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New consumerism, technology will boost field
A decade after the birth of the accountability movement in health care, outcomes management remains in its infancy. Great strides have been made in developing quality measures and patient-oriented surveys, but incorporating those into daily practice is a challenge. Several leaders in the field of health care quality spoke to Patient Satisfaction & Outcomes Management about their vision of the future:
PSO: Many medical groups still don’t know much about their patients, such as how well diabetic patients are controlling their hemoglobin or how many patients suffer from asthma. With all the talk nationally about health care quality, do you see an evolution beginning in the average medical office?
Mark Zitter, MBA, president of The Zitter Group, a San Francisco-based education and communications company that focuses on outcomes and managed care:
"I don’t think we’re seeing a lot of change in the smaller or medium-sized groups that don’t have a lot of incentive to do something about [outcomes management]. Most of the larger groups are realizing they have to do something with this. We still have more medical care that we can deliver than payers want to pay for. The most palatable way [to determine appropriate care and cost] is to tie it to quality or outcome. As more and more organizations get the information systems in place, they can really manage what they’re doing. The places that can do that have an enormous advantage over everyone else."
PSO: In other industries, quality-based comparative information (such as Consumer Reports) feeds a consumer demand. That hasn’t happened so far in health care, where consumers rely heavily on interpersonal relationships to select their physicians. Will that change? What will drive the change in health care consumerism?
David Lansky, PhD, president, Foundation for Accountability, Portland, OR:
"It will change because the world is changing. It is unstoppable. In information-rich western nations, people are demanding information to make decisions. Every market except health care has become dominated by the decisions of consumers. It seems unlikely that this would be the one area where people would have no power to get what they want.
"If you believe, as I do, that outcomes are an expression of what people care about, once people have political and economic power to express their needs, they will use this information to make sure their needs are met. People don’t currently articulate their health care needs in the same words and concepts that we outcomes researchers use. We have to create a bridge between where people are today in the health care experience and the concepts of quality and outcomes that the gurus think are important. I think building that bridge is very doable. People care about the things we want to measure, but no one has given them information to say that’s how you should decide about where to go.
"There’s a huge amount of education that needs to occur before there will be public demand for outcomes information. I think it will be a 15-year or 30-year time frame. The analogy we often use is to the environmental or smoking awareness movement. It took a generation to change widely held assumptions in the public mind."
PSO: Gathering and analyzing outcomes information is still quite expensive and time-consuming, often requiring a staff person devoted to the task. How will changes in technology make it cheaper or easier for small group practices to take part in outcomes management?
Eugene Nelson, DrS, professor of community and family medicine, Dartmouth Medical School, Hanover, NH, and director of quality education, measurement, and research, Dartmouth-Hitchcock Health System, Lebanon, NH:
"Technology will change not only the practice’s ability to measure outcomes and track them, but will fundamentally change the nature of the doctor-patient relationship. For example, at the Spine Center at Dartmouth-Hitchcock Medical Center and the Nashua Internal Medicine practice that’s part of the Dartmouth Hitchcock Clinic, feed- forward information is becoming integral to the flow of the patient and the practice of medicine.
"When patients come in to be seen, they either complete at that time or have already completed a full functional, clinical and expectations health assessment. [The Value Compass tracks] clinical status, functional status, their expectations of care, their satisfaction of care, as well as cost-related information. The clinician and patients can plan their next step around the care regimen that matches the changes in outcomes that have been observed and the patients’ current status. You can very quickly understand and hone in on areas that could very easily be missed otherwise.
"Today’s technology has been scannable forms and laptops. Today and tomorrow, [the major tool] will be the Internet so the patient and the physician have the capacity to have a shared medical record. Part of the medical record can have modern, quantitatively-based measures of health status and health outcomes.
"The technology is moving very, very quickly. I can be on vacation or business travel in Boise, ID, and you might be my physician in Chicago. I can contact you via e-mail. Using the Internet, shared medical records, e-mail, and not far off, desktop-based interactive video, you can see what this can do to two-way communication and the doctor-patient relationship."
PSO: Physicians have been fearful of comparative information that may be misinterpreted or based on faulty data. Their concerns have been justified in some cases, particularly when improper sampling techniques are used. Yet consumers are most interested in the quality of care delivered by their physician, rather than by medical groups or health plans. Will physicians eventually be rated in report cards? Could such a trend actually become a harmful byproduct of "accountability" demands?
William F. Jessee, MD, president, Medical Group Management Association, Englewood, CO:
"Physicians have good reason to be wary of the process because good data (i.e. valid, reliable data on use, cost, quality, and patient outcomes) are exceptionally hard to generate and even harder to evaluate. The major problems stem not so much from sampling as from using data collected for very different purposes [usually for billing] for profiling and from the use of inadequate case-mix adjusting techniques to ensure comparability of patients across each physician’s patient panel. Second, there is a real and growing demand for this type of profiling on the part of the public third-party payers (Medicare, Medicaid, indemnity insurance, and managed care plans) and employers.
"Physician group report cards are already being used in some settings and individual physician profiling is increasingly common. While this trend is likely to accelerate, there is a growing awareness that there is a need for substantial improvement in the quality of the data generated for these purposes, and for advancement in the tools and technologies used to create such profiles. CRAHCA and MGMA have been engaged in several initiatives to improve the "State of the Art" in provider profiling.
"The lessons learned from our four-year Physician Profiling Study are being applied through our PSPA [Physician Services Practice Analysis] software. The Profiling Study data are also being analyzed to inform decisions on the design and development of new systems that can provide truly valid and comparable profiles. Data validity, reliability, and comparability must be thoroughly evaluated well before any publicly used profiles or report cards are constructed."