Patient Unfriendly Environments

Bridget Duffy is the "Chief Experience Officer" for the Cleveland Clinic and gave a presentation at the first "Gel" conference looking at the patient experience from a personal standpoint when she broke a leg and as she described "became invisible". You can see the presentation here (it is 25 minutes long but worth the time from a provider perspective as well as the patient perspective)

Bridget Duffy at Gel Health 2009 from Gel Conference on Vimeo.

And if that does not work click this link here. Fascinating insight that I can only echo from recent experiences that start long before any interaction with the hospital. Dealing with insurance coverage is an excruciatingly painful experience. When I called my local, friendly and most importantly the pediatric orthopedist who I knew and knew my family I discovered he no longer accepted . There a whole side bar here on why he would stop accepting an insurance but who wants to bet that it has something to do with the pain and agony his office has in getting reimbursed for care and the rates he is forced to accept with those patients.

So now the patient choice is to pay "out of network" or find another provider who you don't know and does not know you (and unless you are religious about collecting your medical records and imaging studies won't have the slightest idea of your medical history). Electing to save money means navigating through the the voice navigation system designed in hell for your insurance company to reach a human being to ask who in the nearby area takes their insurance. Does this feel like rolling the dice in Vegas to anyone else? I spend more time researching the hard drive upgrade for my PC than I have and can spend on where to go for my care. Imagine if you were buying a hard drive but although you liked the Geek Squad at Best Buy could not go there because they did not take your credit card - frustrating. But then again perhaps Best Buy would not want your business if when you bought the hard drive worth $100 but your credit card company actually only paid them $35....

Back to the orthopedic referral - now you have to call the office and spend 15 minutes redialing as the number is constantly engaged! I thought that problem had disappeared along with my Vinyl records! Finally you get through and must finish strong persuading the receptionist that you do need an appointment today. Not unreasonable having placed your 11 year old patient in a painful holding pattern over the weekend because you knew that marching off to the local ER was a gargantuan waste of time and resources and nothing would be done over the weekend anyway. This step alone saved the insurance company hundreds of unnecessary dollars of spending but will never be taken account of.

Does any of this seem broken to you - it does to me and as Dr Duffy explains some of these things are not difficult to fix. If the first things I heard when I attended a medical facility was concern for me and how I appeared to them vs the typical first interaction that is composed of data and financial gathering I'd already feel better treated.

What insurance do you have
or
What is your Patient ID

Hello.....!
Sadly few facilities are likely to find the money or resources to allocate to a CEO (that's a Chief Experience Officer) for their facility or being able to run a Code Lavender that delivers Spiritual Care, Counseling, and arrange of other holistic type support services to departments and staff alike but you can bet that they all need one. There are few I have visited that have the slightest inkling of the challenge patients face every day dealing with their organization. To be clear this is not so much an individual criticism as an institutional one.

Ask yourself this question

Can you facility pass the Mother Test: can you drop your mother at the door of your hospital and leave her there for a few days and know that she has been treated with compassion, care and understanding and will emerge happy and contented at the end of it

If you can answer yes - please tell use where this is so we can direct people to this facility. If the answer is no what can you do to fix this and what would make you feel comfortable with a facility that it would pass your mother test?

Ready or Not Electronic Health Records are Coming

The games afoot or as they say in England "Game on".....healthcare standards are published (actually the Notice of Proposed Rule Making NPRM - which can be found here) and supplemented by an article posted by David Blumenthal "Launching HITECH" posted by the New England Journal of Medicine.

As before there are multiple stages that include incentives linked to each of the stages but if we focus on Stage 1 that starts in 2011. This includes electronically capturing health information, clinical decision support for disease and medication management, clinical quality measures all tied with protection and securing of the information (don't forget liability for security breaches is now much further reaching). The investment is made (numbers vary but range from $14 - 27 Billion). To receive incentives providers must use their electronic medical records to improve the overall quality of healthcare delivered by demonstrating achievement of a series of objectives. These include (this is not an exhaustive list but captures the main elements):

