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The PCMH Congress met for the third time in Orlando (Nov 3-5 2017); the program is catching on, there are now about 1000 accountable organizations of record, including ACA's and PCMH's.

The themes of the Congress are diverse, from operational progress in practice transformation; to the role of PCMH in MIPS and MACRA; to coordination and collaboration of providers. Even though provider support in the community is mixed, the presenters are enthusiastic and excited about practice transformation because of the palpable effect on patient and staff satisfaction. Interestingly, the practice transformation seems to occur in small practices, at least these are the presenters at the Congress, not the large integrated practices.

Of the many themes this communication will focus on, is the Quadruple Aim which is the addition of physician satisfaction as the fourth aim. "If the physician is not happy the patient is not happy".

Widely known, there is a major issue of widespread physician burnout effecting all specialties. The rate attested by numerous surveys approaches 50%. It is not surprising in a time of health care transformation, that the cooperation of providers, in this transformation, is less than is needed. In fact as accountable organizations have proliferated, there is the realization that formal accountable programs, incentive structures, and basic collegiality necessary for meaningful practice transformation that leads to the critical objective of cost reduction, has not happened.

The mantra of Value drives both models, whether payment or clinical. However achieving Value at the transactional care delivery level always runs into barriers. Physician burnout may be a core barrier to Value. Why? It is no surprise today that the dynamic information age drives disruption which is anathema to clinicians, conservative as they are. But this conservatism is necessary, consider how a bug in software can be reengineered, not so easily can a medical mistake be corrected. This pressure to be correct in diagnosis and to cause no harm in treatment is stressful. Adding cost evaluation as part of the care processes increases the pressure to not only perform, but to do so efficiently.

Unfortunately these new dimensions added to care processes are almost always handled by the provider in isolation from other providers. The new medium of communication is the health record, designed not for communication but for transmission of diagnostic codes to insurance plans. The to and fro normally important for sharing diverse perspectives to improve care processes and a variety of patient level techniques, is overlooked by patient level IT. Ask any provider how frustrating it is to go it alone with the many demands on their time, and one can see how burnout follows from the impossible task of knowing how to provide Value without the collegiality of many thoughtful clinical minds.

These clinical minds deserve an IT system that reflects the patient level diversity and variation found in normal clinical activity. If there is a spark of venturesomeness in clinicians, they need support from an IT system that captures variation at the clinical level. When communicated as part of a collaborative clinical practice, learning from this variation can be fun, and most importantly can promote provider crosstalk that will be an antidote to isolation that is probably the most significant hallmark of burnout.

It is clear achieving the Quadruple Aim has a solution that is almost too obvious; this would be to socialize clinical activities to make them fun again. The driver for this socialization is an enabling IT infrastructure that captures the diversity of information available from the provider network and the population level data from insurance plans. Creative clinicians in partnership with graphical IT specialists can make visuals of the clinical events and processes.

In short, realizing the Quadruple Aim and thereby fighting burnout needs only 2 features; provider collaboration and information transparency at many levels. As the mechanism of burnout is solved, so too are many barriers to Value removed.