The biggest barrier in primary care at the current time appears to be belief in the ability of innovation to address serious and worsening primary care woes.
The first thing to consider is why do we think innovation is necessary. What do we accomplish? What innovation in what dimension or area of primary care? What is innovation? Can something as basic as primary care be innovative?
Primary care delivery boils down to an interaction between a nurse or a practitioner or a physician and a patient or their proxy.
We have electronic ways to address this interaction - this is not innovation, it is the situation at the current time.
Primary care always adapts to use the current communication tools - letters, telegraph, telephone, etc.
We have skilled health care team members.
Primary care has always depended heavily upon nurses that used to do much of the therapy, advising, counseling, instructing - and they still do. Personnel are always blurring lines and divisions to get the job done.
We may have specialized the team members and may have more team members but primary care can be delivered simply with the simple basic elements.
Even the more complex patients have simple solutions. To get to the highest quality measure levels in more complex patients, Gordon Moore in his simple collaborative care doc and nurse model noted that the patients needed simple problem solving techniques that a good mom could provide.
Right now with all the hoopla on innovation and reorganization I would propose that a major reason for lack of progress in primary care is the thought that innovation can fix primary care. When patients go to charlatans who promise what they cannot deliver, this can delay diagnosis and proper treatment.
Focus on the continuity home still hides sufficient health spending and sufficient nursing and sufficient primary care workforce - not innovative solutions but required top priority steps to solve primary care woes. Innovative new primary care forms have not really worked out well due to failure to remain in primary care.
Public Health 101 teaches that in the absense of sufficient funding - reorganize or innovate - this hides the problem of insufficient funding that limits progress toward real solutions.
Deming was not innovative. Deming in his management techniques taught focus. During an immersion process focused on quality, the obvious steps to take can be identified. Those less obvious will be eliminated. Most important was the outside perspective - often those most involved. What is most commonly missing is the perspective of those actually delivering day in and day out primary care. Academics are fine people and innovation is a high expectation, but academic ideas can distract. Ideas are often great for innovation and grant funding, but does this really focus on what is really needed.
When nations go to war, they quickly find out that what they thought was impossible is possible, innovative torpedos fail to work, electric bomb arming devices also fail, and the top officers that do well in bureaucratic times do not function as well in wartime.
Primary care improvements require a wartime front line focus on primary care workforce. Once we have sufficient workforce and we want to explore ways to move from 90% efficient to 94% efficient, then we can be innovative. But until we are on the way to 440,000 primary care physicians to serve a nation of 400 million (preferably 500,000 primary care physicians) not much else will matter. All else is just rearranging deck chairs.
Bob Bowman