• Entering orders, medications etc in CPOE
• Maintaining problem lists in ICD9-CM or Snomed-CT coding
• Maintain active medication list and electronic prescribing
• Recording vital signs, smoking status
• Receive and display lab results encoded with LOINC codes
• Generate patient lists based on specific conditions and generate patient reminders
• Provide patients with electronic copy and electronic access to their record and discharge instructions
• Generate a clinical summary for each visit
• Exchange clinical data with other providers
• Protect the information, encrypt it and record disclosures

There are others but these are broad categories and groups and represent a major push to genuine electronic medical records that are digital, contain useful data and are shareable between systems. Certification (as currently provided by CCHIT based on their existing criteria and what we know to date about the requirements for meaningful use) has 11 products certified for 2011 - list here. This is a work in progress and expect to see many more and probably other certification bodies.

The overall tenet of this initiative is summarized by Dr Blumenthal in his article:

...so as to reward the meaningful use of qualified, certified EHRs — an innovative and powerful concept. By focusing on the effective use of EHRs with certain capabilities, the HITECH Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters.

There are other strands/programs that are designed to address the obstacles to adoption - summarized in this chart from the NEJM article:




Behind the scenes the health information exchanges that allow for the easy sharing of clinical data between systems, clinical users and patients will be essential.

This is a broad set of criteria and for many clinical practices a long way from where they are now. The shape of this program is clear - sign up and participate now and receive additional funding/payment or wait and be punished later if you do not implement. There remain many challenges not least of all the products and expertise required to roll these technologies out but to me the message is clear - this train is leaving and failing to get on board will will cost you more in the future.

In the first instance we have an opportunity top provide input to the NPRM - the link for this can be found on the main page of the HHS HealthIT page here or the actual system here. Have you managed to wade through the 600+ pages or found a great summary of the content highlighting key aspects - share the knowledge, leave a comment with your thoughts and/or links and help everyone get up to speed with this material and provide input to the rule by the end of February 2010.

Time with the Doctor

Scientific American publish an article titled "Are Doctors getting slower or are patients getting sicker" that was based on a paper written and published in the Archives of Internal Medicine: Primary Care Visit Duration and Quality: Does Good Care Take Longer? Chen et al. Arch Intern Med.2009; 169: 1866-1872. (unfortunately subscription required). Apparently people are going to the doctor's office more often and for longer visits than 9 years ago. Whether this is because we need more medical attention or because there are more treatments available, the end result is the same as it is for imaging and radiology. Fewer resources spread over more work. In radiology the explosion of images (imagine the effect of single slice CT to 64 and more slices CT exams) has created less time to review per image for the number of radiologists available.

In medicine in general, if we the patient are consuming more time with more visits and for longer consultations - assuming the number of clinicians stays constant this should result in a decline in time per consultation. This represents a challenge in achieving the goals of modern healthcare

Two of the most pressing goals for the U.S. health care system are to deliver higher-quality care and to lower costs

Since most studies suggest that better care is linked to time spent with the clinicians - especially in complex cases. It turns out according to this study that

(they) found no evidence for the commonly held belief that physicians are spending less time with their patients or that quality of care has diminished

Time spent had increased from 18 minutes per consultation to 20.8 minutes. The investigators discount clinicians inefficiency as the reason for the increase:

Although it is possible that physicians are becoming less efficient over time, it is far more likely that visit duration has increased because it takes more resources or time to care for an older and sicker population

And while I think the complexity has increased in care delivery I think it is far more likely a combination of both (complexity of care and inefficiencies in the clinical care system) contributing to increase in time necessary to spend with the patient. Unfortunately much of this inefficiency is the new clinical systems and the complexity of capturing the information that has added significantly to the time required. No doubt we will see more studies that segment the time in more detail. In fact in some results published in this article in the Healthcare Ledger (Medical Transcription Relevance in the EHR Age - warning pdf) a study suggested that documentation time had quadrupled adding more than 110 minutes per day!

