Redefining quality through a patient-centered approach

Ask any physician what quality is, and you’ll get many different answers.

You will hear answers such as “finding a cause for their pain,” “ruling out a life-threatening condition,” “partnering with patients to improve their health” or “offering the most evidence-based and up-to-date medical treatments.”

Here’s what quality isn’t: Running a bunch of useless tests, prescribing non-evidence-based medicines, or spending hours on documentation in an EHR.

Therein lies my frustration with the government’s (and insurers’) de facto definition of quality. It’s a frustration shared by most physicians, who are rightly cynical with “metrics” and programs that seem like an excuse for using data to pay less, not to improve the health and wellbeing of the patients we care for. And, frequently, the metrics themselves are meaningless. Recently, the American College of Physicians analyzed 86 performance measures included in Medicare’s MIPS and Quality Payment Program (QPP) and found that 32 were valid, 30 were not valid, and 24 were of uncertain validity. Of the 30 measures rated as not valid, 19 were judged to have insufficient evidence to support them, with inadequately specified exclusions, “resulting in a requirement that a process or outcome occur across broad groups of patients, including patients who might not benefit.”

One of my biggest issues is with the metric of “patient satisfaction.” As Dr. Rummans noted in her 2018 report, “How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis,” the financial incentive for both doctors and hospitals to have high patient satisfaction scores only escalated the growing opioid crisis. When reimbursement became tied to patients’ perception of pain control, increasing amounts of opioids were prescribed, which led to dependence.

As this example illustrates, what started as good medicine to help patents is now a mess of bureaucracy, questionable motives and potential patent harm all in the name of quality.

And don’t even get me started with EHRs and the “meaningful use” program! We are now tied to these expensive tools designed for billing and tracking “quality metrics” rather than helping to care for patients.

My friend Dr. Gene Quinn, medical director of quality and population health at Alaska Heart and Vascular Institute, puts it another way.

“Quality is well defined, but hard to measure,” says Quinn. “Quality metrics are the tool that helps us measure the abstract concept that is quality. The side effect of this misunderstanding is that people think that changing the metric is the goal of quality improvement. This is wrong.”

So once we realize this, what do we do? How can we make our patients healthier — without draining the system that feeds them? And how do we do it in a way that does not burn out physicians?

First, we need to redefine the term “quality” so it aligns more closely with the latest evidence-based medicine. Quality may mean giving the right antibiotics in a timely fashion to a patient with sepsis, but may also mean not giving antibiotics at all because the patient’s sore throat is likely from a virus.

Second, we need to look at how technology can bring meaningful data to the bedside. We need to explore new ways to use the tools and resources at our disposal to point us in the right direction, to deliver high-quality care while being mindful of value. Amazingly, one of the most useful tools I use does not help me “check a box” toward more meaningful use but gives me transparency into a patient’s ED utilization patterns (so I can see if a patient is frequenting emergency rooms or has unresolved issues). The tool, a network that connects me to other providers in other states to share data, cuts through the noise of multiple notification systems and gives me exactly what I need when I need it.

By having the information I need when I need it, I get my time back and my patients’ time back. For example, if I’m treating a patient who has been seen multiple times over the course of a month in the state of Washington before landing in my ED, I’m immediately flagged. Having this one slice of their health information at the point of care may save hours of time and thousands of health care dollars when I’m trying to figure out what’s really going on.

Ironically this particular technology tool is not designed for cost or quality, yet has saved Washington State $33.6 million in one year, driving down opioid prescriptions out of the ED by 24 percent. That, in and of itself, gives me pause to how we define quality.

So with all due respect to existing quality metrics, let’s embrace real “value-based purchasing” and invest in innovative tools that cross systems to make it easier to care for patients. Let us create “quality” health care by building a system that puts the care of the patient, not the business of medicine, at the heart of all we do.

Anne Zink is an emergency physician. She is on the clinical advisory board, Collective Medical.

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