Tuesday, November 30, 2010

Two stories about transparency

Here are a couple of stories about transparency of clinical outcomes. I present them for your review and comment.

The first is one from the Los Angeles Times, entitled "'Error-free' hospitals scrutinized." Here are some excerpts:

California public health officials are scrutinizing hospitals that claim to be error-free, questioning whether nearly 90 facilities have gone more than three years without any significant mistakes in care.

Eighty-seven hospitals — more than 20% of the 418 hospitals covered under a law that took effect in 2007 — have made no reports of medical errors, according to the California Department of Public Health.

The high percentage has raised concerns that errors have gone unreported. Some patient advocates say it is an indication that hospitals are unwilling to police themselves. State officials have given hospitals until Tuesday to verify their records as error-free or to report errors, as required by law.

Next, a report from The Health Foundation in the United Kingdom. Martin Marshall, Clinical Director and Director of Research and Development, and the late Vin McLoughlin, Director of Quality Performance and Analysis, have published a paper called, "How might patients use information comparing the performance of health service providers?" It is on the BMJ website. They note:

There is a growing body of evidence . . . describing what happens when comparative information about the quality of care and the performance of health services is placed in the public domain. The findings from research conducted over the last 20 years in a number of different countries are reasonably consistent and provide little support for the belief that most patients behave in a consumerist fashion as far as their health is concerned. Whilst patients are clear that they want information to be made publicly available, they rarely search for it, often do not understand or trust it, and the vast majority of people are unlikely to use it in a rational way to choose ‘the best provider’. The evidence suggests that the public reporting of comparative data does seem to play a limited role in improving quality but the underlying mechanism is reputational concern on the part of providers, rather than direct market-based competition driven by service users.

. . . How should policy makers, managers and clinicians respond to these findings? Some might be tempted to suggest that we should focus only on those who work in the health service and discount patients as important stakeholders. We believe that this would be wrong. The public has a clear right to know how well their health system is working, irrespective of whether they want to use the information in an instrumentalist way. Improving the relevance and accessibility of the data should be seen as a good thing in its own right and may start to engage a large number of people in the future.

. . . That patients might want to view health as something other than a commodity presents a conceptual as well as a practical challenge to those responsible for designing and producing comparative performance information. We suggest that for the foreseeable future presenting high quality information to patients should be seen as having the softer and longer term benefit of creating a new dynamic between patients and providers, rather than one with the concrete and more immediate outcome of directly driving improvements in quality of care.


e-Patient Dave said...

I'll be really interested to see how this issue unfolds as Americans become more "consumerized" about healthcare, as they are about restaurants, cars, etc.

We (the outspoken, the empowered) are far from the majority today, but the colleague in your post yesterday Is this normal? is part of a growing breed.

Methinks this is the sort of thing where a critical mass will arise someday, when enough people realize that they've been severely and avoidably screwed (or "ruded"), and they don't have to take it anymore.

Ironically, this will be hastened as insurance premiums get inexorably higher while quality and service don't improve, so more people choose to punt the system or get priced out. (I'm not talking about Massachusetts here, but it's happening everywhere else.)

Look at the comment stream in today's post on e-patients.net about the President's Cancer Panel. A surprising number of uppity patients getting pretty disgusted at how the medical establishment still thinks patients aren't worth including in serious discussions. Interestingly, half the commenters are people we've never heard from.

My bottom line: at present patients may not have wised up to (a) their right to be respected and know their options, and (b) the fact that they're often getting shafted.

We shall see...

Anonymous said...

I may be acting as straight man, but your point is well taken, that transparency cannot be legislated but must be internalized as a cultural imperative. I am reminded of your 'creative tension within the organization' statement.
As far as the public, just because they are not looking at this stuff now does not mean they won't in the future. There is culture change to be internalized on both sides.


John R. Morrow said...

Oh my! Let's please leave British behaviour and the NHS out of our discussion. Their single-payer system allows little choice, and their 2-classe social system doesn't think much of patients' rights. Have you seen a ward in a UK hospital?
In the US hundreds of millions of consumers are looking at public comparative information, and despite the anecdotes from foreign lands consumers/patients are being felt and heard...like in a NY minute.
Finally who cares whether the comparisons motivate providers, purchasers or consumers...the transparency is being demanded and since we first started publicly benchmarking performance publicly all levels of quality, safety and outcomes have improved ratably. Sure there are some exceptions, but WE have come a long way baby. Our independence and American spirit make us more different than the rest of the world.
The British were great inventors, but their economy is more tourism (like France's is more agriculture) than the US service economy.
30 million American people a month search for doctor information in search engines...who do you think this is serving?
The Ratings Guy - Was CEO of the largest outcomes consultancy in the UK and introduced some of the first publicly reported safety and outcomes scorecards in British history.

Anonymous said...

In regard to zero error data, few hospitals ever measure error, and most do very poorly at measuring adverse events. Quality committees should ask for reporting data on a regular basis, and be glad when the numbers are high enough to suggest that providers care about improvement.

On external transparency: Patients will act like consumers when they pay for healthcare directly (see Herzlinger at HBS). As long as insurers and provider networks act as brokers, and the comparative costs of services are not transparent, the patient use of quality data to 'shop' will be limited. Patient use of the data in 2010 is one very limited outcome of transparency - improving quality is the most important. I have faith that a new generation of internet savvy patients are coming of Medicare age, and they already have 'Consumer Report Health' bookmarked on their browser.

Anonymous said...

e-patient Dave:
I agree the "outspoken and empowered" are the minority and unfortunately the medical community (not all but many) label those who are; which in turn is one of the reasons patients are afraid to speak up.

Look at the last post from Is this normal. An internist said “c’mon it’s eczema”….he/she clearly missed the entire point. In my opinion, c'mon it's eczema was quite shaming... I don’t believe the research fellow was looking to drive up costs but looking for a provider that he felt comfortable with and wasn’t “luke-warm”…..Patient satisfaction impacts outcomes and “compliance”. If it was just an easy case of eczema, a PCP is more than able to manage it but clearly it isn’t an easy case and likely something underlying the eczema and or a different issue altogether. In addition, had he gone to the derm that his PCP suggested it is possible it wouldn’t have been a right fit and would have sought another opinion…so, the cost goes up for a second consult.

My suggestion to medical providers that have a tendency to label and shame is the following: Give patients choices, be more caring in your contacts with patients, ask and truly listen and hear what patients are looking for; and remember that everyone will be a patient one day and as different and complex as you are as a provider the same will be true when you are a patient…Don’t use a “cookie cutter” approach….

Sjoerd van Belkum said...

Really interesting post. I'm actually working on a research project about the patient as a consumer.
I think it is really difficult for a patient to be a consumer and I'm actually thinking it is morally wrong to think they should be. Being a patient and being a consumer is something completely different. The BMJ article actually supports that view in a way. I'm not saying I am against informing patients and giving them a choice and listening to them, I'm saying a market system won't work in health care; there are other ways to reach these goals.

@ anonymous 1, at 10.39am: do you have a link to share to this view from Herzlinger? I think it is quite interesting what you are saying and I would love to see that data. I would be grateful.

Sjoerd van Belkum
the Netherlands