There is consensus on the value of clinical systems and digital information in particular the opportunity of providing more useful data at the time of the doctor-patient interaction. But it was clear from recent discussions that there is a divide in the way in which doctors and clinical staff should interact with these systems to capture and record information. There are those who view additional resources appropriate for assisting (Moving Transcription Back into the Hospital). And there are those that see a need for a change in approach and style to adapt to this process and incorporate into the doctor-patient interview. My own personal experiences support both answers. In some instances the interaction with the clinical system forces a change in the way doctors interact with patients and the process, work flow, methods and materials suit a new way of working. But in a recent experience at a clinician specialist's office (in this case a pulmonologist) it was very clear watching the interaction and in particular the flexibility and dynamic nature of the paper based note taking that any imposition of a digital system would not only slow the consultation to a grinding halt but would reduce the information captured dramatically. This is not to suggest that there is not (or will not be) a solution to this problem but the "standard" digital note capture system would be hopeless in this setting and be quickly rejected.

The comments to the article demonstrate some of the strong feelings - those of doctors overwhelmed with administrivia

Patients are NOT sicker and Doctors are slower, but only because of the inordinate amount of documentation required. My office note 40 years ago might have been: Sore throat-----Penicillin. We all knew what a sore throat was and that Penicillin was prescribed. In contrast Today's visit must include all vital signs, past history, a history of the presenting complaint, history of allergy, plus a rather extended physical exam, otherwise we do not get paid by the insurance companies or the Government. I used to see 50 or more patients a day and see them very well. Now, with all the rules I"m lucky to see 30 and am exhausted after doing so.
Dr. Michel Hirsch, FP, FAAFP (1967-present)
Donaldsonville, LA.

and the patients who feel they are getting less at a higher cost

I must live on another planet. Nurses have always performed all of the routine stuff like vital signs etc. I am 54 years old and have type 1 diabetes. I have never had a doctor spend more than 10 minutes with me, ever. It's usually 5 minutes and $70.

Both are right - doctors are required to do more in less time and patients are getting less. I like many others buy the vision of electronic medical records but perhaps not exactly as they exist today. The current large scale implementations and clinical systems struggle to account for the variations in specialties and their needs and while there is some element of best of breed approach many shy from this concept given the historical challenges of integration and intelligent sharing of information between systems from different providers. Things have improved - Healthstory (using HL7 CDA) as an example of an open standard that allows sharing of clinical data. This is a journey not a destination....and if there is a destination Ill bet that will be constantly changing! The challenge in the coming months and years will be guiding the beleaguered, over worked and underpaid clinicians through the maze of systems, their features and functions and helping them adapt their technology to their practice and vice versa.

How important is the digital record and if given the choice of doctors with and without what would you choose. For the practicing physicians that has an electronic medical record - is it a good or bad experience. For doctors still working in the paper world - can you see this changing or are your needs met currently and cannot be sustained in any of the digital models you've seen?

Moving Transcription Back Into the Hospital

What's old is new again......A recent article in USA Today (High-tech 'scribes' help transfer medical records into electronic form) highlighted the latest innovation in healthcare documentation - "High-Tech Scribes" who help "transfer medical records into electronic form. Is it just me or does that sound like something that is already going on in the electronic documentation industry with medical transcription and editing for the last 20+ years?

The challenge of capturing clinical documentation in digital format have remained the same and the continued struggle of adoption is highlighted by the poor adoption rate of electronic medical record systems

Today, only 1.5% of hospitals have a "comprehensive" electronic health record, and 8% have a basic version, according to Jha's March study in The New England Journal of Medicine. Most hospitals are intimidated by the cost, which can range from $20 million to $200 million.

Pretty poor given how long the industry has been working on this and despite the length of time still no clear exchange format or standard to facilitate the sharing of information

because there are no common standards for these records, doctors who do implement electronic charts may not be able to share them with a hospital across the street

But the value of digitizing medicine and implementing these systems has been clearly established and the terrifying level of errors that do occur as detailed in the landmark "To Err is Human - Building a Safer Health System" published in 2001 and many follow on reports and studies including he 2005 Health Affairs study that reported:

The country could eliminate 200,000 drug mistakes and save $1 billion a year if doctors in all hospitals entered their orders on computers

Despite these drivers we are still languishing in single digits of adoption and continue to struggle to roll out healthcare technology that effectively improves quality and safety without crushing efficiency and effectiveness of clinicians. So the University of Virginia Doctors elected to employ "scribes" to document the clinical encounter and these individuals such as:

