From the trenches of their small group practices, Michael Dohm, M.D., and Marilyn Haas have battled in isolation to start up and maintain programs to measure outpatient outcomes.
Theirs is a winnable, rewarding struggle, say Dohm, who is an orthopedic surgeon, and Haas, a nurse practitioner and outcomes analyst.
They have run unrelated outcomes programs for four years and are watching their ideas spread beyond their initial start-up groups into their communities.
But experts in the medical quality movement say comparable efforts to measure results in outpatient settings elsewhere in the country remain scattered, isolated affairs. "There are little onesies and twosies all over the place, but my gut is that's very tough sledding," says Michael Millenson, principal with the Chicago consulting firm William M. Mercer. His book, Demanding Medical Excellence, chronicles the history of the outcomes movement.
"Despite all the IOM reports, we need a cultural change, but it hasn't happened yet," Millenson says.
Carolyn Clancy, M.D., agrees. She directs the Center for Outcomes and Effectiveness Research at the Agency for Healthcare Research and Quality in Bethesda, Md.
With two Institute of Medicine reports focusing on the need for improvement in hospital care, quality is getting a lot of attention, Clancy says. "Patients are going to demand this more and more." Still, "there are some huge challenges to transferring it to the outpatient sector," she says. "Right now, most of the action is at the health plan and hospital level."
One of the biggest hurdles, Clancy says, is the low level of adoption of electronic medical records systems among outpatient practitioners.
Another problem is money. Health plans talk about quality, Clancy says, but they typically don't reimburse physicians for implementing and running outcomes assessment programs.
Both Haas and Dohm have helped establish outcomes programs in their practices by being proficient in computer technology, limiting the scope of their projects and, above all, being persistent with can-do attitudes.
"I think anybody can do this," Dohm says. "We just need to teach them how."
Dohm is a partner in the 10-physician Rocky Mountain Orthopedics in Grand Junction, Colo.
Haas works in the four-physician Mountain Radiation Oncology in Asheville, N.C. She is co-author of Outcomes in Radiation Therapy: Multidisciplinary Management,
a book based in part on her experiences running the Asheville outcomes program.
"You need just one champion in a group," says Haas. The rest, she says, can be learned.
Dohm traces the roots of his program to discussions in 1996 with his colleagues about outcomes measurements, discussions that a year later led to the formation of the Western Slope Study Group, a not-for-profit corporation that runs the outcomes program.
The program has grown to include participation from 16 of the 56 orthopedic surgeons in Mesa County (Grand Junction). But it was a struggle at first, Dohm says.
"I couldn't get anybody in this region interested," he recalls.
"They said: 'If we put any money in this, what do we get out of it? We're so busy anyway. We can't fill out all these forms, and our patients don't want to fill them out either."'
Undeterred, Dohm started the program himself, paying the $60,000 start-up costs for software and staff assistance out of his own pocket and narrowing the focus to only those needing total hip or knee replacements, about nine patients a day.
Patients fill out a 57-question survey form that is fed into a computer system developed by Cedaron Medical of Davis, Calif. The system records and analyzes the data, reporting metrics that include pain, infection rates and durability of the implants.
Western Slope patients are surveyed pre-op, post-op and at intervals of three months and one, two, five, 10 and 20 years, Dohm says.
Follow-up surveys are done either by mail or during subsequent patient visits.
Dohm says having an independent, neutral entity preparing the data is important to obtain physician buy-in. Physicians are identified only by an ID number.
"What I've learned is this makes everybody feel vulnerable," Dohm says. "We've worked very hard at being very confidential. The whole idea is we don't want to hammer someone for doing a poor job because most people are doing a good job. We want the good people to do better."
So far, the group has used the surveys to compare the effects of two post-operative rehabilitation techniques to prevent blood clots. One uses a $75-a-day machine to bend the patients' knees, while the other employs conventional movement therapy.
"We looked at this device and found out after three months it didn't make any difference," Dohm says.
The program, which costs about $110,000 this year, including outreach and educational conferences, is funded through grants from the American Academy of Orthopaedic Surgeons, aid from two local hospitals and Grand Junction-based Rocky Mountain HMO.
The HMO also agreed to release 30% of physician withholds, or about $3,000 per doctor, for the program's early participants. A broader incentive program is being discussed with the HMO, Dohm says.
Additionally, the HMO is using the Western Slope program as a model for a similar outcomes assessment for clinical depression, according to Lori Stephenson, the HMO's director of quality improvement.
Haas, who has master's and doctoral degrees in nursing and a master's in nursing education, learned as a graduate student to use the powerful statistical analysis software program made by SPSS of Chicago.
But Haas says her clinical experience was even more important in setting up her outcomes program, which measures results from nine cancer treatment regimens.
Under Haas' system, physicians, nurses and patients fill out paper forms that are fed into an optical scanner.
A character recognition program, Autodata, reads the forms, and Haas uses SPSS to analyze survey results.
Since the program began in 1997, approximately 1,000 patients have been surveyed. Around 95% of them continue to fill out the surveys through the one-year interval, Haas says.
Haas says she estimates a practice could replicate the hardware and software they use today for about $18,000 to $20,000.
Annual operating costs for the program are about $3,000, she says.
An Asheville hospital, St. Joseph Health System, is using the Mountain Radiology program as a model to measure weight maintenance and pain relief in mouth cancer patients using a pain-killing tetracaine lollypop.
Planning, Haas says, is key to starting a successful outcomes program.
It begins with physicians researching, developing and agreeing on treatment protocols based upon their training and the medical literature.
"From that, you develop a survey so you put into practice what your guidelines say," Haas says. For example, she says the group decided on a range of 30 to 33 treatments for one type of cancer "because we took into consideration everybody's training."