Physicians need to compare themselves with their peers

Imagine that an innovative health plan – aware that half or more of health care cost is waste and that physician costs to obtain the identical outcome can vary by as much as eight fold – hopes to sweep market share by producing better quality health care for a dramatically lower cost.

So it begins to evaluate its vast data stores. It’s goal is to identify the specialists, outpatient services and hospitals within each market that, for episodes of specific high-frequency or high value conditions, consistently produce the best outcomes at the lowest cost. Imagine that, because higher quality is typically produced at lower costs – there are generally fewer complications and lower incidences of revisiting treatment – the health plan will pay high performers more than low performers. Just as importantly, it will limit the network, steering more patients to high performers and away from low performers.

Suddenly, it will become very important for physicians and other providers to understand, in detail, how they compare to their peers within specialty, and how to provide the best care possible. And if they find the results aren’t so positive, they may want to figure out where their deficiencies lie, and how they can improve.

Now imagine that clinicians could easily view data about their patients and themselves.

  • Basic demographics: e.g. age, gender, length of time since last visit.
  • A problem list based on diagnoses within the past year.
  • A list of medications prescribed, including ordering physician, dates and fulfillment information.
  • A list of lab tests ordered, by physician and date.
  • A list of immunizations.

Suppose the clinician could review, revise or copy this information to create a lasting “patient profile,” saving it online and retrieving it for use at each subsequent visit as appropriate.

Now imagine that this same Internet-based application provides a report based on aggregated patient claims data as current as 8-10 days old, and not just a single health plan’s patients, but from all payers. The kinds of reports or “dashboards” available would include, but not be limited to:

  • A count of patients with particular diagnoses or conditions, by provider.
  • A count of medications ordered, by most to least common.
  • A count of lab tests ordered, by most to least common.
  • Average number of visits per day, week, month.
  • Percentages of patients meeting targets for key metrics (e.g., blood pressure control, diabetes screening testing, smoking cessation).
  • Days before payment broken down by insurance companies and health plans.

Then add some basic clinical decision support:

  • Analytics to identify patients at risk for chronic diseases or major acute events during the next year.
  • Care gap analyses to create lists of actionable care items for each patient, based on the information in claims, drug, lab and electronic health records.
  • Artificial-intelligence (AI) driven diagnostic aids.
  • Best practice guidance.
  • Online, real-time access to all prescriptions previously filled by the patient, along with automatic drug interaction information.

Now suppose that each physician or clinician could:

  • Invite other physicians to provide their (de-identified) data to be pooled and compared with others in the pool.
  • Select benchmarks from local, state, regional, and national data sets to compare each physician’s quality, safety and episodic cost performance.
  • Start conversations and discussion groups with other physicians based upon questions raised by the data and its analytical indications: e.g., performance, the data itself, its reliability, evidence for higher or lower utilization, etc.
  • Begin to assemble the components of a “meaningful use” EHR technology suite that will meet the requirements for EHR incentive payments starting in 2011.

We could pose lots of additional “what ifs,” but you get the picture. Information is available now from clinical records, claims, drug and lab orders, and could be provided to all clinicians in a manner that:

  • When reported in the aggregate, is completely de-identified,
  • Is compliant with applicable privacy and security laws and regulations, and
  • Comes with an explicit invitation to make suggestions about how to improve the data’s quality, accuracy, currency and integrity.

We are very near to a ‘tipping point’ that will make physicians, medical practices, and provider organizations of all kinds very hungry for these kinds of data. There is growing pressure to control cost, both through reform and the marketplace, and moves afoot to significantly penalize physicians and organizations that have unnecessarily high costs.

In all businesses but health care, success is impossible without good information about customers and performance. By contrast, the combination of fee-for-service reimbursement and a lack of cost/quality transparency have let health care business achieve financial success, even when the business itself is oblivious to its performance. Physicians, hospitals and other health care organizations have made so much money, and have increased their incomes/revenues so easily by simply increasing demand, that rigorous monitoring of quality and financial status have been discouraged.

We believe that is all about to change. There is now evidence that health care purchasers (Medicare, health plans, employers, patients) have reached the limits of their capacity to pay and are “putting the money on the stump and running.” In most metropolitan markets, and to a lesser degree in rural markets, health care organizations’ efficiency and productivity will become increasingly critical to their survival.

As we run out of resources to spend on fee-for-service health care, the payment methodology will change to reflect selectivity in purchasing and contracting for services. Affordability and value will become more important than ever.

The government is leading the trend towards health care data collection and transparency of reporting. ARRA/HITECH and the Meaningful Use EHR incentive programs are notable for their emphasis on data collection for both performance and quality measurement.