Leiner, 22, a University of Virginia graduate who plans to apply to medical school

Who follow the doctors around and capture the clinical interaction on laptops. The consensus appears to be this will not catch on although a recent debate on the AMDIS list server offered some differing opinions that included some potential to reduce mistakes given the second set of eyes reviewing the documentation and the capture of the information real time with the patient. There is complexity in this approach made worse with gender conflicts (female patient and male scribe for example) but this approach appears to represent a modification of the current documentation process that uses dictation and transcription and perhaps offers some potential to free up clinicians to interact with patients rather than focusing on the clinical documentation and the electronic health record.

Moving the medical editor out of the bowels of the hospital just formalizes one of the well known methodologies in many transcription departments that attempts to link doctors to the same transcriptionists so they learn to "work together" (albeit remotely). This would make the bond stronger, the connection greater and the opportunity for error reduction using a trained and qualified "scribe" to document with the clinician. The medical editor is qualified, experienced and a highly knowledgeable resource that is currently disconnected from the clinical process.

Technology just becomes a facilitator in this process with speech understanding and speech recognition providing tools that can be used by one or both of the documentation team. The electronic medical record becomes integral to the documentation process. And although the real time aspects of alerts, evidence based medicine and the application of real time clinical knowledge to the interaction is still once removed from the physician the real time team documentation can provide direct access to the clinician through a combined approach to the capture and recording of the patient encounter.

How would you feel about a scribe being part of the clinician patient interaction - as the patient, as the clinicians or as the scribe?

Agreement on Healthcare Reform

The healthcare debate continues front and center with every last group weighing in on what needs to change, what needs to stay the same. In fact I'd be willing to bet that for every position in favor of change or status quo you can find the opposing view from another group.

But there are some core principles that I think some level of agreement:

• Elimination of Waste
• Improve Patient Care
• Care for Everyone (Life sustaining not lifestyle sustaining)
• No one should be bankrupt paying for Care

Based on a totally unscientific poll with friends and colleagues who represent from both sides of the aisle there was agreement with the above principles. No doubt the devil is in the detail but if we can agree on some basic principles and start with agreement rather than disagreement perhaps there is some hope for much needed reform of our healthcare.

Each of these issues is complex and as I wrote in my other blog on a recent incident involving abuse of services for a bee sting it may seem obvious in this case but the problems arise when you look at cases that are not so obvious. The level of waste is staggering - based on this report from Price Waterhouse Coopers:

more than half of the $2.1 trillion spent on healthcare every year is

This is spread across many areas and reasons why but as they point out in looking at one large facility - John Hopkins which is representative of the complexities facing the other 4,500 hospitals around the US:

About 700 different organizations, health plans, and employers pay the bills at Johns Hopkins Health System in Baltimore. Each one has different rules about what’s eligible for payment, how much to pay and when to pay....Reducing the redundancies could save the hospital more than $40 million annually, and that’s only “numbers we could identify if we could just get computers talking to each other”

This is basic stuff and these savings alone could go along way to help pay for some of the proposed reforms that, on principle, we agree are desirable such as care for all. In the words of one reporter in the UK: US Healthcare - the Biggest waste of Money in the World. I might not go that far but the idea we are getting any degree of value for money. What is interesting in the breakdown shown is the public/private split of payment


Interesting since in this view it would appear that the number in the US is skewed so high in excess cost because of the Private Costs. Maybe focusing on fixing the excess cost int eh private system might be a place to start on cutting waste.

I look forward to hearing the President's address and hope he can focus on the areas we agree on and set a framework that unites people to overhaul the system for the benefit of everyone.

What do you think - can you agree on the principles above or are these even subject to disagreement?

Rating Doctors

The blogs and twitters are alive with commentary both good and bad on the concept of rating doctors. It all seemed to be triggered by a NY Times article: Restaurants Brings Its Touch to Medicine that discussed briefly the concept of developing a ratings system for doctors.

