The patient-centered medical home (PCMH) model can potentially address many current safety concerns in primary care, wrote Mark Graber, MD, of Stony Brook University Medical Center in New York, and Hardeep Singh, MD, of Baylor College of Medicine in Houston, in a commentary published in the July 28 issue of the Journal of the American Medical Association .
In particular, strengthening aspects of a comprehensive, coordinated primary care model could potentially lower errors in diagnosis—the single largest contributor to malpractice claims (about 40 percent) with a cost of approximately $300,000 per claim, according to the authors.
“Whether medical homes can effectively improve safety will depend substantially on their ability to deliver timely and reliable diagnosis, one of the core functions of primary care,” wrote Graber and Singh, who used the “Five Rights” framework to recommend ways to reduce diagnostic errors in future PCMHs.
Right teamwork : Delegation of physician tasks to other PCMH team members, if handled appropriately, could mitigate diagnostic errors related to patient follow-up. For example, team members could monitor test results, referrals, and appointments for high-risk patients to ensure appropriate follow-up and prevent diagnostic delays, the authors wrote. "Task delegation also may facilitate diagnosis by creating additional opportunities for data gathering, a common breakdown in the diagnostic process, and by making available more non–face-to-face time for clinicians."
Right information management : PCMH models must emphasize reliability not only in the transmission of information but also in completion of required follow-up actions by the recipient. Related problems include the communication breakdowns that develop at the generalist-subspecialist interface. Despite facilitated electronic referrals, unclear responsibility for patient follow-up between generalists and subspecialists might contribute to a significant number of breakdowns in care.
Right measurement and monitoring : “Refined metrics of processes and outcomes should address compliance with preventive measures as well as key indicators of diagnostic performance (e.g., appropriate management of diagnostic test results). These monitoring processes could be accompanied by feedback about specific prevention strategies to improve common breakdowns in the diagnostic process, such as history and physical examination skills and test ordering. Equally critical is the capacity for robust internal reporting systems to identify errors made in practice and generate feedback to clinicians,” wrote Graber and Singh.
Right patient empowerment : Current PCMH models emphasize patient engagement in chronic disease management, but future models should involve patients as final safety nets to prevent or detect errors. Encouraging patients to ask “activating questions,” such as How do I make sure I hear about all my test results? Do I need another opinion?, should become part of the PCMH commitment to reducing these errors, they wrote.
Right safety culture : “For PCMH to transform primary care, patient safety must be a central organizing principle,” the authors stated. Systems and human factors engineering can reduce inefficiencies and error-prone conditions, thus reducing or eliminating risk factors for diagnostic delays.
“Diagnostic error reduction requires major transformational changes in health care delivery, and the PCMH model offers an important opportunity to address these errors,” the authors concluded. “The outcome of this difficult task could depend on how these five rights are engineered into this enterprise.”