I came across an article in the October 2007 edition of HealthLeaders Magazine on the issues facing hospitals around sharing their quality data:
"Reporting quality scores on certain core measures is common practice for hospitals, but senior leaders across the country are encountering mounting pressure from board members, regulators, competitors and customers to take their data reporting a step further: full transparency. Hospital leaders and quality departments meet regularly to debate the whys and why nots of such disclosure, but few have pulled the trigger. With a small but growing number of hospitals opting to report quality data on their own Web sites, however, that could be changing."
What are your thoughts on how transparent a facility/system needs to be? Can you think of valid reasons why a facility might not want to share its data?
The full article can be found at http://www.healthleadersmedia.com/magazine/viewmagfeature/content/92899.html
Kim
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12 comments:
I'm in favor of increasing patient information but I do see some problems with transparency. I think that different hospitals serve different populations and looking at indicators may be misleading. For example, infertility clinics are now required to post information about the success of in vitro fertilization programs. However,there are a number of factors that influence the success of an IVF cycle. For example, women are more likely to be successful if they are younger, have tubal obstruction rather than ovarian dysfunction, and have not failed on a prior cycle. Some clinics have strict exclusion criteria for women undergoing in vitro fertilization. By selecting a more favorable population of patients, the clinic can product more favorable outcomes. Patients may be unaware of selection biases that can influence clinic outcomes.
I would imagine that hospitals could face similar issues with patient selection. A hospital that serves a population with a high level of infectious disease might be more likely to report infections in their outcome data. It makes me wonder if patients will be carefully able to sort through hospital outcomes.
Increasing public availability and awareness of hospital quality records seems like a great idea. One of the most common catchphrases ways to describe and promote the US healthcare system is to bring up the notion of personal choice as a cornerstone of the system, and it follows that informed decision making should likewise be regarded as fundamental to the system. Creating a comprehensive and easily understood system to process hospital quality indicators seems imperative when viewed in this light, and it appears that the authors and contributors to the article view it as such as well. The problem seems to be in design and implementation.
I also agree with the article that there are serious problems that need to be overcome. As Laura mentioned above, I was struck by how hospitals could make attempts to improve their ratings by manipulating their patient base and changing the types of care delivered. Different populations and conditions have vast variance in outcomes entirely unrelated to the quality of a particular hospital or caregiver. In a system where hospitals already view uninsured and high-risk patients unfavorably, pressure to compete in ratings to attract new patients might create undue incentive to shut out populations most in need of care. This problem would be exacerbated in databases that are a compilation of several hospitals' ratings, whereas if individual hospitals were responsible for their own data you'd run into the problem of consistency and comparability between hospitals (which is almost the whole point). Also, creating a ratings system that is both comprehensive and comprehensible to patients or prospective patients is a difficult task.
As a consumer of health care, I am personally very much in favor of increased transparency. I want to know that I receive care in an organization that provides the highest-quality care. I can imagine that hospitals trying to make the decision for or against full transparency have many concerns about how publishing their data might affect patients' selection of hospitals for their care, since we are moving increasingly toward a market-driven system. It might seem like a daunting undertaking for an organization still in the earlier phases of quality improvement. A hospital might want to wait to publish data until they are performing as well as, or better than, their competitors so that they don't lose market share in the current environment, where payers and purchasers all want to get the best value for their healthcare dollars, and are using indicator data to find those best values. We touched on this in PH298.2 (Healthcare Quality, a phenomenal class that I highly recommend). A couple take-aways from our in-class discussion of this issue were:
1. Simply publishing performance data on quality indicators can improve scores - it has to do with accountability.
2. Availability of quality data doesn't necessarily mean that patients will leave for the hospital in the next town. Despite the increasing availability of consumer-level information about many aspects of healthcare, we currently aren't at the point where consumers are informed enough to make judgements about the best care settings based on indicator data posted on the web. In addition, with the way insurance works, people can't usually just pick any hospital they want -- they are sent to a hospital that has a relationship with their PCP and insurer.
