognitive services
(that is, most services other than surgery and the application
of technology) receiving relatively low reimbursement.
The large difference in reimbursement between cognitive
and technological services produces strong incentives to
perform procedures that may or may not be in the best
interests of patients. The use of office-based technologies,
such as chest radiography and simple laboratory tests, can
substantially increase the reimbursement for a typical office
visit (12). These same disincentives also affect services provided
in institutions. At the University of Washington
Medical Center, Seattle, Washington, for example, the primary
care clinics would appear to be in substantial financial
deficit, except that revenues generated from computed
tomography and magnetic resonance imaging scanners in
the same building are listed on the same balance sheet.
The financial structure of health care and the current
reimbursement system cannot be changed overnight. We
believe that the best way to change the economic incentives
in health care is to design new financing systems in parallel
with the creation of new patient-centered systems of care.
While there may be winners and losers among clinicians in
a redesigned reimbursement system, the design should be a
“win” for patients, with the reimbursement system designed
to support core primary care functions. At a minimum,
the current financial disincentives toward adequate
primary care should be eliminated; optimally, the reimbursement
system should support and encourage continuity
of care and patient-centered and accountable systems
of care.
We also believe strongly that while changing the cur-
Future of Primary Care Primary Care: The Next Renaissance
270 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 www.annals.org
rent financing system is absolutely necessary, it is not a
sufficient precondition for the reconstruction of primary
care. Without substantial changes in the way health care is
organized and delivered, changing reimbursement for primary
care services would be, at best, a stopgap measure.
Principle 6: Primary Care Education Must Be Revitalized,
with an Emphasis on New Delivery Models and Training
in Sites That Deliver Excellent Primary Care
Health professions education has begun to recognize
the changing demographics and needs of the population,
with the increase of cultural competence, health promotion
and disease prevention, and community service as part of
the formal curriculum. Most primary care clinical education,
however, occurs in settings that are not structured to
provide optimal care.
Academic health centers and graduate training programs
in primary care should be leaders in testing and
implementing new and innovative ways to deliver highquality
care. The clinical experiences of primary care trainees,
however, often occur in relatively dysfunctional and
user-unfriendly clinics with poor information systems and
little or no continuity among different types of clinicians.
Too often the result is discouraged primary care residents
who opt for subspecialty training and practice. To make
matters worse, in these times of economic difficulties,
many academic health centers are emphasizing lucrative
specialty care and increasing the historic marginalization of
primary care.
New models or settings need to be considered for primary
care clinical training. Clinical training should occur
in settings that provide high-quality, continuous, patientcentered,
outcomes-oriented, and team-based care. The delivery
models suggested here would provide much more
appropriate settings for primary care clinical education experiences.
Principle 7: The Value of Primary Care Practice Must Be
Continually Improved, Documented, and Communicated
A concerted, national effort to redesign, implement,
and evaluate new forms of primary care delivery is needed.
Studies should identify the appropriate functions necessary
to deliver care to particular patient groups, the strengths
and weaknesses of different configurations of primary
care clinicians and systems, and ways to restructure the relationship
between primary care clinicians and medical
specialists.
To support the design and evaluation of new models
of care, a Primary Care Institute should be established
within the National Institutes of Health to perform, fund,
and disseminate the results of research on primary care
organization and delivery. Some of the work of such a
proposed Institute has already begun in the Center for
Primary Care at the Agency for Healthcare Research and
Quality, but the budget to support the level of work truly
required for such an enterprise is woefully inadequate. The
creation of Centers of Excellence in Primary Care Practice
would also facilitate the development and evaluation of
new models of care. Similar to the Centers of Excellence in
Patient Safety Research supported by the Agency for
Healthcare Research and Quality (13) and the Cancer
Centers Program of the National Cancer Institute (14), the
Centers of Excellence in Primary Care Practice would perform
innovative multidisciplinary research to improve the
organization and delivery of primary care services, develop
new training models for primary care, and disseminate the
latest research findings about best practices in primary care.
The current Primary Care Practice-Based Research Networks
(15) could be used as a basis for some of this research.
