Two years ago, leaders of the seven national family medicine organizations embarked on a serious re-examination of the specialty and the U.S. health care system when they initiated the Future of Family Medicine (FFM) project. The group’s goal was ambitious: to develop “strategies to renew and transform the discipline of family medicine to meet the needs of patients in a changing health care environment.” Now, work on the first stage of the project is complete. The result is a diverse examination of the specialty and 10 strategic recommendations that will serve as a guide for transforming the discipline.

No more doom and gloom

The project’s final report and accompanying recommendations were published in the March/April 2004 issue of the Annals of Family Medicine (http://www.annfammed.org/cgi/content/full/2/suppl_1/S3). “I think the report represents the first positive we’ve seen in a long time,” says James C. Martin, MD, AAFP board chair and chair of the FFM project leadership committee. “The recommendations will give family physicians a compass to direct us so that we can get off this hamster wheel and get reimbursed for the value that we bring to the system.” The recommendations for a rearticulated vision of family medicine appear on page 36. They include the following:

• A new model of practice that is locally adaptable, builds on the core values of family medicine, stresses a team approach and is congruent with the six aims of high quality health care identified by the Institute of Medicine’s Chasm Report¹ (i.e., safe, timely, effective, efficient, equitable and patient-centered);

• A more functionally designed office practice that incorporates advanced information technology, including just-in-time information systems that allow physicians to retrieve the best evidence at the point of care, and a standardized electronic health record (EHR) that integrates easily into daily practice and is affordable to most family physicians;

• A model of family medicine residency education that is more flexible and emphasizes cultural proficiency, quality improvement, informatics, evidence-based medicine, practice-based research and the biopsychosocial model of care;

• A comprehensive lifelong learning program for family physicians based on continuous personal, professional and clinical practice assessment and improvement;

• New reimbursement models that sustain and promote family medicine and primary care practices.

Those involved with the project readily admit that successful transformation of the specialty cannot occur without system-wide changes to the present reimbursement models. “We’re already getting the message out that payers, particularly Medicare, must pay for the value they receive from family physicians,” says AAFP President Michael Fleming, MD.

Currently, a special task force on reimbursement and financial issues is working to formulate a plan for a new model that will pay family physicians fairly. “However, we can’t expect the system to just cut us a check,” says Stephen J. Spann, MD, the task force chair. “In order to receive enhanced reimbursement, we’re going to have to demonstrate and enhance the quality of care we deliver.” A report from this group is expected in late 2004.

Next steps

The seven national family medicine organizations intend to share responsibility for carrying out strategic initiatives resulting from the FFM project. For example, the Association of Family Practice Residency Directors and the Association of Departments of Family Medicine will take the lead in bringing about changes in family medicine education, whereas the AAFP will head the effort to redesign the work and workplaces of family physicians. Any proposed changes will not occur overnight. They will be preceded by much discussion and a period of active experimentation, in which family physicians and their partners envision, test and evaluate the effect of innovations. “FPs are going 70 miles an hour so we want any transitions to be as seamless as possible,” Martin says. “We can’t succeed if we don’t supply business plans, models and advisers who can work with physicians along the way.”

The priorities highest on everyone’s list include developing a new model of practice, integrating EHRs into practices and residency programs, and creating a unified strategy for promoting an awareness and understanding of family medicine.

New model of practice. While some elements of the new model will seem familiar to family physicians, such as a patient-centered approach to care, it will require family physicians to develop additional competencies in relationship, information and process management (see “Traditional vs. new model of practice”). And while the new model is designed to be flexible enough to accommodate practice variation depending on geographic location and the needs of the community being served, two concepts will be emphasized: offering patients a “medical home” and an expected “basket of services.”

A medical home is “a place you can go with any concern and receive, first, a healing relationship with a personal physician, and second, the comprehensive, integrated care that you need,” says Larry Green, MD, director of the Robert Graham Center for Policy Studies in Family Practice and Primary Care and chair of the task force that helped to develop this new model. “We want to ensure not only that every person has access to a medical home, but that the ongoing relationship between a patient and physician isn’t disrupted by administrative hassles with health insurance.” Green hopes that patients will come to identify their medical home as a place where they can receive a full basket of services, either provided directly by their physician or coordinated by their physician and provided by another physician with which the practice has an ongoing relationship. These services are for both sexes, across all ages and health care settings, and include the management and prevention of acute illnesses and chronic diseases, preventive care, well-child care, primary mental health care and advocacy for patients within the health care system. “There’s been a lot of confusion over the last few years about who does what medically,” says Green. “The market research performed early on in the project showed us that people don’t really know what family physicians do. Managed care folded us into a bucket called primary care and we lost our distinctiveness. Providing an expected basket of services is one way we can stand out.”

