One of the greatest challenges when it comes time to affect major change in any system is figuring out who the stakeholders are, who has a vested interest in seeing a project rise or fall.

Without knowing who all the players are from the word go, there is almost no way to move things forward. But recognizing that we can’t keep everyone happy is also a big part of this process.

So to try to build a patient-centered medical home at an academic medical center, in a resident-based internal medicine practice, as we are trying to do, we needed to ask ourselves, who are the stakeholders? What do they really want?

Whose toes are we going to step on? Whose applecart are we going to upset? Who already has some other major initiative working that goes completely against what we think is the right way to go.

These are not easy questions to ask, nor are they easy questions to find answers to. But answer them we must.

So who cares if we fix this broken system? Who do we need to bring to the table, the leaders, team members, organizations, entities, groups?

The list seems almost endless. We can consider each individual patient, and each group of patients (for instance all patients with a certain medical condition, all patients with a certain insurance status, all patients from a certain neighborhood).

There are the insurers, the employers, the administrators, the hospital, the medical school, the medical students, the residents, the nurses, the unions, the vice presidents, the deans.

For everything we suggest as a way to bring about change, there is almost always somebody who thinks it’s just fine the way it is or has another brilliant idea about how things ought to be. How do we get all these disparate viewpoints together, on all the varied things that need fixing?

If we keep foremost in our thoughts, and at the top of our negotiation process, the ideal that we are trying to create a system to better care for patients, to achieve better healthcare outcomes, to provide more efficient and compassionate care, and ultimately to create a more affordable and survivable healthcare system, then perhaps we can move towards consensus on these matters.

Consider for example, the concept of access to care. Written in almost every description of a patient-centered medical home is improved access to care, nearly 24-hour access to one’s healthcare provider.

Is this feasible? Is this fair? Is this safe? Is this economically viable?

Perhaps as we and all the stakeholders come together to consider various models and options, we will be able to arrive at a better, a more equitable system to provide for access, while still allowing healthcare providers a few moments of respite and a little sleep.

The electronic health record we use at our practice has an excellent patient portal that technically fulfills the 24-hour access. It allows patients and providers to communicate electronically 24/7. Patients can request refills, see their test results, query all their doctors, request appointments, be active members of their own healthcare team.

But managing this system effectively and efficiently has been a challenge, with lots of bumps along the way. Patient expectations as to when they’ll get feedback need to be managed, and to providers it often seems like this is just one more set of messages they need to get to (along with phone calls, regular e-mails, walk-ins, and more).

And although 24-hour-a-day access seems like a great idea, everyone seems to have a different idea about what this means, and how to accomplish it.

Insurers, for instance, want to keep communication lines open, to prevent unnecessary use of the emergency departments for non-urgent/after-hours care. But who monitors the portal in the wee hours of the morning? And who provides the care? Residents might once have been the go-to choice, but they are limited by new duty-hours regulations, and mid-level providers are often paid hourly and covered by different contracts that hamper their availability and the scope of their practice.

Getting all the stakeholders to the table, and working out a model that satisfies all, is the name of the game, and a work in progress. And sometimes it feels like herding kittens. But not proceeding is not an option.

Fred N. Pelzman is associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.