In addition, the results of evaluations of primary
care models and practices need to be aggregated and reviewed
in light of the increasing diversity and changing
needs of our population, and a clearinghouse should be
developed through which information about primary care
education, delivery, and research can be disseminated.
The value of primary care is not understood well by
the public or by most clinicians, administrators, and policymakers.
While patients place a high value on primary
care, many feel that primary care has failed to live up to its
promise (2). Unfortunately, and mistakenly, primary care
has become synonymous with hassles and obstacles in obtaining
care. The public needs to be educated about how
primary care should work and why primary care sometimes
fails in today’s often uncoordinated medical care system.
An important step would be a national communications
strategy that educates the public, clinicians, and policymakers
about the value and rationale of primary care. Primary
care supporters should identify outstanding innovative
primary care practices and then disseminate this
information through a variety of means, perhaps including
an award for such innovation (such as the “Glen Cove
Medallion Award”).
CONCLUSION
At the start of the 21st century, a vital, patientcentered
primary care system has much to offer a rapidly
changing population with increasingly diverse needs and
expectations. The potential for a new renaissance of primary
care is a great opportunity for patients and health
care professionals. The suggested changes may not be easy
to accomplish or acceptable to some, but if we keep the
needs of persons and patients clearly in sight and design
systems to meet those needs, primary care will thrive and
our patients will be well served.
From University of California, San Francisco, California; The RAND
Corporation, Arlington, Virginia; University of Washington, Seattle,
Washington; and the Robert Wood Johnson Foundation, Princeton,
New Jersey.
Acknowledgments: The authors thank the participants at The Future of
Primary Care meeting, Glen Cove, New York, October 2001, who
helped form and focus some of the ideas presented in this paper.
Primary Care: The Next Renaissance Future of Primary Care
www.annals.org 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 271
Note: The opinions and suggestions presented are those of the authors
and may not necessarily represent those of other participants, the authors’
own institutions, or the Robert Wood Johnson Foundation.
Grant Support: By grant 039940 from the Robert Wood Johnson Foundation.
Corresponding Author: Jonathan Showstack, PhD, MPH, University of
California, San Francisco, 3333 California Street, Suite 265, San Francisco,
CA 94118-1944.
Current author addresses are available at www.annals.org.
References
1. Moore G, Showstack J. Primary care medicine in crisis: toward reconstruction
and renewal. Ann Intern Med. 2003;138:244-7.
2. Safran DG. Defining the future of primary care: what can we learn from
patients? Ann Intern Med. 2003;138:248-55.
3. Anderson Rothman A, Wagner EH. Chronic illness management: what is the
role of primary care? Ann Intern Med. 2003;138:256-61.
4. Sandy LG, Schroeder SA. Primary care in a new era: disillusion and dissolution?
Ann Intern Med. 2003;138:262-7.
5. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. Through the
Patient’s Eyes: Understanding and Promoting Patient-Centered Care. San Francisco:
Jossey-Bass; 2002.
6. Institute of Medicine. Crossing the Quality Chasm: A New Health System for
the 21st Century. Committee on Quality of Health Care in America. Washington,
DC: National Academy Pr; 2001.
7. National Committee on Quality Assurance. The Health Plan Employer Data
and Information Set (HEDIS). Accessed at www.ncqa.org/Programs/HEDIS/ on
9 September 2002.
8. Singer AJ, Enthoven AC, Garber AM. Health care and information technology:
growing up together. In: Shortliffe EH, Perreault LE, Wiederhold G, Fagan
LM, eds. Medical Informatics: Computer Applications in Health Care and Biomedicine.
New York: Springer-Verlag; 2001:663-96.
9. Pear R. Bush rolls back rules on privacy of medical data. New York Times. 10
August 2002;A:1.
10. Larson EB. General internal medicine at the crossroads of prosperity and
despair: caring for patients with chronic diseases in an aging society. Ann Intern
Med. 2001;134:997-1000. [PMID: 11352700]
11. Pear R. Many doctors say they are refusing Medicare patients. New York
Times. 17 March 2002:1.
12. Schroeder SA, Showstack JA. Financial incentives to perform medical procedures
and laboratory tests: illustrative models of office practice. Med Care.
