A pair of conflicting viewpoints published in the Annals of Family Medicine have highlighted the debate around quality reporting, and whether such reporting actually improves health outcomes and makes doctors better at their jobs.
David R. Scrase, MD, who works in internal medicine and geriatrics at the University of New Mexico Medical School in Albuquerque, contends that quality reporting made him a better doctor, although he said it's important to understand how to make quality reporting more effective.
The first step, said Scrase, is simply to assemble a group of physicians to agree on the current standard of care, as there are divergent guidelines for a number of scenarios -- how often a mammogram should be obtained and by whom, for instance, or the appropriate age range within which a patient should be screened for colon cancer. The U.S. Preventative Services Task Force criteria are a good place to start, he said, but face-to-face conversation on the matter is key.
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Subsequently, it's important to ensure the quality measure and its definition are configured properly in the electronic medical records to match the criteria agreed upon by the physician group.
Scrase is also a fan of arguing -- as long as it's constructive.
"When we start arguing about the data, we are halfway there," he wrote. "There simply is no route that can take us from 'no data' to 'good data' without passing through 'bad data.' There just isn't. Instead of rejecting the 'bad data,' those of us being measured must help those who are doing the measuring become more accurate."
Errors are gifts, he said, because they can help improve the reporting process. Erroneous patient names, birth dates or provider names must be fixed, every error repaired, so that the reporting algorithms can continuously revised and improved.
But the main reason why quality reporting hasn't yet won the full respect of physicians, in Scrace's view, is because the data that's derived from this approach has to be actionable. In taking these steps, he said, quality reporting can improve health outcomes and the financial performance that goes along with that.
David L. Hahn, MD, isn't convinced.
Working in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health, Hahn said quality measures have limitations. They use disease-oriented rather than patient-oriented measures, he said, and the benchmarks are arbitrary.
Hahn said incentivizing performance over informed patient preferences can force clinicians to choose between providing top-notch, personalized care, or being paid equitably. Therein lies a conflict: choosing good medical practice versus giving patients what they demand in order to increase patient satisfaction scores.
Also, he said, the measures are based on opinion, not evidence. And the benchmarks that determine rank performance are largely arbitrary, an approach that inevitably leads to gaming.
Quality assessment, in Hahn's view, should focus on the shared decision making process, in which the clinician offers options to the patient, and the patient then makes the choice that is best suited to them. He said a conflict of interest exists for clinicians practicing in settings that link the achievement of arbitrary benchmarks to clinician pay.
He also thinks quality reporting can be a contributor to burnout.
"I wonder to what extent clinician burnout may be attributable to knowing that one is being judged unfairly by metrics that undermine effective practice," write Hahn.