Now the editors are asking people covered by one of the country’s largest commercial insurers to post reviews of their doctors and rate them in categories like trust and communication. As in other Zagat guides, the responses are summarized and presented as scores that, in this case, are edited by the insurance company WellPoint. They can be viewed only by WellPoint customers. The reviews are being introduced online to millions of WellPoint’s Blue Cross plan members across the country.

Many folks jumped in - I tweeted the article and Paul Levy Blogged the conundrum which generated a veritable avalanche of comments including my own both positive and negative. e-Patient Dave (I still have not received an answer to where he keeps his time machine to cram 33 hours into a 24 hour day!) weighed in

I don't know how it'll all shake out. Being publicly judged by others is challenging at first; I've come to accept that some people are crazy and there's no accountin' for tastes, let alone the variability of provider or reviewer having a bad day.

and the justifiable concerns (this from Lachlan Forrow MD FACP)

...but if we develop systems that make it easy for any unhappy patient to post for the world her/his unhappiness and name my name, that would be a serious threat to my morale, and while it might not make me actively avoid patients I thought might express their unhappiness (though it might) it would almost certainly have reduced my energy for actively seeking out “difficult patients” because I found the challenges and occasional rewards had satisfactions that outweighed the frustrations.

But I think anonymous said it best for me:

Ratings are coming: On the web nobody needs your permission or approval to set up a ratings system. If it seems unbiased, fair and rates the things people care about it will get traction.
Do you want to help steer the bus or get run over by it?

I agree and here is what I said

1. We have to start somewhere and adapt as we learn more about this concept
2. It is currently being done anyway and with little consistency or transparency
3. Like it or not much of the rating is about the overall experience, not so much the care or the doctor but the decor, cleanliness, friendliness & helpfulness of the staff, the quality of the food..... to quote a recent discussion with a specialist radiologists in cancer care "the value measurement has changed: it used to be measured based on whether you were carried out in a box or walked out, now we are so much better and more successful the measure of success is about everything else, food, decor, the linen"
4. Having seen some of the shocking comparisons of success/failure rates in different hospitals for the same conditions even taking account of a different case mix I would definitely want some indicator on quality/comparison to help make my choice for obtaining what I believe to be the best care for myself and my family.

So lets get over it and get the ball rolling - the beauty of rating systems is that the community is self policing and correcting. Outlandish claims that are out of sync with the majority are quickly identified and squashed and attempts to manipulate the system are discovered and exposed quickly.

Why Participating in Blogs is Important

I had the privilege of meeting e-PatientDave at the TEPR conference this week. He was there to bring the patient's views to this conference - wow - that's a novel thought! Getting patient input at a conference on healthcare......this does not happen often enough. It was a commanding performance and one that should have been videoed and then youtubed but I think he has this in the plan based on what I read.

He has his own blog(s) e-PatientDave and is of course on twitter and is an advocate for the inclusion on the patient in the care process (whew - two eureka moments in a single post!). He made many compelling points, delivered an emotional and riveting diary of his incidental finding of an especially aggressive form of Renal Cell Carcinoma that he fought and won. He joined an impromptu tweetup at the evening reception and continued to engage throughout the conference. Much of what he does is on his own coin and time and done with the attitude that given the history every second is a bonus.

A post from last month on why he loves participating in blogs and healthcare is descriptive and a great study of the relevance of this media to our future.....if you are not involved in this media the world is going to pass you by. This post linked to Paul Levy's "Running a Hospital blog that is definitely leading the crowd in communication and openness. He had cited the news of the day on "Check Lists" - I talked about this last year in this post - Simple things save lives crediting Peter Pronovost and congratulating him on his recognition as a newly inducted fellowship. There was a great article in the New Yorker titled "The Checklist" that detailed the concepts and the amazing results

Social media power. Connecting and engaging everyone. If you aren't on board you should be. Do you agree or is this just more "stuff" to distract us form delivering care - you tell me.

There are so many ways to participate and here are some of mine (it's horses for courses - pick the media you like):

Twitter
Technorati
RSS Feed - Speech Understanding
RSS Feed - Navigating Healthcare
Linked-In
Plaxo
Facebook
Digg
del.icio.us
Follow me on Twitter
DM Reply on the Twitter

Americans Pay More for Healthcare - But Why?