1978;16:289-98. [PMID: 651395]
13. Agency for Healthcare Research and Quality. AHRQ to Support Centers of
Excellence Under New Comprehensive Patient Safety Research Program. Accessed
at www.ahcpr.gov/news/press/pr2000/excellpr.htm on 9 September 2002.
14. National Cancer Institute. Description of the Cancer Centers Program. Accessed
at www3.cancer.gov/cancercenters/description.html on 9 September 2002.
15. Agency for Healthcare Research and Quality. Primary Care Practice-Based
Research Networks. Accessed at www.ahcpr.gov/research/pbrnfact.htm on 9 September
2002.
Future of Primary Care Primary Care: The Next Renaissance
272 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 www.annals.org
Current Author Addresses: Drs. Showstack and Anderson Rothman:
University of California, San Francisco, 3333 California Street, Suite
265, San Francisco, CA 94118-1944.
Dr. Lurie: The RAND Corporation, 1200 South Hayes Street, Arlington,
VA 22202.
Dr. Larson: University of Washington Medical Center, 1959 North East
Pacific Street, Box 356330, Seattle, WA 98195.
Dr. Hassmiller: The Robert Wood Johnson Foundation, Route 1 and
College Road East, Princeton, NJ 08543-2316.
www.annals.org Annals of Internal Medicine Volume • Number E-273
Jonathan Showstack, PhD, MPH; Nicole Lurie, MD, MSPH; Eric B. Larson, MD, MPH; Arlyss Anderson Rothman, PhD, MHS, FNP; and
Susan Hassmiller, PhD, RN
Three decades ago, a renaissance helped create the foundations of
primary care as we know it today. In recent years, however, new
challenges have confronted primary care. We believe that the
current challenges can be overcome and may, in fact, present an
opportunity for a new renaissance of primary care to address the
needs of our population.
In this paper, we suggest seven core principles and a set of
actions that will support a renaissance in, and a positive future
for, primary care. The seven principles are 1) Health care must be
organized to serve the needs of patients; 2) the goal of primary
care systems should be the delivery of the highest-quality care as
documented by measurable outcomes; 3) information and information
systems are the backbone of the primary care process; 4)
current health care systems must be reconstructed; 5) the health
care financing system must support excellent primary care practice;
6) primary care education must be revitalized, with an emphasis
on new delivery models and training in sites that deliver
excellent primary care; and 7) the value of primary care practice
must be continually improved, documented, and communicated.
At the start of the 21st century, a vital, patient-centered
primary care system has much to offer a rapidly changing population
with increasingly diverse needs and expectations. If we
keep the needs of persons and patients clearly in sight and design
systems to meet those needs, primary care will thrive and our
patients will be well served.
Ann Intern Med. 2003;138:268-272. www.annals.org
For author affiliations, see end of text.
Three decades ago, a renaissance in primary care helped
create the foundations of the field as we know it today.
While primary care has developed as a vital intellectual and
applied concept, the changes that had been hoped for in
the medical care system to support the goals of comprehensive,
continuous, patient-centered, and outcomesoriented
care have not occurred. In fact, the dominance of
specialty care is increasing, interest in primary care as a
career has waned; and changes in reimbursement and
health care organization, such as the advent of managed
care, have been relatively negative for primary care. We
believe passionately in the basic principles of primary care
and are deeply concerned about its future.
The current state and direction of primary care are
discussed in this supplement of Annals (1– 4). In this paper,
we suggest seven core principles (Table 1) to support
a renaissance in primary care and a set of actions (Table 2)
to address this crisis and enable primary care to play a
substantial role in achieving the goals of high-quality,
patient-centered, efficient, and user-friendly care for individuals
and populations.
CORE PRINCIPLES
Seven core principles should guide the next renaissance
of primary care: 1) Health care must be organized to
serve the needs of patients; 2) the goal of primary care
systems should be the delivery of the highest-quality care as
documented by measurable outcomes; 3) information and
information systems are the backbone of the primary care
process; 4) current health care systems must be reconstructed;
5) the health care financing system must support excellent
primary care practice; 6) primary care education must
be revitalized, with an emphasis on new delivery models
and training in sites that deliver excellent primary care; and
7) the value of primary care practice must be continually
improved, documented, and communicated.
