Every once in a while, a new “chief” title makes its way into healthcare. Chief innovation officers are now fairly common. In 2014, I wrote about a new title popping up for system-wide chief medical information officers: the chief health information officer. Organizations such as Duke Medicine, Texas Health Resources, OHSU, and Geisinger all have CHIOs.
Now two leaders in primary care are proposing a new hospital role: the chief primary care medical officer.
Writing in the Annals of Family Medicine, Noemi Doohan, M.D., Ph.D., of the Department of Family and Community, Medicine at the University of California Davis and Jennifer DeVoe, M.D., chair of the Department of Family Medicine at Oregon Health Sciences University in Portland, make an intriguing case that although hospitalist programs are strong, discontinuity is the biggest challenge of hospitalist medicine, because the long-term relationship with the patient ends as the patient walks out the hospital door.
“As a step toward fixing the discontinuity in our health care systems, we propose that every hospital needs a Chief Primary Care Medical Officer (CPCMO), an expert in practice across the spectrum of care,” they wrote. "The CPCMO can lead hospital efforts to create systems that ensure primary care’s continuum is complete, while strengthening physician collaboration across specialties, and moving toward achieving the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers.”
Giving a few examples of discontinuity, they described a woman whose primary care physician (PCP) recently retired. After a lengthy hospitalization for a hip fracture, her discharge to a skilled nursing facility was overly complicated and prolonged because she had no PCP to accept her discharge. Or for an uninsured man with hypoxia who presented to the emergency department, the lack of a PCP allowed no endorsable pathway except hospital admission. Learning that his CT scan findings suggested end-stage metastatic lung cancer, he said “If I have incurable cancer, I want to go home to die.” But without a PCP to facilitate his discharge home with hospice, he was admitted and died in the hospital.
They add that payment schemes and delivery systems make it nearly impossible for PCPs to coordinate care transitions and support the inpatient team.
To address situations like these, Drs. Doohan and DeVoe propose that every hospital should appoint a primary care physician to lead hospital efforts to create systems that ensure primary care’s continuum is complete, even for the most complex patients.
“In broad terms, the CPCMO will be tasked with building systems that facilitate needed bidirectional flow of information and care between inpatient and outpatient settings, and creating maps of community resources and PCPs.”
They describe the CPCMO building longitudinal continuity with community PCPs, traveling to meet with community partners to better understand and advocate for their practices. “Metrics such as the neighborhood stress score (NSS7) can be monitored by the CPCMO to determine if additional resources are needed to support partnering PCPs and as a means to better identify patients with high levels of neighborhood stress and other social determinants of health,” they wrote.
Speaking of social determinants of health, earlier this year I had the chance to interview Dr. DeVoe about her work on pilot projects to gather social determinant data in the EHR. She said a primary care team sees people often and can identify some of these needs.
“We are looking at ways to use that data to help us identify people at risk and trigger referrals,” she explained. “As a primary care physician, I can identify a patient who has a cardiovascular condition and who might need to be referred to a cardiologist, and I can put that consult into my EHR, and hopefully information flows back to me,” she said. “The analogy would be in partnering with social service agencies and others who address a patient’s social vulnerabilities. Certainly it is not as easy as referring a homeless patient to a housing service, but it is a first step.”
She told me that her team also has experimented with a set of community vital signs. By bringing those into the EHR, they could know who is living in an area that is vulnerable and potentially act on that information.
Devoe called this area of research very nascent, but she believes it has incredible potential. “Zip code is more predictive of health outcomes than genetic code is,” she said. “After collecting this information in the EHR, the next step for us is figuring out how to partner more effectively with the larger communities of organizations.”
Does your hospital or health system have someone playing the Chief Primary Care Medical Officer role now, even if they don’t have that title, or is it a gap that needs filling? Are new population health efforts making this bridge between the hospital and PCPs more critical?