Editor note: I appreciated this author’s (a medical student) view of the future of primary care although many primary care physicians (me included) are already performing most of the practices described here. Clearly, the evolution of the PCMH practice transformation model and adoption of currently available technologies will allow more efficient and effective care to be delivered to patients. –CWS

Abstract

Summary:
Keywords: Primary care, medical home, personal health record, PHR, electronic health record, EHR, participatory medicine.
Citation: Allencherril JP. The future of primary care: one medical student’s view. J Participat Med. 2014 Nov 12; 6:e14.
Published: November 12, 2014.
Competing Interests: The author has declared that no competing interests exist.
 

As a patient, I yearn for a primary care visit that is pleasant, comprehensive, convenient, and efficient. As a future practitioner, I hope for a visit that is unhurried, educational, efficient, and holistic. We have grown too accustomed to the status quo — on both ends — that is, we have come to expect the 45-minute wait prior to our beckoning by the nurse, and proceed to a further 15-minute wait after measuring vital signs, before we finally meet the physician. And even once he is in the room with us we may unable to voice all of our true concerns, both parties being aware that there are other patients to be seen. Even with the best of intentions the physician is often already running behind schedule. And the patient likewise through no fault of her own, is left to wait though she may have many other items on her agenda.

But there is a better way. The primary care visit of the future, is a model that achieves greater convenience, and better outcomes for both practitioner and patient:

Clarence Patience is 46 years old, a mother of two, and a third-grade teacher. She also is one of the patients of Dr. Michael Prudence (whom she lovingly calls “Dr. P”), who has had an outpatient internal medicine practice in the suburbs for the past decade. A few weeks ago, Clarence had a nagging sore throat and was contemplating whether or not to schedule a visit with Dr. Prudence, or if her symptoms merited a visit to the local ER (she was worried because one of her students had recently developed pneumonia). Through her intuitive, user-friendly personal health record (PHR), which integrated with Dr. P’s patient portal, she had access to an online evidence-based symptom checker – available to her on both her phone and computer. As she answered a simple series of questions, she was informed that this was likely a viral pharyngitis that did not require antibiotics, and would likely resolve on its own.

However, she was still slightly worried about her persistent cough and wondered if Dr. P. could provide her with a prescription for antibiotics. Based on the questions she had answered through the symptom checker, she was shown several 7-minute clinic appointment slots scattered throughout the afternoon. Simple acute visits are usually scheduled into 7-minute slots, while patients managed for multiple chronic conditions are assigned to 20-30-minute slots. Due to the calculated low acuity of the situation, the portal gave her the option of either having a secure e-visit or an in-person clinic visit. The e-visit option would be quite convenient since she worked at a full-time job and she did not want to spend a lot of time commuting for what would be a straightforward, short visit. So she decided to have an e-visit at 1:10pm that day – right before the kids would be returning from recess. The PHR continued to prompt her through a series of questions about the history of her present illness: onset, timing, and duration of symptoms, associated symptoms, as well as aggravating and relieving factors.

And at 1:10pm sharp she had a secure video session with Dr. P., who prescribed benzonatate capsules to help suppress the annoying cough. He told her to schedule another visit should her symptoms persist longer than one week. She was able to pick up the medication the same day from her pharmacy. Thankfully, just a few days later, she was back to her usual state of health.

A few months later, it was time for her hypertension and diabetes visit with Dr. P. – this time she had the time to see him in person for a complete exam. The portal had scheduled her for a 20-minute visit at 4:30pm on a Friday, based on her selection of time preferences and clinic availability. Before her visit, she updated her PHR: she had cut her alcohol intake to only 2 drinks a week and her father had suffered a heart attack just a few weeks prior. Fortunately, there were no hospital admissions or consultant visits to report — had there been, notes from these encounters could have been electronically uploaded to her PHR, with her permission of course, by the respective providers. In the worst case, she could request the records and manually scan these for upload to the PHR. No longer did she have to carry stacks of paper notes when she shuttled from one doctor to the other.