Principle 1: Health Care Must Be Organized To Serve
the Needs of Patients
Health care should achieve optimal health and medical
outcomes within available resources and respect and respond
to a patient’s needs, values, and preferences. Patientcentered
care (5) includes the patient as an active participant
in the clinical decision-making process and
incorporates an understanding of the patient’s preferences
and needs. Such care is user-friendly to both patients and
clinicians, with everything from the design of information
systems to the hours of operation structured to create a
partnership between patient and clinician.
Patient-centered care is a core principle of primary
care and is supported by the goals of comprehensiveness
and continuity. Much of the current organization of medical
care, however, is structured to accommodate incentives
in the reimbursement system and the preferences of clinicians,
often with patients’ needs included only as an afterthought.
Responding to patients’ needs and desires must
be a fundamental objective of future health care systems.
Principle 2: The Goal of Primary Care Systems Should Be
the Delivery of the Highest-Quality Care as Documented
by Measurable Outcomes
The central goal of primary care systems should be the
delivery of high-quality care that leads to the best possible
outcomes. We agree with conclusions of the Institute of
Medicine’s recent analysis of the quality of health care,
Crossing the Quality Chasm (6); it is time to create systems
that are safe and effective. The definition of quality could,
and should, be based in large part on definable outcomes.
Accomplishing this goal requires research to establish appropriate
indicators of primary care quality and the development
of methods to identify, collect, and evaluate the
Future of Primary Care
268 © 2003 American College of Physicians–American Society of Internal Medicine
most relevant information. While a true, outcomes-based
system may be some years away, what is known today
about processes and practices that lead to good outcomes
can help guide the redesign of primary care systems.
Systems of care need to be accountable to consumers,
clinicians, and payers, and this accountability must include
the measurement of individual and population outcomes.
The concept of accountability has not fully evolved, and
today’s systems of oversight, such as the Health Plan Employer
Data and Information Set measures (7), are oriented
more toward overall system outcomes than toward assuring
individual outcomes. As accountability becomes more
clearly defined and operationalized, it should become part
of, and assist in, routine quality-improvement efforts. This
will require patient- and outcomes-oriented information
systems with adequate mechanisms to protect confidentiality.
Principle 3: Information and Information Systems Are the
Backbone of the Primary Care Process
Information and the exchange of information are key
to excellent primary care to assist in the clinical decisionmaking
process, track the preventive and acute care provided,
educate patients, assess outcomes, and provide patients
with the information they need to manage their
health and make decisions about their care. The effective
provision of primary care requires processing large amounts
of knowledge, ranging from an individual’s risk factors and
health status to the likelihood that a particular diagnostic
procedure or therapy will be optimal for a patient. More so
than for procedure-based specialists, information is at the
core of the primary care process, and information systems
are primary care’s “technology.”
Today’s health care information systems were designed
primarily in response to administrative needs, with reimbursement
at the top of the list (8). While these encounterbased
systems may serve their narrow administrative purposes
well, they rarely collect information that allows
management of a patient’s needs over time or an assessment
of the effects of clinical processes on patient outcomes.
Encounter-based systems encourage discontinuity
for patients, poor communications among clinicians, and
underuse of the information that is available, and they
often produce less than optimal care. Even in academic
medical centers, where the most advanced clinical technologies
are developed and used, patients often cannot be
tracked from the inpatient to the outpatient setting or
among different types of clinicians, nor can patients and
clinicians access and share information.
A “Personal Health Information and Choice” system is
needed. This system would be an essential component of
patient-centered and accountable health care and would,
almost by definition, enhance the role of primary care clinicians.
Containing information about a person’s health,
risk profile, and recent preventive and clinical care, this
system would be patient centered in both the information
that it contains and the ability to access that information.
Persons, whether they are active patients or not, would be
able to interact with the system, communicate with their
clinician, review their medical records (a recently established
requirement [9]), view results of tests and therapies,
and add information about their current health status.
