Why not inside out empowerment rather than outside in abuse?

Just in from Annals of Family Medicine (Miller, Rubenstein, Howard, Crabtree) Shifting Implementation Science Theory to Empower Primary Care Practices

Hope for primary care, generalists, rural health, and care where needed requires a very different perspective after decades of failed designs.

Not surprisingly this will need to come from inside of these practices and places.
Not surprisingly policies and practices dictated from outside have been not only a poor fit - but have been abusive to the populations most in need of care and the practices that serve them.
There is hope from the primary care research community. The perspective must be inside of practice looking out - instead of outsiders forcing changes. Qualitative research explores and discovers and reflects as Ben, Will, and others taught me along with the various rural family physicians interviewed and researched in the 1990s in Nebraska.

The current focus on quantitative research has demonstrated little to offer - particularly in primary care, outcome, and overall health care improvement. Even if there is data, or relevant data, or complete data – there can be little understanding of what the data and analysis means. This is particularly true when the research proceeds from the outside in rather than having some qualitative understanding of relationships, situations, conditions – and more.

From the article where the researchers discovered important themes of inside out in 3 practices that they studied:

"The 3 illustrative cases reveal it is possible for some primary care practices to seize ownership of their care and prioritize their craft of family medicine. These practices began with their founders' realization that matching their practice to their values was impossible, given the conventional financing system and commercial EHRs designed to serve it. They came to this conclusion differently but took similar action by developing business models that circumvented the limitations of fee for documentation and pay for performance.

Although their clinical care and business models differed, all 3 practices succeeded in shifting the source and directional emphasis of change from outside-in to inside-out.

Reimagine Our Approach
These examples compelled us to reimagine our approach to the science of dissemination and implementation: from helping practices comply with externally sourced evidence and recommendations to empowering practices to discover and enact their own wisdom within a challenging environment.

Based on these examples, we seek to remind practitioners, researchers, and policy makers that internal and external forces are dynamic and mutually constitutive."

Readers are encouraged to review all of this at    http://www.annfammed.org/content/17/3/250.full.pdf+html

Reimagine our approach to the science of dissemination and implementation

Or stop implementing policies and practices before adequate study – especially regarding the consequences.

My comments:

The practicing physicians turned researchers also have indicated the difficulties facing small practices (Mold, Casalino, others) - particularly when policies or interventions from outside are a poor fit – and even when the "support" for a change is free.

Why not focus on what primary care practices do and the time for them to relate?

Why continue to force changes that hurt what they do and blame them for not doing what they cannot do?

Bob Bowman

Basic Health Access


We Are Not Growing Primary Care, We Are Shrinking It - Not only is primary care delivery capacity declining, we are shrinking primary care from within by compromising team member functions.

Real Health Care Solutions, Not Value Focus

The CMS Contribution to the Demise of Rural Health - CMS leads by example - the wrong way

You're Killing Us Smalls - Small health is being killed off by design.

#payforperformance #primarycare #healthpolicy #healthreform #research #electronicmedicalrecords


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