The Patient-Family Journey from Outpatient to Inpatient: Improving Quality and Safety With the Outpatient EMR and PCP Collaboration

The principles of the PCMH support the desired outcomes of healthcare reform. The shift to the PCMH, though, must be accompanied by successful support of primary care. We must eliminate or reengineer the numerous process barriers and competing demands that misuse the resources of primary care practices. Our current primary care resources are critically low, and their optimal use can be articulated by PCMH workflow analyses. This includes reviewing service areas, such as patient access improvements; prior authorization; prescription refill and referral management; care management; and primary care integration with behavioral health and pain management, among others.

A successful patient-family journey  

For a successful transformation of the healthcare system, we must look at the patient-family journey from beginning to end.

The journey begins at the primary care level, where the PCMH model can prove valuable. Each touchpoint experience throughout the journey can make all the difference for the patient’s outcomes. The journey must be streamlined through the use of technology, such as EMRs, as well as increased communication among healthcare providers to deliver value to all stakeholders.

PCPs should be the constant partner along the journey to ensure quality and safety of care. If a patient needs to go to the ER, for example, he or she should notify the PCP, who will alert the intake person at the hospital with details of the patient’s health history (via the patient’s EMR). If the patient needs to be admitted, the patient’s EMR should automatically be transferred to the admitting physician and nursing staff, who should also communicate with the patient’s PCP. This constant communication and regular use of EMRs throughout the journey can prevent medical errors.

Clinical and vertical integration of primary care through tertiary and quaternary care with a shared EMR and quality assurance platform is vital to the transformation of care. In addition, efficient and proficient systems investments and outcomes are required to improve our EMR tools and increase our ability to deliver the Quadruple Aim, including reduction in per capita costs.

Call to action for value transformation of healthcare 

The PCMH transformation of primary care will help eliminate the problem of patients who are medically homeless. Without a medical home, patients have no guidance to navigate the complex health system.

The call to action for value transformation of healthcare will yield benefits to all stakeholders and improve health outcomes in patient communities, including:

  • A deliverable, cost-responsible, and foundational best-care model
  • Improved patient-family journey and healthier outcomes
  • Improved quality and safety, while driving service and deriving value-based healthcare costs for the full cycle of care
  • Communication with the PCP and the outpatient EMR to reduce medical errors during handoffs throughout the patient-family journey


The redesign of value-based primary care funding will drive success. Innovation through PCMH and accountable care organizations is positive, embraceable, and deliverable, but it requires a properly supported redesign of primary care. We must disrupt the current conditions that are driving failure in healthcare to ensure the opportunity for success remains at hand.



Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy of Sciences. doi:10.17226/10027

Joint Commission on Accreditation of Healthcare Organizations (2012). Joint Commission Center for Transforming Healthcare releases targeted solutions tool for hand-off communications. Joint Commission Perspectives, 32(8).

Porter, M. E., & Teisberg, E. O. (2006). Redefining health care: Creating value-based competition on results (1st ed.). Boston, MA: Harvard Business Review Press.


David J. Badolato is founder, CEO, and board member of Life Laboratory; president of Family Practice Associates of Upper Dublin; and president of concierge medical services of Family Practice Associates of Upper Dublin. Dr. Badolato is a board-certified family physician and has been practicing in Fort Washington, Pennsylvania, since 1978.