We recently implemented a full-featured electronic health record in our independent, 4-internist, community-based practice of general internal medicine. We encountered various challenges, some unexpected, in moving from paper to computer. This article describes the effects that use of electronic health records has had on our finances, work flow, and office environment. Its financial impact is not clearly positive; work flows were substantially disrupted; and the quality of the office environment initially deteriorated greatly for staff, physicians, and patients. That said, none of us would go back to paper health records, and all of us find that the technology helps us to better meet patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart notes), and creates new ways in which we can improve the health of our patients. Five broad issues must be addressed to promote successful implementation of electronic health records in a small office: financing; interoperability, standardization, and connectivity of clinical information systems; help with redesign of work flow; technical support and training; and help with change management. We hope that sharing our experience can better prepare others who plan to implement electronic health records and inform policymakers on the strategies needed for success in the small practice environment.

Primary care practices typically measure productivity according to the number of visits, which also drives payment. Work that does not involve a visit from a patient is invisible to those who support and purchase primary care. Several studies have estimated the amount of time that primary care physicians devote to nonvisit work. 1,2 To provide a more detailed description, my colleagues and I used our electronic health record to count units of primary care work during the course of a year. Pr ac tice ProfileGreenhouse Internists is a community-based internal medicine practice employing five physicians in Philadelphia. In 2008, we had an active caseload of 8440 patients between 15 and 99 years of age. Of these patients, 68.6% were women; 59.5% were black, 29.8% were white, and 10.7% were another racial or ethnic group or were not identified. Our payer mix included 7.2% of payments from Medicaid (exclusively through Medicaid health maintenance organizations), 21.5% from Medicare (of which 14.0% were fee-forservice and 7.5% capitated), 64.7% from commercial insurers (34.5% fee-for-service and 30.2% capitated), and 6.5% from pay-for-performance programs. With the exclusion of copayments and fee-for-service payments received on behalf of patients in capitated plans, 35.2% of our total revenue came through capitation.Throughout 2008, our physicians provided 118.5 scheduled visit-hours per week, ranging from 15 to 31 weekly hours each. We regard this schedule as equivalent to the work of four fulltime physicians, with physicians typically working 50 to 60 hours per week. Our staff included four medical assistants, five front-desk staff, one business manager, one billing manager, one health educator (hired midyear), and two fulltime clerical staff. Our staffing ratio was approx-imately 3.5 full-time support staff per full-time physician. We had no nurses or midlevel practitioners. We saw patients from 7 a.m. to 7 or 8 p.m. on weekdays and from 8 a.m. to noon on Saturdays and did not provide hospital care.

A great gulf exists between the way we think about disease as physicians and the way we experience it as people. Much of this separation derives directly from our basic assumptions about what illness is. Our medical world view is rooted in an anatomicopathologic view of disease that precludes a rigorous understanding of the experience of illness. What we need to remedy this problem is not just the admonition to remember that our patients are people, but a radical restructuring of what we take disease to be. The philosophic discipline of phenomenology is used to present a vision of disease that begins with an understanding of illness as it is lived. "Nonmedical" descriptions of illness show how we can reorient our thinking to encompass both our traditional paradigm and one that takes human experience as seriously as it takes anatomy.

PURPOSE Despite growing calls for team-based care, the current staff composition of primary care practices is unknown. We describe staffing patterns for primary care practices in the Centers for Medicare and Medicaid Services (CMS) Comprehensive Primary Care (CPC) initiative. METHODSWe undertook a descriptive analysis of CPC initiative practices' baseline staffing using data from initial applications and a practice survey. CMS selected 502 primary care practices (from 987 applicants) in 7 regions based on their health information technology, number of patients covered by participating payers, and other factors; 496 practices were included in this analysis.RESULTS Consistent with the national distribution, most of the CPC initiative practices included in this study were small: 44% reported 2 or fewer full-time equivalent (FTE) physicians; 27% reported more than 4. Nearly all reported administrative staff (98%) and medical assistants (89%). Fifty-three percent reported having nurse practitioners or physician assistants; 47%, licensed practical or vocational nurses; 36%, registered nurses; and 24%, care managers/coordinators-all of these positions are more common in larger practices. Other clinical staff were reported infrequently regardless of practice size. Compared with other CPC initiative practices, designated patient-centered medical homes were more likely to have care managers/coordinators but otherwise had similar staff types. Larger practices had fewer FTE staff per physician.CONCLUSIONS At baseline, most CPC initiative practices used traditional staffing models and did not report having dedicated staff who may be integral to new primary care models, such as care coordinators, health educators, behavioral health specialists, and pharmacists. Without such staff and payment for their services, practices are unlikely to deliver comprehensive, coordinated, and accessible care to patients at a sustainable cost. 2014;142-149. doi: 10.1370/afm.1626. Ann Fam Med INTRODUCTIONP ublic and private health care payers nationwide are testing whether making primary care more patient centered, accessible, coordinated, and comprehensive will improve health care quality, cost, and patient and clinician experiences. [1][2][3] Many are piloting versions of the patient-centered medical home (PCMH) model as defined by the primary care physician societies. 4 A cornerstone of these new care models is team-based care, in which staff work collaboratively with patients and their caregivers to achieve coordinated, high-quality care. [5][6][7][8][9][10][11][12] Traditional staff, such as medical assistants, often take on expanded roles, and new staff types may be added. The team is expected to collaborate to deliver high-quality, comprehensive care efficiently; however, we know little about the current or optimal practice team composition.Expanding staffing and shifting roles offers possible advantages. Expanded staffing could provide additional expertise and resources to support patient-centered, evidence-based primary care 13...

With 68% of all physician-patient encounters occurring in physician groups of 4 or fewer, improvements in small practices will be necessary to close the well-documented national gaps in consistent delivery of high-quality care. Many believe that adoption of electronic health records (EHRs) is the key to success, and that improvement will almost automatically follow. However, EHR adoption occurs today in an environment shaped by paper chart thinking, which may limit success. Having successfully implemented an EHR in their small practice, the author and his practice colleagues attempted to use it to support a simple project to improve their mammography rate. Although they achieved a real 10% improvement in their rate with only modest additional expense, their experience highlighted critical elements for success beyond the adoption of the EHR, including physician appreciation of structured data, the need for widespread adoption of standards, and a restructuring of the primary team with additional resources. An approach supporting EHR adoption along with these system changes could substantially affect public health.

The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.

Becoming a medical home is a radical change, requiring both a new mental model for primary care and the skills and resources to accomplish it. Although numerous reports indicate practice change is feasible-particularly with technical support and either insulation from or alignment with financial incentives-sustained transformation appears difficult. We identified the following critical success factors: leadership, financial resources, personal and organizational relationships, engagement with patients and families, competence in management, improvement methods and coaching, health information technology properly applied, care coordination support, and staff development. Each factor raises researchable questions about what policies can facilitate achieving success so that transformation becomes mainstream rather than the province of the innovative few.

Early data reporting, practice preparation for the first learning session, monthly narrative reports from practices, and clear and concrete change packages all seem integral to the improvement process. The future of the PA Chronic Care Initiative will include spreading to more practices and moving beyond the initial work in diabetes and asthma to other aspects of primary care, including prevention.