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Fam Pract Manag. 2000;7(5):10

The Idealized Design of Clinical Office Practices (IDCOP) initiative of the Institute for Healthcare Improvement has attracted a great deal of attention recently, and deservedly so. It is one of the most ambitious quality improvement projects in medicine. It seeks “fundamentally new levels” of clinical and financial success as well as patient and staff satisfaction.

If the phrase idealized design sounds like pie in the sky, don't be too quick to dismiss it. The mere fact that more than 20 health care organizations are willing to pay tens of thousands of dollars a year and commit significant staff time to participate in the project is an indication of how seriously some serious people are taking it. (See also our cover story and the editorial by Bruce Bagley, MD.)

And the need is great. You and I both know that there's a lot wrong with the health care system. True, if we had the job of fixing what is broken, we might not think to look first at physician practices. After all, surely the financing of health care is more in need of reconstruction than the delivery of health care. But in focusing on the office, IDCOP is redesigning the locus of most health care — and it is addressing the part of the health care system that physicians have most direct control over.

How broken is it?

Part of the rationale for IDCOP is the idea that the office practice of today is fundamentally flawed — that incremental improvement is inadequate, that present practices are beyond repair and that revolution is the way to the future. Do you believe that? I can certainly imagine that you might not. Looked at in the right light, office practice may seem to be the only part of the health care system that comes close to working well.

But I think the true measure of how bad things are now is not how well a practice can function within current limitations but how far it is from what it could be or should be. In today's practice, things that should happen automatically 100 percent of the time do happen, maybe even most of the time — but not automatically. They happen as often as they do because dedicated, overworked physicians and staff members push themselves to make sure they happen.

But they fail to happen often enough that potential drug interactions are missed, ineffective treatments are delivered and effective ones underutilized, calls aren't returned, co-payments aren't collected, questions go unanswered, time is wasted, services delivered aren't documented, specula aren't returned to the right drawer, unpaid claims aren't collected, patients who should come in for a visit don't and those who don't need to do, evidence from the literature is ignored, patients are forced to wait for appointments, preventive services aren't delivered, abnormal lab values aren't followed up, and on and on.

Beyond repair

Today's practice is part science, part art, part blind, unquestioned habit and part luck. And today's practice isn't keeping up with today. For example, as an editor, I can call up from home any article being edited for FPM. Yet why is it that, as a physician, despite the human importance of your work, you can't call up your patients' records when you get a call in the evening? For that matter, why can't patients e-mail you with questions and information about their health? Why can't they access their records through your Web site? Why don't you review your patients' blood pressure readings over time on a statistical control chart? Why can't your staff send a reminder letter to all diabetic patients in your practice who are overdue for foot exams?

No, the system is broken. And as Dr. Bagley says in his editorial, you've already proved that hard work is not enough: Just look how hard you're working now. Hard work is the baling wire that holds your practice together, and working harder will just give you more baling wire.

You need a new practice. It's high time somebody fomented a revolution. In fact, the changes needed are so large that no mere three-year project is going to bring them about, even in the 42 IDCOP prototype practices. And as the revolution progresses — as a new practice design is worked out — the battle will intensify. Eventually, if forward progress is not to bog down, we'll have to take on the grotesque and antiquated reimbursement system, demolish the idea that the patient visit is the reimbursable unit and establish a payment system that rewards proper care, whatever it is. If the revolution succeeds, you might not recognize your practice in 10 years or so, but I think you'll be happy with it.

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