More on quality

I love the intellectual interchange between blogs. Matthew Holt has stimulated my thinking, and hopefully I have reciprocated. As he has updated his entry (with reference to yesterday’s rant), I will respond specifically to a couple of his points. His permalink is working now – QUALITY: Why doesn’t evidence-based medicine happen in practice? Now with UPDATE

… The “data” we do not have and the data that I was (obtusely) referring to earlier in this post was the data directly gathered about how physicians actually practice from their records. It’s the lack of accessible electronic records which stops us accurately understanding (and then managing) how practice works in real life/real time. Several medical directors of leading medical groups have been telling me for years that they don’t have an accurate picture of what their MDs are doing because they can only get statistical glimpses of their practice patterns at the end of each month. …

Oh but that we could fit medicine into databases with such immediate feedback. Unfortunately, we have two problems – cost and the extent of the task. The cost problem has two parts – the program and data entry. Having physicians enter data on their patients is not an intelligent use of their skills and time. In order to understand quality we would need such a large and broad database that data entry would take longer than patient encounters.

The extent of the task seems even more daunting. We can measure (and expect quality on multiple issues). Each quality measure has provisos which require additional information.

I understand the desire for real time feedback, but fear that the task remains beyond any reasonable solution.

… Part of the reason behind the UK’s investment in electronic records is the desire to get at the information source that is the everyday recording of clinical activity. If it’s achieved that huge data set will be used to both monitor medical care and assess what is the best evidence-based practice from huge data sets, rather than from chart abstracted studies done later. And eventually the one (practice) will be monitored against the other (evidence based guidelines)–something not all doctors will welcome.

Many physicians (and non-physicians) throw out the term evidence based guidelines as if one can develop a clear solution to medical issues. Oh but that it was that easy. Let me give an example that is close to my own interest – the management of adult sore throats.

Two organizations – the Infectious Disease Society of America and the American College of Physicians – have published “evidence based guidelines” on the diagnosis and management of adult sore throats over the past 3 years. These guidelines disagree in major ways. Unfortunately, many issues in medicine depend on one’s perspective. In the sore throat example, the answer depends on how one values symptom resolution as opposed to minimizing overuse of antibiotics. These viewpoints and their resulting guidelines both have merit. But which would we choose for our computer program?

While it is easy to criticize anecdotal information and experience, many medical situations do require judgements for which the data are either unclear or absent. We (physicians) must have the experience and skills to make reasonable decisions with patients. This requires more than formulaic care.

Medicare and many managed care companies do have programs which are encouraging physicians to provide higher quality medical care. Our research group studies different techniques for influencing care.

Fixing a single deficiency will remain easier than remedying broad practice. We can (over time) teach physicians to prescribe beta blockers after all MIs (although we do not know how to insure that patients take their medications). But most patients are complex and many have multiple problems. How do we influence physicians to care for those complex patients and address all the indicated quality issues? And remember time is limited both in the US and in Great Britain. Maybe we could make generalist care financially stable, encouraging physicians to spend enough time with patients to address the broad scope of issues.

But then I digress and start dreaming. But a man can dream!