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Future Vision Gaps

Principles Underlying the Care Delivery Future Vision

  1. Quintuple Aim achievement is essential for both practical and ethical reasons.
  2. We should promote patient autonomy.
  3. We should promote shared decision-making, recognizing that this process involves a series of stages with varying content. (208)
  4. We should support both lay and professional care teams.
  5. The feasibility and sustainability of the initiative will be greater if we address work in primary care that should be abandoned, that should be added, and that should be continued. We must also address work that can be offloaded from providers to other clinical staff to free providers to spend more face time with patients and more time using critical thinking skills rather than administrative work.
  6. Infrastructural approaches are needed for doing and supporting all of this.

Assumptions Underlying the Care Delivery Future Vision

  1. The current state of primary care does not support the idealized model due to both internal (practice) and external (regulatory, payment) factors.
  2. To fully achieve the desired future state, payment and technology enablers will need to support eliminating time-consuming activities that do not add value and adopt and nurture the alternative high-value activities outlined in the desired future state.
  3. Patients and the lay and professional care teams will need ongoing support and coaching in order to move toward the idealized model.
  4. We must assess the patient’s and the lay and professional care team’s ability and willingness to use the idealized care framework and tools to co-create the desired future state.
  5. Keys to success will involve attention to technology, tools, and means for creating and sustaining collaborative lay and professional care teams.

Gaps/Offerings Related to Interventions & Scenario

The following tables describe the gaps and next steps to address the necessary improvements to the interventions defined in Table B-1. Interventions Underlying the Future Vision and necessitated by the Mae scenario. They also list some existing resources from AHRQ and others that could be leveraged or enhanced to realize the future vision for those interventions.

Gaps to Address / Next Steps



Gaps to Address / Next Steps


Patient Portal

Reduce the number of portals with which patients must interact (ideally to one) and enforce interoperability between separate portals operated by different health provider organizations.


Patient Education / Self-Management Tool

Redirect patients if/when appropriate and match material to specific patient condition and situation.


Referrals to Community Support Resources

There is no “Google Maps” of community support resources. Have social workers readily available to assist in identifying and connecting with these resources.


Symptom Evaluation Tool

Integrate with patient portal, EHR, and care plan generators. Automatically trigger appropriate tool based on the complaint or problem being addressed.


Patient Parameter Tracking Journal

Integrate with patient portal and any automated devices (e.g., blood pressure monitors, glucose monitors, physical activity trackers, symptom diaries, food diaries).


Screening/Assessment Tool

Automatically suggest screening/assessment tools when and where appropriate (e.g., depression screening at annual visit) and automatically import results into the EHR as discrete data.


Pre-Visit Questionnaire

Seamlessly interface pre-visit questionnaire and clinician’s view and incorporate responses into clinical notes and address those responses dismissed.


Care Guidelines

Make available, transparent, appropriate to the patient, and non-interruptive to workflow.



Provide appropriate access in remote locations with the ability to include family members and caregivers.


Documentation Template

Provide SMART and flexible templates.


Shared Decision-Making Tool

Suggest decision-making tools automatically when specific decisions are considered (e.g., screening modalities or selection of alternate treatments with different adverse effect profiles).


Patient Monitoring / Management Dashboard

Allow the patient and all members of the care team to determine “at a glance” how the patient is doing with regard to control of chronic conditions, completing recommended testing and treatment, and keeping up-to-date with preventive health measures.


Condition Management Policy / Procedure / Protocol

Dynamically link to knowledge sources integrated with the EHR so that patient-specific data can be used to determine the recommended actions and these recommendations can be displayed to providers at the point of care and inserted into the integrated care plan.


Care Plan

This is the least developed of the technologies needed to support the future vision for care delivery, but rapid progress is being made. Many questions need to be answered and gaps need to be solved for a care plan as described in this document to be feasible:

·       Ownership, access, and privacy (e.g., Who has access to the care plan and to which parts? Can patients dictate who sees each piece of information? Who can make changes?).

·       How are data shared across settings? Through the HIE? Carried by the patient on a smartphone app?

·       Data standards are lacking for many important data elements. (This is an area of rapid progress, especially for social determinants.)

·       Many health systems use internal/proprietary coding systems rather than common standards (e.g., LOINC, RxNorm).

·       How accurate is data when pulled from the EHR to inform the care plan?

·       How will the care plan fit into existing clinical workflows?


Clinical Calculator

These should be readily available at the point of care and the results should be inserted into the EHR as discrete data. Although some calculations have clear best practices, providers should have the ability to select preferred calculators when alternatives are available.



Provide seamless access to patient’s prescription drug dispensing data. To be useful, this must be available within the EHR without requiring a separate sign-in and must be able to pass context-specific data (e.g., the patient’s name and birth date) to the PDMP so providers do not have to re-enter the information.


Order Set

Increase physician awareness and ease of use of existing order sets (i.e., ordering a la carte). Maintain order sets in keeping with current standards important to address.


Patient Registry

Set up registries for all conditions that the healthcare organization wants to track and automatically enroll patients when certain conditions are met. For example, all patients with a diabetes diagnosis should be included in a diabetes registry. All patients with precancerous colon polyps should be entered into a registry for future surveillance.


Care Gap, Need, or Issue Detection and Notification Tool

Not just a notification tool, but a facile way to queue the suggested interventions for physician one-step approval. Care coordinators must be available to carry out this work outside of traditional office visits.


Provider Selection Tool

Enable patients to become a key market driver of QI. High-performing clinicians will tend to receive more patients, which will drive lower performers to improve their outcomes. To get to this stage, we need standards for service definitions. What defines a colonoscopy? Does it include a biopsy or polypectomy? Does it include anesthesia or pathology review? Do we need cost bundles (the entire “colonoscopy service bundle”) even if we define service quality independently? What quality measures are needed to support patients making informed choices? This requires a conversation with patients and new thinking about how to get the data that will allow our health systems to serve patient needs.