Sensors tracked her medicine intake during the previous months, about which she had received reminders through her smartphone. Her electronic glucometer and blood pressure reader had been automatically uploading readings to her PHR all the while. Looking at her log over the past few months, she noticed her blood pressure was a little higher than she liked. Her exercise was tracked by her cloud-connected smartwatch, and she received electronic reminders to go for a jog at appropriate intervals.

In the past, with her busy schedule, she would occasionally forget about the clinic visits she had scheduled, since they had been made so far in advance. But Dr. P’s clinic sent her automatic reminders via phone, text and email. If she did not confirm by the last reminder, given 48 hours before the visit, she would receive a call from the office. If canceled with less than 24 hours’ notice, she would be charged a small fee (a small incentive to keep the schedule running smoothly on behalf of other patients and Dr. P).

As requested, Clarence arrived at Dr. P’s beautiful office at 4:15pm. The space was tidy and open, with a brilliant view of the surrounding wooded neighborhood. She had enough time to elaborate on her current symptoms with a secure electronic tablet given to her at the front desk – it would stay with her through the rest of the visit. She completed her review of systems and entered her preferred time for the next visit, and an e-appointment card was sent to her email. She quickly confirmed that the rest of her family and social history were in sync with her PHR.

At 4:30, receiving a notification that Clarence had completed her work on the tablet, Maria, Dr. P’s medical assistant, called for Clarence. She subsequently measured her weight, height and vital signs and seated her in exam room 3. Finally, the tablet instructed her to remove shoes once she entered the exam room for diabetic foot inspection. At her prompting, it proceeded to play instructional videos about nutrition and exercise.

Meanwhile, Dr. Prudence was just finishing his note for the previous patient. Having also received the notification that Clarence had completed entering her information online, he reviewed her chart in the uncluttered electronic health record (EHR) which integrated with Clarence’s PHR. Now this was an EHR his colleagues were jealous of – aesthetically pleasing, and didn’t require days of training to grow accustomed to. Sure, it helped with billing, but above all, it enhanced his workflow throughout the day and improved the safety of his patients as it provided evidence-informed reminders for preventive screening and procedures.

As he perused Clarence’s diagnostic questionnaire and her own freestyle history, he quickly noted that her blood pressures were markedly above the recommended range. The EHR also reminded him that she was due for an influenza vaccine for the season. He sent an electronic consent form to Clarence’s tablet for her approval. The EHR noted that she was also due for a Pap smear, providing a recommendation for a gynecologist referral. Given her increased risk for coronary heart disease, a lipid panel was also recommended. She was otherwise up to date on her immunizations and other preventive care. His EHR frequently combed through his patients and identified those due for preventive screenings – his staff diligently followed up with those who did not respond to the PHR reminders and texts.

At 4:34, he entered exam room 3 and greeted Clarence. After discussing their families with one another (their children played on opposing high school football teams), they moved on to the matter at hand – her consistently elevated blood pressures. He would be increasing the dose of her ACE inhibitor for better control. In a few weeks he would receive an update on her at-home blood pressure readings to see if they needed to titrate upwards again. He commended her on her well-controlled blood sugars and consistent exercise regimen as he explained the need for the flu vaccine, Pap smear, and lipid panel. As the visit continued, he wrote the visit note with her, as Clarence offered slight clarifications along the way. At 4:47, his smartphone, also linked to the EHR cloud, discreetly beeped twice, signaling that two minutes were left before the next patient’s scheduled appointment. He wrapped up by sending patient instructions and educational information to the PHR. As they said their goodbyes, he reminded her that Maria would be back to administer the flu vaccine and direct her to the lab for the blood draw. She would be notified of her results through the PHR with an option for a followup visit to discuss abnormal results.

Clarence left knowing why her blood pressure medication had been increased and what to do in case she experienced any adverse side effects. In the palm of her hand, she could review all of her past visits and learn more about her health issues.

She felt healthy. Really healthy.

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