Measurement, a blessing and a curse


Category : Medical Rants

Our society has a measurement obsession. We rank sports teams, colleges, box office receipts, financial worth, and almost anything else that can be measured. Colleges work to improve their academic ranking in US News & World Report. Hospitals brag about being in the top 100. We strive to succeed in the area being measured. Albert Einstein had this wonderful quote about measurement:

Not everything that can be counted counts, and not everything that counts can be counted.

I consider myself partially responsible for the P4P crisis. I have participated in studies which examined “quality” as measured by adherence to performance indicators. While I am a minor player here, I have published literature on this “problem”.

Why did we do this research? We (and the many other investigators in the field) have a legitimate interest in how we can help physicians take better care of their patients. We designed studies to help physicians improve on this dimension of care, fulling understanding that medical care has more than one dimension.

This blog entry from 3 years ago addresses the same problem in a different field – An Obsession with Measurement

Tom DiMarco once said, “You can’t manage if you can’t measure.” And without a doubt quantifiable measurements are invaluable tools; they provide objective proofs of progress and success, as well as early warning of impending failure. Processes that are founded on measurable objectives are almost always more efficient and effective than processes that are not. In a society founded on scientific values, it’s unsurprising that measurability is often insisted upon by many managers.

The problem is that many valid and important objectives may be inherently difficult to measure. “Provide an excellent user experience” is one such objective, so is “improve programmer productivity”, “increase the sense of community of our website”, and “improve employee morale”, for example. Yet rather than leave these important issues to softer evidence, often people will try to graft numbers onto the objective (efforts in software metrics, starting with counting lines of code, come to mind) or will just ignore the objective outright (especially if their incentives favor maximizing the quantifiable objectives). But now we’re starting to look like that drunk under the street lamp; we’re carefully measuring the wrong thing, just because we figure that somehow measuring something will be better than having no measurement at all.

That isn’t necessarily the case. A programmer whose pay depends on how many lines of code he cranks out will write sloppy, inefficient, overly verbose code just to crank up the line count. A UI designer who will be fired if his interface doesn’t start “passing” more in-lab usability tests will inevitably design for the novice users in the lab, probably at the expense of any other usability objectives. These examples of “metrics that miss” can be more of a curse than a cure for the project as a whole.

What’s perhaps most frightening about all this is that any objectives that have to do with values or ethics are frequently notoriously unmeasurable. And they might be the ones that are most unsafe to ignore.

So what’s the solution to all this? Only to think carefully about what exactly your metrics are measuring, and to not be afraid of techniques that yield softer evidence when quantifiable metrics just won’t do. A quote attributed to Albert Einstein goes “Not everything that can be counted counts, and not everything that counts can be counted.” Better light won’t help you if you’re looking in the wrong place.

I believe these words apply to medical care. This Thursday I will be speaking at a conference which is highlighting the problem of performance measurement in patients with multiple comorbidities. One message which I will highlight is the problem that this rant highlights. Even if we can measure things perfectly, we may not improve medical care. Our challenge as physician leaders is to take this complex concept and make it understandable by those obsessed with measurement.

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Comments (3)

As someone whose career had been about healthcare measurement for so many years I had to smile when I read your words about the softer side of measurement. I “crossed over” to the other side (the softer side as you well describe it) when I began a CKD early identification and management project about 18 months ago. I had convinced the physician leaders to implement the CKD model and to begin evaluating the 40 or so primary care physicians’ compliance with K/DOQI guidelines for treatment. I built templates in the electronic medical record to facilitate compliance with treatment algorithms. I had meetings and “lunch and learn” sessions. I required the inhouse labs and the external national labs to print the K/DOQI kidney disease stage information on the lab results whenever eGFR was less than 60mL. We thought we had included everything to give the physicians all the tools necessary to support decision making and guideline compliance. Then we would start to measure, compare and reward.

But what we learned very quickly was that our patients really controlled the outcomes and the measurements. If the patient learned that he had a reduced kidney function and was able to enter a comprenhensive patient education track for his “stage” and his co-morbid conditions, we could “see” improvements in lab values and compliance. If the patients were left alone to navigate multiple conditions with medications and dietary restrictions(sometimes in conflict with each other) and not offered any organized support, lab values declined and compliance was compromised. Individual physicians could follow the treatment guidelines and treat the patients uniformly, but the patient outcomes for these patients with chronic disease were certainly not consistent.

So, our plans for measurements and compliance with CKD guidelines as one component for P4P for the primary care physicians were scrapped. We began to look at our results differently. The process now includes what tools and support are offered to the patient and his family. We now take team responsiblility for the numbers; cardiologists who order a chem profile to check potassium levels do not ignore a low eGFR and expect the primary care physician to see it in the electronic medical record. A high A1C generates a flag to all physicians, not just the primary. A nurse in the lipid clinic can ask the patient about all of his “numbers” and will expect to update the electronic chart and the paper wallet card with the latest lab values. The performance measure is no longer the burden of the primary care physician or the specialist. We are trying to improve the medical care for these patients who have the good fortune to learn through screening that their kidney function is reduced. We hope our model will provide evidence that early identiification of compromised kidney function prevents or delays CKD in patients with comorbid conditions. And yes, we do hope that our primary care physicians and the specialists use the tools we are providing to them improve medical care for these patients. And when P4P comes up in the discussion again, I think we will focus on the process and what was offered to and done for the patients with chronic diseases, instead of the plotting graph of lab values.

Sorry for long comment. I just wanted to say that I now practice from a new place and agree with your observations.

Thank you, thank you, thank you!!! This is what I’ve been trying to say with all my P4P rants — but with far less eloquence.

Thank you!  I'm speaking this week at the Colorado OT Conference and found this very insightful.  As an occupational therapist in acute care, I value both the science (measurable) and art (not-so-measurable) of my profession.  It's good to see that this struggle is shared amongst many medical professionals.  

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