My (probaly naive) hope is that whether or not the market drives publication of data, hospitals will increasingly decide to take on the administrative challenge of aggregating and examining the data, with the knowledge that this process has many positive results, including some "accidental" improvement on performance indicators. Since patients don't generally have full choice of provider organization, we all depend on hospitals taking on the challenge of publishing their data and their improvements. The tricky piece will be to identify the most relevant indicators and ensure that hospitals don't simply publish their best-performance indicators.
I believe that the move towards transparency is a good one because ultimately, it would help incentivize hospitals to achieve higher quality outcomes and help consumers make more informed decisions regarding their health. While changing hospitals may not be feasible for all individuals because of insurance parameters and location, the consumer can demand higher quality within their own system. As Maura mentioned, simply making the data public encourages accountability. I think it’s also important to note that more essential than simply having transparency is the validity of the data. Without appropriate population risk adjustments and adequate implementation of systems to accurately capture the data, facilities will be less inclined to share their data and consumers may be misinformed. Though the article makes a good point about making incremental progress and using measurements that do exist because if we wait until consensus is reached, the debate could continue for decades.
Great points everyone! I'm very much on the fence with this topic. I think that transparency can have both positive effects (in that it makes public areas for organizations to improve upon and pushes accountability to rated organizations to make improvements) but in some cases can be negative or useless. In different class projects I've looked at various rating methods and many of the published metrics are hard to comprehend for someone like me who knows more or less what the lingo means. I find that many of the reporting is either too simplistic (using red,green,yellow to represent scores but failing to explain exactly how a score is obtained) whereas other are fairly complex and require a high level of health literacy.
On a similar note a really neat article came out a week ago http://www.usatoday.com/money/industries/health/2007-10-21-wellpoint-zagat_N.htm?csp=34 that talks about physicians being rated by Zagat (the same ones that bring us our restaurant ratings). A part of me is really happy that mainstream trusted rating organizations are beginning to get involved with the health care market (as it could lead to better awareness and reform) but I'm still very skeptical of the validity, methodology and accessibility of these ratings to the regular Joe Shmoe. But for now wine anyone with that womens ' annual?
I am a newbie when it comes to quality measures, so I don't know the full scope of this topic, but having worked in a hospital and been a patient, I see the value in full transparency when it comes to accountability. I can only assume that if a hosptial discloses their quality data they would want the data to be attractive, right? Therefore, hospitals would strive to make sure their data is up to par, but if desperate enough they might even manipulate the data as mentioned in the article - this frustrates me. How can such a good idea (at least to me) go so bad?
Now what? What can be done so that patients are able to exercise free choice and choose the best physicians, hospitals and clinics for them? Also, what is being done to fill the technology gap? There are many Americans who are not computer literate or those who do not have access to the internet (I know hard to believe). Are these Americans at a disadvantage? Is this another health inequality in the making? I pose these questions becasue I am full of them. It is my way of venting my frustration at public health because this field has many good ideas or policies with good intentions, but they backfire or they leave us asking the question, "Are things really ever going to get better?"
- Frustrated in the library
I agree with Laura's comments. Transparency is a wonderful idea, but implementation and correct use have yet to be clearly defined. The surgical literature often uses 30-day mortality as a quality marker for surgical care. However recent articles show the gross inaccuracies and inappropriate conclusions in using mortality as a marker for surgical quality outcomes. Many confounders exist as previously mentioned by other people's comments. I worry that making all hospitals transparent without appropriate data to achieve the goal desired could lead to unwanted consequences. Some literature has showed, moreover, that people often choose a hospital or physician based on recommendations from family and friends, further emphasizing other factors that cannot be readily computed (such as bedside manner, interpersonal skills of a physician) that are so crucial in the quality of health care delivered.
Great topic of discussion – very contentious!
I recently learned as part of the new Massachusetts mandate that requires everyone in the state to carry health coverage, there is a different part of the legislation that aims to increase transparency. The new law creates a Health Care Quality and Cost Council, and gives it the authority to collect cost and quality data from health care plans and providers. The Council can then make the data available to the public.
