The health care industry is making some great changes -- particularly noteworthy is the attempt at creating tangible ways of measuring the quality of care. Part of this is driven by the pay-for-performance mandate as directed by the Affordable Care Act (ACA). The other part is due to industry changes: Consumers are becoming more empowered, care providers are becoming more transparent, and options are widening for individuals. More importantly, if you are facing a life-threatening illness, you will want to make certain you are being advised by the top expert in your area of concern.
While I applaud the industry for attempting to create metrics to evaluate care, as a physician I'm disappointed so far. Someone anonymously once said, "convenience sacrifices quality," and I believe this sums up the health care industry's efforts to date.
Metrics as determined by well-meaning but misguided organizations like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are focusing on the wrong assessments. Many physicians and organizations are making the mistake of measuring operational and administrative goals such as waiting room times, quality of magazines in office rooms, and the length of an ER stay. These metrics do not provide any insight into how well a patient was treated.
Why the focus on operational metrics? Maybe because Yelp reviewers focus on magazine selection and waiting room times rather than physician quality, and operational metrics are the easiest to immediately identify and review. Most likely, though, it's an industry compromise: Health care providers have argued for decades that tracking individual patients post-treatment is costly and complex. So the compromise is to follow patients but focus on the easiest and most convenient metrics. The other argument is that existing attempts of quality measurement only provide a snapshot rather than a comprehensive report. For instance, The New England Journal of Medicine reports that "primary care physicians manage 400 different conditions in a year, and 70 conditions account for 80 percent of their patient load. Yet a primary care physician currently reports on as few as three PQRS (Physician Quality Reporting System) measures."
Metrics should examine medical judgment and determine the quality of the outcomes versus operations. Today, radiologists are judged on how quickly they sign off on a report -- not on the accuracy of the report. Likewise, surgeons are judged on whether they give patients antibiotics before an operation -- not on whether the operation should have occurred in the first place, or follow-up treatment. We should be focusing on analysis, further investigation, change of treatment, etc.
There are some organizations and governments doing it right by focusing on outcomes. Germany, for example, can not only determine the mortality rate for prostate cancer, but it also tracks numerous side effects of treatments such as erectile dysfunction and incontinence. Armed with this knowledge, German prostate cancer patients can weigh the pros and cons of various treatments and outcomes.
There is definitely value for measuring operational issues such as the comfort level of patients (magazines, wait time, etc.), but organizations need to leave that to the administrators. Quality care physicians should be focusing on medical judgment, gathering the right people and the right technology to identify and measure the metrics that truly drive optimal healthy outcomes.
Dr. Lawrence "Rusty" Hofmann is Chief, Interventional Radiology at Stanford, and Co-Founder of Grand Rounds
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