The McKinsey report "Why Americans Pay more for health care" (free registration required for access to full report) provides useful insights into the spending patterns and some of the underlying reasons for the high cost of health care in the US

While the higher costs is expected in part due to the wealth of the country:

Across the world, richer countries generally spend a disproportionate share of their income on health care. In the language of economics, it is a “superior good.” Just as wealthier people might spend a larger proportion of their income to buy bigger homes or homes in better neighborhoods, wealthier countries tend to spend more on health care.

Despite taking account of this the US spends some $650 Billion more than might be inferred from its wealth. As for the where this spending goes

The research also pinpoints where that extra spending goes. Roughly two-thirds of it pays for outpatient care, including visits to physicians, same-day hospital treatment, and emergency-room care. The next-largest contributors to the extra spending are drugs and administration and insurance.

But do we receive value for money - not based on outcome measures as compared to other OECD countries where we lag in many areas (more here and here where the US ranked last in a group of 19 countries). The report looks at possible reasons for the additional costs including the possibility that a less healthy population would mean higher treatment costs........survey said no.

So where does this additional expenditure go? Two thirds of this goes to outpatient care and while the US is doing well by shifting care and cost from in patient treatment to outpatient (and the legacy of President Bush's community clinic outreach has been a positive component of that as detailed here) this has actually added to the cost of health care in the US because of much higher utilization. Unfortunately not only was the utilization up but so too was the cost visit in part due to increasing use of expensive diagnostic testing (CT and MRI's being major contributors). The system is structured in such a way as to incentivize this type of care with the delivery of more services offered that are more expensive.

After outpatient care the next highest contributor is pharmaceuticals and not because of increased usage of drugs but because the mix is of more expensive and and the higher cost of drugs in the US

the price of a statistically average pill is 118 percent higher than that of its OECD equivalents

Even taking account for the possible explanation that the US pays more for a "superior product" and the high prices that subsidize the R&D for the rest of the world this still does not explain the large differential

But none of these factors, by itself, can explain the gap between the price of drugs in the United States and the rest of the OECD. When we adjust for US wealth, we find that the country’s branded-drug prices should carry a premium of some 30 percent, not 77 percent for branded small-molecule drugs.

Finally administration and insurance costs are the third highest but although these costs are significantly higher than other countries, the good news it

.....we find that given the structure of the US system, its administrative costs are actually $19 billion less than expected, suggesting that payers have had some success in restraining costs

The possible solutions are wide and varied but must involve all the stakeholders. Despite the high spend the US continues to lag behind in the general health of the population and as such "reformers should therefore focus on the preventative efforts" which represent a potential big win. Community clinics as supported by President Bush's administration are one such effort. In addition the consumer must be more engaged and informed and this requires the sharing of health care information that is structured so as to provide real information and not just make the medical haystack bigger. Technology plays an important part in the sharing of data and the ability to structure and make it available quickly and in meaningful ways to allow decisions and choices to be made.

Healthcare CIO's Grappling with EMR Adoption

SearchCIO online magazine ran an article on EMR adoption that made for interesting reading:

When patients, physicians and payers embrace the electronic health record (EHR), life will be different in pretty amazing ways.....For the first time, patients will be treated by a personal team of clinicians. When a new drug for hypertension comes on the market, all patients (not just Nobel laureates like James Watson) will be able to map their genotypes and phenotypes to that medication to determine if it's right for them. Hospitals will be held to the "perfect care" standard -- the elimination of all medical errors in instances of preventable harm.

Wow! But the problem is we are nowhere near the level of adoption necessary to achieve these kinds of advances and the barriers to adoption remain frustratingly present and challenging. Privacy, interoperability, liability issues and physician reimbursement are all main stays of resistance to the move towards wide scale adoption of the EMR. As expected there are some frightening stories to hammer home the point from an emergency room physician who estimated he treated 80,000 patients "with my own hands

...the thing that stuck out as he looked back on his career was how many times he was put in a position of "guessing over and over," "flying solo," in an information vacuum. In situations where people "die right in front of you," he said he often felt he was "one data element away" from stopping a patient from dying.

