Essays

Essays April 2019
A Prescription for Primary Care Leaders

Nothing Truly Valuable can be Achieved Except by the Unselfish Cooperation of Many Individuals

David M. Kaplan

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Susan Brown, a 47 year-old woman, has a long-standing relationship with her family physician, Dr. Porter. Over the course of the last few months, Susan noticed that her periods were becoming heavier and more frequent. This change in her health began to worry her and she went to Dr. Porter’s practice website to book an appointment. Without having to call the office, she found a suitable time and left a robust explanation about her need for a visit.

After Dr. Porter completed her in-office assessment, she opened the Heavy Menstrual Bleeding Patient Guide in her electronic record software and explained to Susan the course of investigation, possible clinical scenarios and treatments.

Susan left the office, had blood taken, and booked an ultrasound of her pelvis for later in the week.

Following this ultrasound and about an hour after the radiologist dictated their report, the results appeared in Dr. Porter’s electronic medical record (EMR). Dr. Porter reviewed the bloodwork and ultrasound, which were normal. The family practice nurse sent Susan a secure message, informed her of the normal results and reiterated that it would be prudent to perform an endometrial biopsy, a procedure used to obtain a sample of tissue from her womb. Dr. Porter securely sent Susan additional information about the biopsy and Susan booked an appointment for the procedure. Once the pathology results came back, Dr. Porter sent Susan a final message letting her know that she had normal tissue in her womb and that a first treatment option could be a medication. Susan replied that she wished to proceed with the medication and Dr. Porter securely sent a prescription to Susan’s local pharmacy for the medication.

This clinical vignette is not a futuristic view of the state of Ontario primary care in 2025. It did not occur in another OEDC country with a ‘mythical’ single patient record. It represents a reality that occurs in Ontario every day. 

The introduction of Bill 74, The People’s Health Care Act, 2019, positions family physicians and other primary care providers to effectively use digital tools coupled with in-person visits to improve the quality of patient care in the province and become leading partners in Ontario Health Teams (OHTs).

A Patient Medical Home, such as Dr. Porter’s practice, can reduce the use of emergency departments for non-emergent care (Tiagi and Checulin, 2014) and help contribute to decreasing “Hallway Medicine.”

Leveraging existing digital tools can ensure that family physicians are the gateway to an integrated healthcare delivery system. However, it requires a commitment to providing primary care practices with back-office and administrative support to examine existing workflows, broadly deploy these solutions, and integrate with other community partners.

This requires two things:

  1. Each OHT must have a single primary care EMR record for each patient. My current family medicine clinic shares a common EMR for over 60,000 patients that specialists, mental health providers, dietitians, and nursing case managers can all access. Patients can book appointments on-line and communicate securely with their providers. All our local hospitals, private labs, outside diagnostic imaging facilities populate this primary care record using OntarioMD’s Health Report Manager.
    1. Having a single EMR allows for clinical standardization, the use of drug formularies, evidence-based workups and patient education tools that are updated once and then available to all providers looking after an OHT’s 300,000 patients!           
    2. It makes central resources available to assist clinicians with coordinated quality improvement activities directed to populations the OHT serves.
    3. Finally, it allows us to embrace the fourth principle of family medicine – to be a resource to a defined population of patients with a commitment to care for them and to organize our practices to ensure their health is maintained whether they physically visit the office or not.
  2. In return for meso-level administrative and back-office support from OHTs, physicians must constrain some of their individual autonomy.
    1. By embracing a culture of quality, team-based care, and standardizing our work, we can maintain our collective professional autonomy and partner in creating a highly reliable healthcare system. (KPMG, 2016)
    2. No longer can physicians operate as unconstrained individual atoms free to roam the universe. We can put our patients at risk by focussing on our individual autonomy instead of welcoming a collective professional autonomy that allows us to operate within a system.

If family physicians are going to be successful in transforming our healthcare system through OHTs, we need to heed the words of Albert Einstein. “Nothing truly valuable can be achieved except by the unselfish cooperation of many individuals.”

About the Author

David M Kaplan, MD, MSc, CCFP, FCFP

Chief, Clinical Quality, Health Quality Ontario

Associate Professor, Family & Community Medicine, Joint Centre for Bioethics, University of Toronto

@davidkaplanmd 

References

KPMG International. 2016. “The more I know, the less I sleep.” Retrieved April 8, 2019. <https://assets.kpmg/content/dam/kpmg/pdf/2016/05/clinical-governance.pdf

Tiagi, R. and Y. Chechulin. 2014. “The Effect of Rostering with a Patient Enrolment Model on Emergency Department Utilization.” Healthcare Policy 9(4): 105-121. doi:10.12927/hcpol.2014.23809. 

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