So much data, so little idea of what to do with it

External reporting inspires improvement

No one would argue that the amount of data a hospital has to collect and report is significant, often duplicated, and never declines. But there are plenty of reasons why putting quality and patient safety data out there for public consumption serves the greater good. "There is a strong body of literature that shows providers and health plans use this information to drive quality improvement," says Lise Rybowski, proprietor of The Severyn Group and content manager for the Agency for Healthcare Research Quality (AHRQ) Talking Quality website (www.talkingquality.ahrq.gov). "Even if consumers do not look at the information, it impacts an organization or provider's reputation," Rybowski says. "There is always a level of competition, and they want to look good compared to others."

Providers have often balked at public reporting of quality data, particularly if it in any way identifies them. "But I think most realize now that this has real value, and I think pushback is declining," she says. Rybowski acknowledges that there is still argument over what is the right thing to report and how well it reflects the true quality of care. But data are improving — it's easier to pull information right from medical records, as opposed to claims data, which many dismiss as providing imperfect information at best.

There is no template for reporting that works for everyone, but AHRQ has developed a program for any who want a template called MONAHRQ (for more on the program, see sidebar below), which can be customized and is based on existing AHRQ tools. Rybowski says that many want to know if there is some list of things that makes for good public reporting that will positively affect quality of care and adequately inform the public. "The problem is that what is easy for lay people to use may be too basic for everyone. Abilities and interest varies. Some people may want more data than others.

There is also tension between what is useful to providers and what is useful for that lay audience. "Providers need useful measures and numbers," says Rybowski. "They want to know where the numbers come from and whether they are risk adjusted. But that's not helpful to most consumers. Some of that deep data wouldn't be helpful at all for assisting a consumer in making a decision."

The other issue is what to use for comparisons. One hospital may have multiple "like" facilities — academic should be compared to academic, but there are regional differences that matter, too, she says. An academic teaching facility may still want to compare with a community hospital in the same city because those facilities will still compete on some level, even though they are very different kinds of hospitals.

Among those who have studied the effect of publicly reported quality data is Judith H. Hibbard, DrPh, professor emeritus of health policy at the University of Oregon in Eugene. "There are plenty of studies that show there is no effect from publishing this data," she says. "But that's only true of the reports that are hard to understand. If you have a report that is not easily understood, it won't result in a change of behavior." What makes providers change their actions and work to improve quality is having the public have access to easily understood quality reports where someone can quickly and easily discern which are the top and bottom performers. "Most reports do not do that, though."

The reason why simplicity is not the rule, says Hibbard, is that providers push back. They want the data to be complex and reflect what they say is the true situation. But it is that very complexity that turns off the public and renders the information useless from both an informational perspective and as a way to improve quality of care.

Another example of bad reporting are sites that compartmentalize the data elements so that they can't easily be brought together. "People really want to know what is the best hospital," she says. "If you have safety over here, and experience over there, but do not show it in one place, it's not effective."

Perhaps the best comparative website Hibbard knows of is www.Calhospitalcompare.org, which is condition-specific, but also easy to understand. Hibbard also found in one study that people like to be able to look at a summarized report on a facility or provider. This can make providers uncomfortable, but it can also spur them to change behaviors because they know that there will be some sort of simplistic method of judging their performance compared to peers.

When gearing up to put your data in the public arena, Rybowski says to remember who your audience is. If you have multiple audiences, make sure that you address the needs of all of them. "If you want a way to help people choose a doctor or a hospital, you want to include measures that are meaningful for that," she says. "Providers will need far more information. But if you show people too much or make it too hard to find, they will give up."

You also have to understand that what your public thinks of as a quality measure may be very different from what your providers think. Be aware of those differences and provide appropriate information based on their needs.

Lastly, she suggests that organizations remember they have another audience for this information that is often overlooked: the media. They may not look at the same things or in the same way that the general public or providers look at the data, but they will look and report on what they find — or what they do not find.

"This is a way to show how you are doing, to differentiate yourself from others, and also a way to draw attention from your internal audience that people are looking at this data and you need to be working to improve it," Rybowski says. "This is how quality improvement happens. Focus on the things you will be reporting."

Hibbard says remembering who your audience is and what they want makes a difference. "If you are going to spend the resources on this, remember that it only works if you do it right."

For more information on this topic, contact:

  • Lise Rybowski, proprietor, The Severyn Group and content manager, Talkingquality.com. Telephone: (703) 723-0951. Email: lise@severyngroup.com.
  • Judith H. Hibbard, Dr.Ph., professor emeritus of health policy, University of Oregon, Eugene, OR. Telephone: (503) 233-2763. Email: jhibbard@uoregon.edu.

Program aims to promote quality data

For those who want to ensure that stakeholders and the general public alike have access to quality data, the Agency for Healthcare Research and Quality (AHRQ) has created MONAHRQ, a web development software package that hospitals, health plans and other entities can use to help create usable and meaningful portals for publishing quality data. The program uses hospital administrative data to compare quality in four areas: hospital ratings, utilizations, preventable hospitalizations, and rates of conditions and procedures. Most of the initial users have been state and local data organizations that provide hospital-to-hospital comparisons.

But the program, which was initially released a year ago, would be great for hospitals, says Anne Elixhauser, PhD, senior research scientist at AHRQ. "They could put their data into MONAHRQ and view hospital-level statistics. Health systems could use it to put all of their hospitals' data on a single site. And this is not just about transparency for the consumer, but a way to improve quality of care through public reporting."

Currently four states are making active use of the MONAHRQ program — Maine, Hawaii, Kentucky, and Nevada. Arkansas and Utah are on the cusp of making it public. Texas is evaluating the program now. Indiana and New York are making use of the program internally, and others may be using the program in non-public ways, too. But Elixhauser says they have no way of knowing who or how many might be doing so.

It takes about a day to go through the user's manual and generate a site at its quickest, she says. Most take a little longer. Those with questions can get technical assistance, often the same day as they pose a question, but "always within two." There are certainly organizations that will opt to build their own website, but in a time of tight budgets and limited time, this is a way to create and maintain one with minimal time and expenditure.

Elixhauser says they created the program after a hospital CEO in Chicago mentioned wanting to take quality data and make it publicly available. "But it took them a year and over $300,000 to put it together. And that was just one hospital. Around the country, there are so many others. But we had tools that were already developed. If we could put them together, we could help organizations who do not have the right personnel or the money to contract with programmers."

Visit the MONAHRQ website for complete information at www.monahrq.ahrq.gov.

For more information on this topic contact: Anne Elixhauser, Ph.D., Senior Research Scientist, Agency for Healthcare Research and Quality, Rockville, MD. Telephone: (301) 427-1411. Email: anne.elixhauser@ahrq.hhs.gov.