Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals

Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges

You need a place of command and control

You need a horizontal platform from which to launch vertical weapon systems

Provide open scheduling.

Provide care management and coordination by specially-trained team members.

Use an EHR with decision support.

Use CPOE for all orders, test tracking, and follow-up.

Medication reconciliation for every visit.

Prescription drug decision support.

Implement e-prescribing.

Pre-visit planning and after-visit follow-up for care management.

Offer patient self-management support.

Provide a visit summary to the patient following each visit.

Maintain a summary-of-care record for patient transitions.

Email consultations.

Telephone consultations.

The development of care plans.

Enable Patients

Manage populations

Manage performance

Digitization & Interoperability

Identify gaps in care

Price / manage risk

Really engage your patients find out what they need and become very patient centered

Integrate value base purchasing with PCMH in your plan designee (understand what the buyer wants)

Stop teaching the past you are in a world of Data, teams, actionable information

Integrate Health and Sick care

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