Journal of Community Health Vol. 2, No. 2, Winter 1976

A PROPOSAL FOR A PRIMARY CARE R E G I S T R Y H e n r y S. Kahn, M.D.

ABSTRACT: A regional, voluntary, registry mechanism is proposed through which any citizen could indicate his intention of seeking primary health care from a physician, clinic, or institution that has also registered. By mutual agreement, the provider would recognize the registrant as a regular primary care patient. Providers would regularly receive lists of their registered primary care patients, including descriptive statistical summaries where appropriate. Such a registry would aid health care planners to promote a more equitable and efficient delivery system for primary care services. F o r the foreseeable f u t u r e in the U n i t e d States, p r i m a r y h e a l t h and medical care will be delivered in m a n y styles b y a wide variety o f practitioners and institutions. This is p r o b a b l y a desirable state o f affairs since n o one as y e t has a d e q u a t e l y d e f i n e d w h a t p r i m a r y care is, s h o u l d be, or h o w it can best be delivered within o u r social and e c o n o m i c system. We as a p e o p l e do n o t k n o w w h a t we w a n t , and we do n o t even k n o w w h a t we have, so far as p r i m a r y care is c o n c e r n e d . I w o u l d like to p r o p o s e a simple registry t h a t could direct n e e d e d a t t e n t i o n to the p r i m a r y care process while at the same time it c o u l d collect r u d i m e n t a r y d a t a o n o u r prevalent p r i m a r y care arrangements. This registry c o u l d be an a p p r o p r i a t e early step t o w a r d a rational solution o f p r i m a r y care p r o b l e m s on a regional or n a t i o n a l basis. H o w a P r i m a r y Care Registry Might Work Each h e a l t h care region o f a suitable size s h o u l d set up a m e c h a n i s m t h r o u g h w h i c h a p a t i e n t and a p r o v i d e r could v o l u n t a r i l y register their m u t u a l i n t e n t i o n s to m a i n t a i n a p r i m a r y care relationship. Patient means a n y person, including those w h o consider themselves well, w h o might s o m e d a y use health or medical care services. Primary care s h o u l d be d e f i n e d very loosely for this p u r p o s e , m e a n i n g the provision o f preventive, diagnostic, and t h e r a p e u t i c health services on a first-contact and c o n t i n u i n g basis, w i t h i n certain resonable limits o f the availability and ability o f the provider, and with an e x p e c t a t i o n o f referral and follow-up for those situations t h a t ~ a n n o t b e a d e q u a t e l y m a n a g e d in a p r i m a r y care c o n t e x t . T h e registration d o c u m e n t n e e d be n o t h i n g m o r e t h a n a s t a n d a r d i z e d short s t a t e m e n t o f i n t e n t s u b m i t t e d w i t h the signatures o f the provider and the p a t i e n t (or a p a r e n t or guardian); it should include the p a t i e n t ' s date o f birth, sex, and address. Medical data and the m e t h o d o f p a y m e n t in the p r i m a r y care relationship n e e d n o t necessarily be o f a n y c o n c e r n to such a registry. Dr. Kahn is with the Department of Preventive Medicine and Community Health, Emory University School of Medicine, 69 Butler Street, S.E., Atlanta, Georgia 30303. 133

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For the purpose of this registry the provider might be a physician, a group of physicians, a hospital outpatient service, an HMO, or any other medical arrangement that offers primary care. There is no reason w h y a registered prima_ry care provider could not also have a specialty practice. But each provider would specify a limit to the number and type of patients to be registered for primary care purposes, e.g., 4,000 adults, or 30 children with renal anomalies, or 400 diabetics, or 1,800 fertile-age females. The registration process would be entirely voluntary. The registry arrangement would not prevent a provider from seeing unregistered patients for primary or specialized care, nor would a patient registered with one provider be prevented from seeking care elsewhere. However, no patient would be maintained on the registry with more than one provider at the same time. The mutual registration could be terminated at any time on the initiative of either the patient or the provider. Who should organize and operate this registry? One would hope that professional and consumer organizations alike would endorse and promote the idea of a primary care registry. However, the registry's administering body should not be identified exclusively with the interests of either the providers or the patients. The registry should function without charge to the registrants. The geographic region covered should be large enough to include most plausible provider-patient combinations, but not so large as to become impersonal and bureaucratic. I think the Health Systems Agencies (HSAs) currently being formed in accordance with the National Health Planning and Resources Development Act of 1974 might be ideally suited for this purpose. To the extent that the HSAs are concerned with the improvement of primary care in their respective regions, a registry of this sort might be an excellent project for them to undertake. The Uses and Benefits of a Registry E a c h major interest group in health care-patients, providers, and p l a n n e r s - c o u l d conceivably benefit from the development of a primary care registry. Once the patient has registered with a provider, he or she would have the psychological comfort of knowing that a physician or institution stands committed to providing primary care, at least within the provider's customary limits of availability and financial arrangements. For the patient who has not been able to establish such a primary care relationship, a well-publicized registry would offer the possibility of locating a provider whose list of primary care patients was not yet complete. The registered patient would presumably then have his or her medical history on file in a known location (with the primary provider) and could reasonably except that any other medical providers would send copies of their findings to the registered primary care location. Each patient could carry a standard wallet-sized card identifying his or her primary care provider for use in b o t h routine and

