Patient-Centered Medical Homes Could Reduce Medical Errors

SUMMARY:
The patient-centered medical home (PCMH) can potentially address many current safety concerns in primary care, including what is likely the leading type of error – diagnostic error (i.e., missed, delayed, or wrong diagnosis). Integral to the PCMH concept are electronic medical records (EHRs), which can enhance access to data and advanced decision support to reduce diagnostic error. However, as currently envisioned, many PCMH models may not address other systems and cognitive problems that cause diagnostic errors.

In this Commentary, authors used Vincent’s framework for analyzing risk and safety in clinical medicine, as well as insights from their own work, to recommend five “rights” for reducing diagnostic errors in future patient-centered medical homes within and outside VA.

The five “Rights” include:

• Right Teamwork – The PCMH model emphasizes team-based care. Through innovative team-training programs, care should be undertaken to ensure that the new model of care does not introduce ambiguous responsibility between team members. Individual accountability and ownership of patients should be emphasized.
• Right Information Management – PCMH models must emphasize reliability not only in the transmission of information, but also in the completion of required follow-up actions by the recipient. In addition, better techniques to summarize and present data are needed to enable providers to find the proverbial “needle in the haystack” among extensive data. The authors also suggest that comparative effectiveness studies evaluate which EHRs are more “effective.”
• Right Measurement and Monitoring – Reducing diagnostic error will require more refined performance monitoring strategies that not only address compliance with preventive measures, but also key indicators of diagnostic performance (e.g., appropriate management of test results).
• Right Patient Empowerment – Providers should enlist patients as key partners in the prevention and detection of diagnostic errors. For example, providers can encourage patient questions such as, “How do I make sure I hear about all my test results?”
• Right Safety Culture – Patient safety must be an organizing principle, which necessitates an appropriate infrastructure and skill set to ensure the effective implementation of the other four “rights.” Cognitive scientists, informaticians, and human factor and systems engineers should collaborate to address the challenges inherent in adopting this new model of care.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by VA and by HSR&D (HFP90-020). Dr. Singh is part of HSR&D’s Houston Center for Quality of Care and Utilization Studies.

Singh H and Graber M. Reducing Diagnostic Error through Medical Home-Based Primary Care Reform. JAMA Commentary July 28, 2010;304(4):463-64.