Most health care happens in primary care, yet it has the least capacity of any setting to understand who is cared for, for what, and how.
Fifty years ago, Dr. Kerr White demonstrated that most care happens in primary care and that many of the people it cares for are not seen elsewhere. Efforts to reproduce Dr. White’s study in 2001 and 2016 found that this pattern had not changed. We desperately need primary care laboratories, otherwise our care is guided and judged by evidence from other settings. The best primary care laboratories have been practice based research networks, but these are severely underfunded and do not often take advantage of the data sitting in electronic health records—data entered meticulously, laboriously, and faithfully by primary care clinicians who derive almost no direct benefit from this work.
The Center is leveraging its PRIME Registry, along with PHATE, as a research and development laboratory to better understand, improve, and support primary care.
Currently, PRIME data pulled from EHRs are being used to help develop quality measures that better capture the value of primary care and to make the case for why they should have priority over the hundreds of other measures currently in use. Those same data can help understand which quality improvement efforts are worthwhile and enhance patient care and population health. More meaningful measures are likely to result in outcomes that matter and help prevent physician burnout.
We are also exploring how these data can teach us basic things like how illness presents and resolves, which medications are most effective or dangerous in patients with multiple conditions, when influenza or coronavirus accelerates, peaks, and goes away, and whether current primary care payments support good care. While most primary care clinicians are not able to participate in PRIME, most are likely to benefit from what it teaches us.
A Primary Care QCDR
CPC+ individual submissions
MIPS Group Practice Reporting Option (GPRO) submission
MIPS individual manual and
Total MIPS and CPC+
submissions for 2017
Helping Practices Stay Viable
PRIME Registry was established by the American Board of Family Medicine (ABFM) in 2016. The ABFMis the only certifying board to run a Qualified Clinical Data Registry and did so because there was not already a resource to help small practices stay viable as reporting requirements ramped up.
A Research and Development Platform
PRIME has also become an important platform for developing and testing high-value primary care measures and getting them endorsed by CMS for MIPS reporting. It is increasingly an important research platform enabling primary care to tell its story about the epidemiology, quality, and effectiveness of front-line practices.
The PRIME Mission
With the PRIME registry, we aim to relieve burden, improve quality assessment/improvement, prioritize measures that matter, and attract resources to primary care sufficient to support comprehensive, relationship-rich care.
Enrolling in PRIME connects you to a network of like-minded peers, dedicated to improving patient health, addressing and reducing physician burnout, enhancing and improving the patient-physician relationship.
Some of our current collaborations include:
• American Medical Society for Sports Medicine (AMSSM)
• American Academy of Family Physicians (AAFP)
• AAFP Local Chapters
• Global Palliative Care Quality Alliance
• EvidenceNow Southwest
PHATE: the Population Health Assessment Engine™
True population health involves measuring and examining patients in a community context, but this can be difficult to do when simply comparing patient data. If we can attach geography to our patient data, then we can better associate them with the community in which they live. PHATE does just that…and more. PHATE is a population health tool commissioned by the ABFM and developed in collaboration with the Center for Applied Research and Engagement Systems (CARES) at the University of Missouri. With PHATE clinicians can gain a fuller understanding of their patient population in the context of their community. PHATE utilizes patient data from the PRIME Registry to assign a Community Vital Sign—a Social Deprivation Index score—to an individual patient based on Census Tract characteristics.Clinicians can also use PHATE to identify clusters of disease and poor outcomes in the community contextwith the Community Hotspots feature. PHATE is also useful in helping identify and address social needs—whether at the individual patient level, or at the community level. The PHATE dashboard provides links to local resources based on the selected census tract, or for a specified zip code.
The Robert Graham Center has developed a complete curriculum for PHATE.
Attend a Demo
The PRIME Registry team hosts monthly demonstrations of PHATE.