Decision-support tools would help both patients and clinicians
to identify clinical choices and probable outcomes in
a manner that is both understandable and useful, and the
system would include links with community resources and
Internet sites to enhance the short amount of time available
for patient education in a routine visit. The system would
also link closely with emerging efforts to rebuild the information
technology components of the public health infrastructure
and maximize the opportunities to develop robust
connections between the personal health services
delivery system and public health.
The knowledge and technology to create and implement
such systems are available today. The political will to
Table 1. Seven Core Principles in Support of a Renaissance of
Primary Care
1. Health care must be organized to serve the needs of patients.
2. The goal of primary care systems should be the delivery of the
highest-quality care as documented by measurable outcomes.
3. Information and information systems are the backbone of the primary
care process.
4. Current health care systems must be reconstructed.
5. The health care financing system must support excellent primary care
practice.
6. Primary care education must be revitalized, with an emphasis on new
delivery models and training in sites that deliver excellent primary care.
7. The value of primary care practice must be continually improved,
documented, and communicated.
Table 2. Reconstructing Primary Care
Redesign primary care organization and finance
Undertake a national 5- to 10-year effort to create new and innovative
patient-centered primary care systems.
Design, implement, and evaluate a “Personal Health Information and
Choice” system that is patient centered and outcomes oriented.
Create new health care financing systems to support and encourage
patient-centered primary care services and systems.
Reform primary care education
Require that primary care clinicians receive their clinical training in
patient-centered, outcomes-oriented primary care settings that include
state-of-the-art information systems.
Revise graduate medical education funding to provide adequate support
and incentives for training in high-quality primary care settings.
Develop a common core curriculum and integrate training experiences
across different primary care specialties and practices.
Expand and disseminate knowledge about primary care
Create a Primary Care Institute within the National Institutes of Health to
perform, fund, and disseminate the results of research on primary care
organization and delivery, and establish Centers of Excellence in
Primary Care Practice to facilitate the development and evaluation of
new models of primary care practice and teaching.
Establish a clearinghouse to aggregate and disseminate the results of
primary care research and demonstration projects to the public,
clinicians, administrators, academicians, and policymakers.
Provide recognition to exemplary primary care practice, such as a “Glen
Cove Medallion Award.”
Primary Care: The Next Renaissance Future of Primary Care
www.annals.org 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 269
devote the necessary resources to this effort is needed now.
We believe that the development and implementation of
patient-centered health information systems should be
among the highest priorities for the future use of resources
in health and health care.
Principle 4: Current Health Care Systems Must Be
Reconstructed
Health care organization is an oxymoron. In reality,
we have an extremely complex and fragmented set of clinicians,
facilities, and services that have been created on the
basis of requirements for reimbursement and the needs of
clinicians. Patient needs and outcomes and clinician accountability
usually have been secondary considerations in
the design of systems of care. While not necessarily the
worst offender in this regard, primary care has generally
played a very passive role in the design and implementation
of health care systems. For example, rather than taking the
lead in developing organizations that are devoted to health
maintenance, and in which primary care has a central role,
primary care clinicians were relatively passive when assigned
the role of gatekeeper by managed care organizations.
We can imagine a new and better type of health care
system that is designed to address patient and population
needs and preferences. Such a system would be participant
controlled, outcomes oriented, structured to address the
needs of the system’s population, and focused on the ongoing
relationship between a patient and his or her primary
clinician. Care models would be based on the functions
that are necessary to achieve desired outcomes. Quality of
care would be measured through active and ongoing assessment,
ideally by an independent evaluator. The organization’s
integrated information systems would provide a realtime
assessment of processes and outcomes so that quality
issues could be resolved quickly, with key indicators of
quality and outcomes published regularly. Such a system
would be much closer to a true health maintenance organization.
Health care systems need to be both flexible and agile,
with a capacity for rapid change in response to new circumstances.
In the future, systems should be allowed to use
resources that produce the desired outcomes in that setting.
For example, while some (perhaps most) patients may prefer
a physician as their primary clinician, others may
choose a nurse practitioner, and some may want multiple
clinicians functioning in a team. The organizing principle
should be achieving the best outcomes possible within the
creative use of available resources, while allowing patient
choices and preferences to help guide the use of those resources.