Needless to say there continues to be the naysayers who are convinced that physicians " know what they are doing; why do you want to tell them what to do" but in all this seem oblivious to the tsunami of knowledge rushing down the luge of clinical practice that is impossible to keep up with.

I agree with John Halamka

that the lives of primary care physicians -- snowed under by paperwork that does not require an M.D. but is required nonetheless, frustrated by prescribing a medication only to find out it's denied by the insurance company and terrified of making a mistake -- is sheer misery. He predicted they will welcome the help, and patients will be better off for it. As the system stands now, "all the medical students are becoming dermatologists," he said.

And it's easy to see why with the information overload with "medical literature published every month that is is more than a doctor could read in a year". Not to mention declining reimbursements and shattered dreams that litter the halls of our hallowed medical facilities. We need EMR's and EMRs need data to provide the decision support that an automated and optimized medical technology infrastructure can provide physicians in their daily practices. But all of this should not turn clinicians into data entry or data capture clerks - they are not good at this task and technology is available to facilitate this issue and provide clinicians with the tools to ease the burden and provide them with the necessary clinical decision support they want and need.

NQF Issue Brief on Measuring Elements of Care

The recently released issue brief from the National Quality Forum titled "Performance Measurement and Reporting at the Clinician Level" can be found here (pdf file) makes the case for clinicians reporting which like it or not is coming. While many resist and there are difficulties in comparing results in healthcare because of the many contributing variables to outcome it seems impossible for me to imagine the future without comparisons of quality by patients.

For heavens sake - I can compare the quality of a dishwasher, the performance of a store and customer service of a technology provider why should I not want or be able to compare the results of my hospital and clinical service provider.

It is important to remember a point I made before:

Millions of times each day, patients interact with the U.S. healthcare system. During these interactions, most patients receive the benefit of solid clinical judgment and technical expertise from their care providers and witness basic and state-of-the-art technology appropriately applied

And rightly they point out that

Current incentives encourage more care rather than the right amount of care

So the effort underway is to refine these measures to make them better and more helpful and specifically to address the charge of Apples to Oranges that we hear repeatedly when data is published showing poor quality in one institution over another. The current work seeks to address this:

Clinician-level measurement is undergoing refinement. The shortcomings of current measurements are driving concurrent efforts to more broadly define relevant, important, and measurable elements of condition-specific episodes of care and related accountability.

In the Charter they focus on the criteria and attributes that are desirable for measuring clinicians from a patient perspective:

1. Measures should be meaningful to consumers and reflect a diverse array of physician clinical activities.
   
2. Those being measured should be actively involved.
   
3. Measures and methodology should be transparent and valid.
   
4. Measures should be based on national standards to the greatest extent possible.
   

But to achieve this as they identify in their discussion paper (Rattray MC, Clinician Level Measurement and Improvement – Improving Reliability, Actionability, and Engagement, Washington, DC: National Quality Forum; 2008) and follow up discussions needs to:

Enrich clinical data. Accelerate efforts to capture relevant clinical data to augment administrative claims data.

To satisfy this need without weighing down the already over burdened clinician requires that this data is enriched as part of the clinical process and not by imposing new and difficult processes onto their current clinical activity. A recent example cited by one of my clinical colleagues had me truly surprised. In this implementation the new clinical system required the clinicians users to be shadowed 1 on 1 for 30 days to help them learn and use the system. If this is what is required there has to be something wrong with the approach and/or the system. Educators are told that if everyone fails their test on material they have delivered to their students then the chances are that there is a problem with the education method, format or delivery and not with 100% of the students. What is surprising to me is that a healthcare facility would consider the necessity to shadow clinicians for 30 days an acceptable aspect of any system..... and rest assured that the cost of this training must be an additional administrative burden on an already stretched healthcare system.

Enriching the clinical data is essential to our move to quality and getting maximum value from our stretched clinical dollars but we cannot capture and impose complex systems and requirements on clinicians to achieve this aim. Use existing processes, tools and resources that are already efficient and use technology to facilitate the enhancement and capture of this information. I am all in favor of new ways and technologies to be applied to healthcare and our lives in general but let's use what is in place and help improve efficiency without burdening the scarcest clinical resource we have - the clinical staff.