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emergency situations. The primary care provider could be called upon to serve as teacher, guide, confidant, and advocate whenever he was faced health care decisions. Certainly many of these benefits are available now to patients who already have the good fortune of being in a primary care relationship with a conscientious physician or institution. I suspect, however, that there are many more patients who have never known the confidence and continuity that good primary care requires. They may on occasion have received competent treatment for a cold, colitis, or carcinoma, b u t they are still floating on their own through our health care nonsystem because no one has specifically offered them the possibility of a committed, ongoing primary care relationship. A primary care registry would help both patients and providers to focus on this concept and its many advantages. The registry would offer providers an opportunity to analyze and to define their own practices. Although many providers would also offer primary or specialized health care outside the formally registered relationships, the registry would be able to describe in modest detail at least the core group of patients for w h o m the provider has accepted primary care responsibility. This information could serve as the all-important denominator that would make possible epidemiological studies and the auditing of ambulatory care outcomes. I envision a quarterly or semi-annual computer printout that would be made available to the providers, listing their registered patients and summarizing them statistically by sex, age groupings, and even by their zip codes. Among other things, this would facilitate the planning of screening programs and the ordering of supplies. Providers desiring a c o m m u n i t y advisory council or a lay review board would be able to use the registry to define the patient population eligible to vote and to serve in this capacity. On certain occasions a provider might request the printing of address labels to be used for a mailing to all registered patients or to a specified subgroup, e.g., all females over 30 years old. For those providers with primary care loads that had become too large or too ill-defined for optimal care, the registry might be one means for helping them to reduce their primary care commitments to a more manageable size. For the provider who desires a larger primary care practice, the registry could help him find new patients. For the health care planner and analyst, the registry would provide data on the demand for and availability of primary care services. Although a substantial fraction of patients and providers will probably choose to remain outside a voluntary registry system, the n u m b e r of patients awaiting entry into a registered primary care relationship could serve as a minimum estimate of the u n m e t primary care needs in a region. This unmatched population could be characterized by age, sex, and address, and thus guide the initiation or expansion of provider services. From an epidemiological point of view, the registry would make

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available a large non-redundant population, every member of which could be assumed to be under at least minimal medical care and observation. Relatively simple surveys could estimate disease prevalence or incidence with an e c o n o m y and accuracy rarely possible in most American populations. Diagnostic, preventive, educational and therapeutic supplies could be distributed more efficiently to providers for their registered primary care populations. The greatest benefits to be derived from the initial years of a primary care registry would most likely be motivational, rather than strictly organizational. The existence and promotion of a registry would encourage providers and patients alike to think more conscientiously about health care resources and their rational utilization. One might expect a reduction in patients' " d o c t o r hopping" behavior and their misuse of emergency and specialized facilities. Secondary and tertiary care facilities would be reminded to return patients to their primary care providers along with adequate documentation of their findings and treatment. New providers and programs would enter an area with a greater awareness of and sensitivity to the unmet needs in primary care. However, the long-range future of a primary care registry carries the possibility of clinical and administrative benefits as well. As social and legislative trends lead us to new forms of health care organization and reimbursement, the registry might be readily adapted to other purposes, such as computerized problem lists, prepaid care, or capitation schemes. At several levels then, a primary care registry could contribute to more efficient, sensitive, and equitable health c a r e - a goal held by most patients, providers, and planners.

A proposal for a primary care registry.

A regional, voluntary, registry mechanism is proposed through which any citizen could indicate his intention of seeking primary health care from a phy...
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