There is an information gap in the healthcare industry between what data providers could release on quality of care and what they do make public. Employers, insurers and some providers are attempting to bridge this gap through a variety of new efforts.
A decade ago, my firm asked hospital chief executives what quality measures they would most willingly release to the public. CEOs said if they released anything it would be patient-satisfaction scores. Recently we asked the same question again. Some hospitals pointed us to data on volume of procedures they had placed on the Leapfrog Group's Web site. Others referred us to individual hospital data that a business group or state provides in an online database.
"We saw this coming several years ago," says Joel Allison, CEO of Baylor Health Care System, Dallas. "We created a quality institute and appointed a research physician, David Ballard, to oversee quality research and improvement. The research that our physicians conduct on quality indicators at Baylor is published in our Baylor University Medical Center Proceedings and in refereed professional journals. Our goal is to make the performance of our hospitals transparent and available to our patients."
Annette Anderson, vice president for clinical outcomes and performance improvement at Texas Health Resources, Irving, says that her system has been focused on creating, with all other hospitals in Texas, the first state database that uses all 25 quality indicators promulgated by the Agency for Healthcare Research and Quality. Inquiries about THR quality measures are directed to the state site. System physicians are encouraged, she says, to use internal quality data when counseling their patients on possible outcomes of procedures.
Nationally, legal liability is often cited as a factor that keeps hospitals from releasing quality information to the public. Liability varies by state. Perception of risk varies by hospital.
Many providers say that local business groups affiliated with the Leapfrog Group have pushed them toward more disclosures.
Patient satisfaction scores are heavily discounted and often ignored by employers as trivial because the scores are based on perceptions, such as whether food is served at the right temperature or whether parking is adequate, rather than on empirical data such as the number of heart bypass procedures performed annually.
However, Brent James, M.D., executive director of healthcare delivery research at Intermountain Health Care, Salt Lake City, says patients tend to pay considerable attention to perception data in evaluating a hospital, especially on four satisfaction criteria: care and concern, information transfer, shared decisionmaking, and dignity and respect.
Employers, insurers and government agencies are looking for harder, verifiable, quality indicators such as use of a computerized physician order entry system, procedure volume, medical complications and infection rates. Meanwhile, the Centers for Medicare and Medicaid Services is looking at bedsore rates, reports of pain, weight loss and other factors in nursing homes. The CMS may move to hospitals next and publish selected rates by hospital on a CMS Web site.
Employers are aware of the quality information gap and seek to influence employee choices with provider-specific data. HealthGrades, associated with the Leapfrog Group, seeks to profit by selling exclusive rights for a hospital to publicize custom-analyzed Medicare data.
Healthcare organizations often limit release of quality data, whether outcomes or satisfaction scores, by saying that the consumer would not understand how to interpret and use the data. Nancy Foster, senior associate director of health policy at the American Hospital Association, cites a 1998 Journal of the American Medical Association study by Eric Schneider and Arnie Epstein as evidence that patients would not make decisions based on outcome data even if they had it. The study found that patients are more responsive to their personal physician's judgment than empirical performance data.
Consumers are using the Internet and learning more about their diseases, medications, actions taken against specific physicians by accrediting boards and medical errors at their local hospitals. In the past, consumers believed that all hospitals had equal quality but now they are learning that hospitals differ from one another in many ways, including costs and outcomes.
As defined contributions become more common, consumers will become more discriminating and want to see their doctor's and their hospital's report cards and will want to know what they will be charged for a procedure.
In the meantime, it is the insurers that are most interested in hospital and physician performance. In some cases, they give better reimbursement to those providers with the best performance records.
Many Web sites promise "quality patient care" but few provide a basis for that claim. Exceptions include Memorial Health Services, Long Beach, Calif., and Intermountain.
Intermountain's online 2001 annual report contains outcomes and performance data for selected programs. The system queries patients to understand what information patients find most useful and what types of information lead patients to be loyal. The findings are reported in an online slide show.
Five-hospital Memorial posts on its Web site and in its patient newsletters comparisons of its hospitals' rates with all hospitals' on complications for joint replacements, angina survival and other items. Clyde Wesp, M.D., medical director of MemorialCare, the system's benchmarking arm, started releasing data in 1996. He says there is risk in releasing data, but the risk is justified because physicians, nurses and employees work harder to get the best outcomes when they know data are being released.
Consumers should be able to get differentiating quality data from accrediting agencies.
But, click on "QualityCheck" on the Web site of the Joint Commission on Accreditation of Healthcare Organizations and you will find little to differentiate hospitals.
Employers, at once purchasers and patients, want healthcare organizations to do more than just provide data and information. They want providers to educate them on what the data and information mean and how quality can be defined.
The National Quality Forum is a promising voluntary group working to define quality by setting core quality performance measures for hospitals, such as one released for adult diabetes care.
Hospitals spend millions on advertising campaigns to distinguish themselves from competitors on services and technology. They promote with pride their valet parking and latest imaging technology but most say nothing about clinical or functional outcomes. Without meaningful education coming from hospitals, it is no wonder that consumers ask their physicians to help them make decisions. Quality is what every provider wants to be known for, but few will publicly define. One quality director told me, "It is much easier for hospitals to look good than to be good."
Ed Sellers, president and CEO of Blue Cross and Blue Shield of South Carolina, says, "There are two factors we take into consideration when contracting with a hospital. One is cost. The other is quality, whatever that is."
Educating the patient about quality and being good is not easy. We must know what each group -- physicians, purchasers, patients, nurses and others want as a quality yardstick. By bringing everyone into the discussion, hospitals will become less error prone, less costly, more competitive with purchasers, patients, physicians and nurses, and ready when a patient or newspaper reporter inquires about the hospital's performance measures.
Emerson Smith is a medical sociologist and president of Metromark Market Research, Columbia, S.C.