Principle 5: The Health Care Financing System Must
Support Excellent Primary Care Practice
Patient-oriented and accountable health systems cannot
survive unless current payment practices are changed
radically. Such changes must, at a minimum, include adequate
reimbursement for basic primary care services, such
as performing a history and physical examination; counseling
patients about their health behaviors; and, possibly
most important, advocating for and guiding patients
through the health care system. The current financing system
is also often a barrier to continuous and comprehensive
care and contributes to quality-of-care problems associated
with both overuse and underuse of services (6).
The government and private payers have ignored the
negative effects of current financial systems on patients and
their clinical outcomes for far too long. There is little
doubt that the current financing system is adverse to the
goals of primary care. In many communities, primary care
practitioners have had to abandon practice because of inadequate
reimbursement and hospitals have abandoned
their sponsored primary care clinics because of continued
losses (10). The recent reduction in Medicare reimbursement
for physicians has arguably hurt primary care more
than other specialties (11).
Despite some movement toward prospective payment
systems, the financial disincentives toward primary care
have changed little in recent decades. These disincentives
were described and quantified over two decades ago (12),
and they still influence how medicine is practiced. Primary
care services remain undervalued in comparison with surgery
and other specialty services, with cognitive services
(that is, most services other than surgery and the application
of technology) receiving relatively low reimbursement.
The large difference in reimbursement between cognitive
and technological services produces strong incentives to
perform procedures that may or may not be in the best
interests of patients. The use of office-based technologies,
such as chest radiography and simple laboratory tests, can
substantially increase the reimbursement for a typical office
visit (12). These same disincentives also affect services provided
in institutions. At the University of Washington
Medical Center, Seattle, Washington, for example, the primary
care clinics would appear to be in substantial financial
deficit, except that revenues generated from computed
tomography and magnetic resonance imaging scanners in
the same building are listed on the same balance sheet.
The financial structure of health care and the current
reimbursement system cannot be changed overnight. We
believe that the best way to change the economic incentives
in health care is to design new financing systems in parallel
with the creation of new patient-centered systems of care.
While there may be winners and losers among clinicians in
a redesigned reimbursement system, the design should be a
“win” for patients, with the reimbursement system designed
to support core primary care functions. At a minimum,
the current financial disincentives toward adequate
primary care should be eliminated; optimally, the reimbursement
system should support and encourage continuity
of care and patient-centered and accountable systems
of care.
We also believe strongly that while changing the cur-
Future of Primary Care Primary Care: The Next Renaissance
270 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 www.annals.org
rent financing system is absolutely necessary, it is not a
sufficient precondition for the reconstruction of primary
care. Without substantial changes in the way health care is
organized and delivered, changing reimbursement for primary
care services would be, at best, a stopgap measure.
Principle 6: Primary Care Education Must Be Revitalized,
with an Emphasis on New Delivery Models and Training
in Sites That Deliver Excellent Primary Care
Health professions education has begun to recognize
the changing demographics and needs of the population,
with the increase of cultural competence, health promotion
and disease prevention, and community service as part of
the formal curriculum. Most primary care clinical education,
however, occurs in settings that are not structured to
provide optimal care.
Academic health centers and graduate training programs
in primary care should be leaders in testing and
implementing new and innovative ways to deliver highquality
care. The clinical experiences of primary care trainees,
however, often occur in relatively dysfunctional and
user-unfriendly clinics with poor information systems and
little or no continuity among different types of clinicians.
Too often the result is discouraged primary care residents
who opt for subspecialty training and practice. To make
matters worse, in these times of economic difficulties,
many academic health centers are emphasizing lucrative
specialty care and increasing the historic marginalization of
primary care.
New models or settings need to be considered for primary
care clinical training. Clinical training should occur
in settings that provide high-quality, continuous, patientcentered,
outcomes-oriented, and team-based care. The delivery
models suggested here would provide much more
appropriate settings for primary care clinical education experiences.