When one of us (DCK) was in his early forties, he designed and taught courses on data and information management for Don Berwick’s Institute for Healthcare Improvement (IHI). Dr. Berwick was never a big proponent for computerization, but he was a stickler on data and its uses for understanding process and outcomes, and for guiding improvement efforts on a continuous basis. He believed strongly in comparing people, teams, and organizations in a collaborative fashion, and using gaps in performance as a stimulus to change for the better. Now he’s running the Center for Medicare and Medicaid Services, CMS. Chances are very good he’ll likely to continue to push for improved data.

We think it should be possible to create a multi-level offering of data, information, and EHR technology services to physicians and practices at a very reasonable cost. Every element in this article’s lists is not only imagine-able, but do-able already.

David C. Kibbe is Senior Advisor of the American Academy of Family Physicians and Brian Klepper is a health care analyst. They blog at Kibbe & Klepper on Health Care.

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  • justin

    sounds complicated and expensive. but I bet someone with a 4 year computer programing degree would be happy to take a share of the health care pie to help us stupid doctors with this computer system. health care is expensive because getting an MD takes at least eleven years, drugs have to be invented and tested, imaging and procedures aren’t free. if you want cheap health care, ration it…if you want good health care pay for it. pay for it like you pay $100 a month for your iphone and $300 a month for your new car lease. it’s simple. why do people think that complicating things will save money?

  • Vernon Rowe

    Before you advocate the lowest common denominator approach to healthcare, I suggest you question some of your assumptions.

    Overall physician income has not risen for many years.

    Hospitals spent $900,000,000,000 in building programs last year, in an arms race for amenities and equipment that is largely unnecessary. This generates beds that have to be filled and surgery and tests that have to be paid for.

    Rather than focus on a bean-counting approach to improving health care, I suggest we keep our eye on the ball and put patients first, rather than focusing on spreadsheets.

    Incentivize organizations that keep patients out of hospital systems, and give the money we save to health departments to enhance physician extender access for the needy.

    You seem to be more about making a more efficient iron lung than about attacking the real problem of overspending for healthcare. Institutionalization of information about mediocrity using computers does little to make that mediocrity better. It’s still garbage in, garbage out.

  • Ed Rodgers

    Over 40 years ago the Cystic Fibrosis Foundation formed a patient registry whereby which organizations providing care to patients with Cystic Fibrosis opted-in to providing the data. What happened was the average life expectancy of persons with CF went from the teens to now being 37+. The CFF encourages the best performing centers to share their best practices with the rest of the centers providing care. There will always exist a bell curve of who is the best versus who is a late adopter, but the science advances much faster through direct comparison and sharing of results. This to me has always been the best base case for demonstrating improvements in health care through the implementation of registries that compare physicians to one another.

    The current fee for service method of reimbursement offers no incentive for other physician specialties to follow suit. If a physician or practice has lower numbers published into the public, it will affect their patient volumes and their practices will dissolve. The best performing practices still have a limitation on the volume of patients they can see, so they will not be able to take on the additional volume. So until a pay-for-quality method of reimbursement hits the market, there is no incentive for care providers to compare themselves to one another.

    That said, there are plenty of new products entering the market designed to aid in the treatment decision process and to aggregate published data so that the best evidence based therapies are available to clinicians. So as you are proposing, there is an absolute need for systems that can look at the holistic view of care, capturing data, treatment interventions, and providing feedback as to outcome so that the way healthcare is delivered can evolve to catch up with technologies available.

  • SteveSC

    Your list is just not all that important to most practicing clinical docs. Take the first group: all are already in most clinical charts, and computerizing them currently takes way more time than it is worth.

    The second group, dashboards? Perhaps nice to have, especially for a practice manager, but not important on a day-to-day basis for patient care.

    Group 3, clinical decision support? Sounds nice, but nothing out there does anything but regurgitate standard (and often outdated) protocols. Where help is really needed is in the exceptional patient, the puzzler, not in the routine. These features will help cookie-cutter care docs and paramedical staff, but not most doctors.

    Feature groups 4 and 5 are again great for managers and bureaucrats, but not for practicing docs. Since this is the big sell on why we need EHRs, it is no wonder the front-line doc is skeptical.

  • r watkins

    “In all businesses but health care, success is impossible without good information about customers and performance.”

    Lawyers? Accountants? Other professionals?

  • Marc Gorayeb, MD

    It is the job of our medical journals to keep us apprised of the current thinking on best practices in medicine. This carrot-and-stick approach will cause practitioners to practice to the most lucrative guideline, and avoid alternative approaches – individuallized for their particular patients – that place their reimbursement at risk.
    A bureaucratic morass is growing, developing, expanding, because ideologues and bureaucrats aren’t interested in incentivizing individual patients to control costs for medical services and products. One tends to demand value for services rendered when one’s own money is on the line.

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