The seven national organizations are also considering developing practice alpha sites to test the new model and establishing a self-sustaining national resource center that physicians can use to obtain very specific advice and recommendations about practice reengineering. “I think that by 2006 you’ll see a real movement taking place,” says Martin.

Electronic health record systems. If all goes as planned, a significant number of practices and residency programs will be using EHRs by 2006. “Anyone unwilling to adopt an EHR will not have the necessary tools to go into the future,” says Wm. Jackson Epperson, MD, MBA, who practices in Murrells Inlet, S.C., and served on one of the FFM task forces. “They’re not only key to business survival, but to patient care and service.” Martin agrees that the EHR will become the central nervous system of the new model of practice. “None of the physicians I talk to deny the value of an EHR,” he says, “but everybody says, ‘I can’t afford to make the wrong choice, and I don’t have time to go look at them and play with them and see what’s going to work best for me.’” In order to promote the adoption of information technology in family physician offices, the AAFP is engaging in several collaborative efforts, including the following:

• The Partners for Patients initiative, a strategic business alliance with leading information technology companies willing to offer physicians discounts on EHRs and other information technology products. These companies have also agreed to help develop standards-based products that adhere to four basic principles: affordability, compatibility, interoperability and data stewardship.

• The Doctor’s Office Quality Information Technology (DOQ-IT) project, an initiative funded by the Centers for Medicare & Medicaid Services to help small- to medium-sized practices move from paper-based health records to EHR systems and to adopt computer-generated decision support tools, such as preventive service reminders and clinical guidelines for diabetes, heart failure, coronary artery disease, hypertension, osteoarthritis, depression and preventive care.

• The Continuity-of-Care record, a joint effort headed by the Massachusetts Medical Society to develop an electronic document standard for summarizing personal health information that physicians can furnish to a consultant and that patients can carry with them to promote safety, continuity and quality of care.

• The Open EHR Pilot Project, a method to study the implementation and promote the use of EHRs in small- and medium-sized family medicine practices.

Communication. The market research conducted at the outset of the FFM project confirmed that while patients continue to value the kind of care family physicians deliver, they don’t understand who family physicians are or what they offer. (For other key findings, see “Family Medicine Takes Center Stage,” FPM, November/December 2003, page 43.) “We haven’t been very successful thus far at creating a brand identity,” says Epperson. “Congress, the Senate, the President, even the average person doesn’t know what we do. In fact, the people who conducted the market research didn’t even know what a family physician did before they got involved with this project.”

Epperson and others involved in the FFM project believe that creating and communicating a brand identity is key to moving the specialty forward. To do that, the AAFP is developing a unified communications strategy targeting, among others, the public, health care policymakers, members of the medical community, and business and academic leaders. National media exposure is expected. “We want family physicians to know that we are advocating on their behalf to ensure the viability of the specialty,” says Fleming. “And we want to show patients that we can better serve their health care needs by adopting new models of practice and education.” Physicians can also expect to see symbolic changes, such as the use of “family medicine” instead of “family practice” and “family physician” instead of “family practitioner.”

No ivory tower exercise

At the outset of the FFM project, the specialty’s leadership decided that no part of family medicine was going to be excluded from the process. The project included physicians with a wide range of expertise, including those in academia as well as those with experience in “the plain old nuts and bolts of family medicine: paying the bills, dealing with insurance and trying to figure out the cash flow of a small business,” says Epperson. “This was no ivory tower exercise.”

Nor is it a fixed blueprint. “It represents a starting point,” says Kurt Stange, MD, PhD, a member of the FFM Project Leadership Committee. “The real impact of the report will be determined by the degree to which people interact with it and the degree to which this interaction stimulates action.”

Physicians are encouraged to read the recommendations and provide feedback. “When I ask myself why anyone should pay attention to these recommendations, I think about myself on those days when I’m in the office until 8 p.m., not providing care for my patients, but doing paperwork,” says Martin. “My focus should be on meeting the needs of my patients and making the practice of medicine fun again. That’s the whole point.”