Principle 7: The Value of Primary Care Practice Must Be
Continually Improved, Documented, and Communicated
A concerted, national effort to redesign, implement,
and evaluate new forms of primary care delivery is needed.
Studies should identify the appropriate functions necessary
to deliver care to particular patient groups, the strengths
and weaknesses of different configurations of primary
care clinicians and systems, and ways to restructure the relationship
between primary care clinicians and medical
specialists.
To support the design and evaluation of new models
of care, a Primary Care Institute should be established
within the National Institutes of Health to perform, fund,
and disseminate the results of research on primary care
organization and delivery. Some of the work of such a
proposed Institute has already begun in the Center for
Primary Care at the Agency for Healthcare Research and
Quality, but the budget to support the level of work truly
required for such an enterprise is woefully inadequate. The
creation of Centers of Excellence in Primary Care Practice
would also facilitate the development and evaluation of
new models of care. Similar to the Centers of Excellence in
Patient Safety Research supported by the Agency for
Healthcare Research and Quality (13) and the Cancer
Centers Program of the National Cancer Institute (14), the
Centers of Excellence in Primary Care Practice would perform
innovative multidisciplinary research to improve the
organization and delivery of primary care services, develop
new training models for primary care, and disseminate the
latest research findings about best practices in primary care.
The current Primary Care Practice-Based Research Networks
(15) could be used as a basis for some of this research.
In addition, the results of evaluations of primary
care models and practices need to be aggregated and reviewed
in light of the increasing diversity and changing
needs of our population, and a clearinghouse should be
developed through which information about primary care
education, delivery, and research can be disseminated.
The value of primary care is not understood well by
the public or by most clinicians, administrators, and policymakers.
While patients place a high value on primary
care, many feel that primary care has failed to live up to its
promise (2). Unfortunately, and mistakenly, primary care
has become synonymous with hassles and obstacles in obtaining
care. The public needs to be educated about how
primary care should work and why primary care sometimes
fails in today’s often uncoordinated medical care system.
An important step would be a national communications
strategy that educates the public, clinicians, and policymakers
about the value and rationale of primary care. Primary
care supporters should identify outstanding innovative
primary care practices and then disseminate this
information through a variety of means, perhaps including
an award for such innovation (such as the “Glen Cove
Medallion Award”).
CONCLUSION
At the start of the 21st century, a vital, patientcentered
primary care system has much to offer a rapidly
changing population with increasingly diverse needs and
expectations. The potential for a new renaissance of primary
care is a great opportunity for patients and health
care professionals. The suggested changes may not be easy
to accomplish or acceptable to some, but if we keep the
needs of persons and patients clearly in sight and design
systems to meet those needs, primary care will thrive and
our patients will be well served.
From University of California, San Francisco, California; The RAND
Corporation, Arlington, Virginia; University of Washington, Seattle,
Washington; and the Robert Wood Johnson Foundation, Princeton,
New Jersey.
Acknowledgments: The authors thank the participants at The Future of
Primary Care meeting, Glen Cove, New York, October 2001, who
helped form and focus some of the ideas presented in this paper.
Primary Care: The Next Renaissance Future of Primary Care
www.annals.org 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 271
Note: The opinions and suggestions presented are those of the authors
and may not necessarily represent those of other participants, the authors’
own institutions, or the Robert Wood Johnson Foundation.
Grant Support: By grant 039940 from the Robert Wood Johnson Foundation.
Corresponding Author: Jonathan Showstack, PhD, MPH, University of
California, San Francisco, 3333 California Street, Suite 265, San Francisco,
CA 94118-1944.
Current author addresses are available at www.annals.org.
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Current Author Addresses: Drs. Showstack and Anderson Rothman:
University of California, San Francisco, 3333 California Street, Suite
265, San Francisco, CA 94118-1944.
Dr. Lurie: The RAND Corporation, 1200 South Hayes Street, Arlington,
VA 22202.
Dr. Larson: University of Washington Medical Center, 1959 North East
Pacific Street, Box 356330, Seattle, WA 98195.
Dr. Hassmiller: The Robert Wood Johnson Foundation, Route 1 and
College Road East, Princeton, NJ 08543-2316.
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