Performance measurement – what has it wraught?


Category : Medical Rants

Most readers know that I am obsessed with performance measurement and why it not only rarely works but often causes negative unintended consequences.  As I have pondered this question recently, computers cannot replace physicians as diagnosticians.  And the same misunderstanding of medicine that would advocate such a position drives the performance measure movement.

Physician decision making requires a complex weighing of disease severity, number of diseases, social situation, the cost of medications, the patient's desires and willingness to address issues and more that you can imagine.  To think that we can apply simple rules to such decision making represents an unjustifiable conceit that patient care is simple and can therefore be broken down into RULES.

The unintended consequences of this movement are many.  We now have nonsensical report cards and, here the author gasps, public reporting.  If we could define excellence, then public reporting would make sense.  But we cannot define excellence through rules that cover only selected diseases and only 1 aspect of doctoring.

How do we stop this madness???

Comments (12)

I work for a state agency.  In our system it has wrought a lot of unnecessary care, unnecessary lab testing, unnecessary medication.  The EMRs are reviewed by nonmedical people who generate negative reports on you if you haven't done the prescribed test at the prescribed time interval or prescribed the "right" medication.  No consideration give to lifestyle changes, patient desires, or any aspect of the "art" of medicine.  I admit–you get to where you comply with all of the nonsensical demands just so you won't get "dinged" and receive a "bad audit" and are asked to write a "corrective action plan" to show why you will never sin again.
I think it is a great training ground for Obamacare, it enables me to clearly see the future.

We are treating papers and computers more than patients; today, my emr screen was seizing and I ordered Ativan and it stopped. Patients on the other hand have good glucose levels with good GI/DVT prophylaxis while they lie intubated in 30 degree position with no foley and a pristine looking central line site as doctors are busy with the ipad fixing the I-patient. 

"How do we stop this madness???"
That's the question, isn't it?
As individual physicians, not much that I can think of.
Logically, we would expect our medical societies to address this issue in a reasoned, logical manner. I don't know about the ACP, but the AAFP has taken a profoundly anti-scientific stand on all aspects of health care delivery. They are enthusiastic promoters of P4P programs, and when questioned about it, refuse to provide any supporting evidence. Most of us just take this as another indication that they're completely owned by CMS and the large insurers.
So, I have no idea what to do.

I agree that we cannot do much individually. I also agree that this SHOULD be the domain of our professional societies.
Unfortunately, like the AAFP,  the AMA and ACC have also let us down. The societies today exist for their own purposes and not for the benefit of members. The AMA owns the CPT code system and makes more money from this behemoth than from member dues. The ACC is enthusiastically offering "products" (read $$$) to "help" doctors meet their performance goals.

It is beyond time for new professional societies to emerge that actually advocate for physicians involved directly in patient care. Perhaps one big "Society for Patient Care Physicians" that could involve everyone who actually sees patients every day, rather than the academic guideline and rule-writing "doctors" who dominate societies today.

A while back, UCSF did a very nice <a href=>study</a> highlighting the inadequacy of standard performance statistics in representing actual quality of care.  The study examines a time when colonoscopy screening rate was flagged by the VA system's performance measures as being an area of low adherence, but a closer look at the individual cases revealed that often appropriate clinical judgement had prevailed over the performance measure mandate, preventing unnecessary testing.  Quality of care means looking at how well we use a test rather than just how often we use it.    

Theoretically, there’s nothing wrong with the concept of performance measurement. It’s the execution that’s lacking. Given a bunch of diagnosticians, a ranking of performance exists – it just can’t be achieved by performance measurements programs in place. Same with computers replacing physicians as diagnosticians. If the programs were better, they could.

Actually we would have to imagine a computer that had cultural understanding, the ability to read body language, and an understanding of how to word the same questions to different people. I cannot imagine a computer that could elicit the data. It is not as simple as asking questions on a screen. It does require a human touch.

As a patient, I agree with the comment of another AL doc and think this would be more beneficial for patients as well.  While it is interesting to read when allowed some of the rules and guidelines, their is often a complete lack of information that is of value for patients.  Most professional websites have little reliable information for patients who are looking for reliable information.  If professional websites could have a direct link to "Patient Info" and then on this page have links to information broken down by subject or topic, much reliable information could be disseminated that could help patients rather than the partial information now provided. 

Maybe this is what is needed in an organization for doctors that actually care for and about patients.

Continually exposing  the flaws and lack of data and unintended consequences on the measures is the first step.  Unfortunately, the response from administrators is usually, "what is your solution to measurement and ratings then?" 
There is no simple answer.  it's complicated to determine what quality care is most of the time.   Focusing on outliers and leaving the rest of us alone?  I fear that doesn't give the measurement people the control they seek.   And it's all about control. 

'the response from administrators is usually, "what is your solution to measurement and ratings then?" '
How about "We'll measure and rate docs the same way we measure and rate administrators . . . and lawyers . . . and accountants . . . and insurance CEOs . . . and . . . "  

 I think No consideration gives to lifestyle changes, patient desires, or any aspect of the "art" of medicine…..

This argument about the problems with performance measurement goes far beyond the medical field. I see it in all professions. In  my humble opinion (and possibly in large part from my practical experience) the problem is not performance measurement, but the fact that it's being used to measure people (to judge the doctors) rather than processes (to give the doctors and others in the field the feedback they need to continually improve patient and social outcomes).
Performance measurement is not meant to be a tool to judge people. It was actually designed as a tool to monitor process performance. Perhaps this is a point worthy of more discussion?

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