Here in California, efforts to establish transparency have thus far been voluntary. As the article indicated, hospitals/health systems are publishing data on their own websites or are participating in voluntary multi-hospital comparison sites like calhospitalcompare.org. As was mentioned in comments above, individual hospitals’ publishing their data in instills accountability – that’s great. However, it seems that to make the system as a whole accountable, we would need to mandate that ALL hospitals participate so that all stakeholders are working from complete information. This would probably necessitate creating some sort of board to audit the info and provide meaningful interpretation for the general public (possibly like in Massachusetts). Yes, there is potential to get quite bureaucratic!
The point is that without complete information, stakeholders in the healthcare debate – patients, providers and policy-makers engaged in health reform -- will just have their own opinions about the actual quality of care that is being delivered. And to move the system forward and increase quality, we first need to know what is going on out there at ALL hospitals.
Hi guys,
As I was reading your comments I was thinking about the same point that Angela made - that it would be important for all hospitals to participate, so that comparisons can be drawn. I see a lot of potential problems with this - one is that hospitals serve greatly different populations, so the outcomes should look different even if they are all doing a great job. You can't do a direct comparison. Also, how to implement evaluation systems that use the same measurements at different hospitals, so that they can be viewed side-by-side? With the difficulties I've been learning about in sharing medical records, it seems likely that it would difficult to develop and implement systems that work for a wide array of institutions. I would imagine that evaluation technology would be most effective if it could interface with patient information technology/electronic medical records.
I also think that it would be critical to have solid PR systems in place to "translate" the evaluation data into useful information for consumers. There could be a lot of misunderstandings if patients are looking at statistics without context.
I was really interested by Laura's comments about selection bias by hospitals, in order to influence outcomes... hadn't thought of that.
This makes me think of school testing, and all of the craziness that surrounds that system. Schools are changing their curriculum in order to gear it towards better test scores, sometimes at the expense of quality education, because the test scores are linked to funding. Could this happen with hospitals? Or is this already happening?
I love what Julia said about needing to have PR systems in place to "translate" the data into consumer speak in order to minimize misinterpretation of information. We can build, design and implement the best systems to report accurate quality outcomes for the public. However, if people cannot make any sense of the data reported, it is as good as reporting inaccurate information.
For example, if the audience of the quality measures are patients, then we will need to educate them on what quality indicators mean and how to interpret the information. Misinterpretation of data can cause the public to make bad decisions.
If the audience of the data are hospital administrators, then they may know what the quality measures mean. However, they might need to know how the quality measures are calculated - to ensure they are comparing apples to apples across all hospital systems. Does the "wait time" indicator in one hospital have the same meaning as the "wait time" indicator of the hospital down the street?
Reporting quality measures for transparency is a great thing. However, it needs to be carefully managed and supported by change management/PR efforts. Knowledge is power...and with power comes responsibility :o)
I believe that transparency in healthcare is important. However, I think it will be difficult for everyone to agree on what healthcare indicators will be helpful to patients. Certain things are very difficult to measure and outcomes presented can be misleading. At the same time I think in a consumer driven healthcare system, people will demand that hospitals disclose information in order for them to make "informed" decisions. Hospitals, on the hand, I think will be reluctant to provide or disclose a lot of information. It may be part of their pitch if the data is positive. However, if it turns out that the health indicators aren't so great then I think hospitals will have more of an incentive to keep those from consumers. It will also be hard to assess how fair it is because not all hospitals have the same populations.
I think that pure data and transparency alone are probably bad ideas. However, it is difficult to offer a context for the data without seeming to frame the data, or skew it in your favor. I think that health quality data are best used by people other than consumers. It is important to be held accountable, and I think Maura makes a good point that just publishing data can lead to better outcomes because of pride and accountability. However, as has been mentioned, it is imperative to compare patient demographics when comparing hospitals, and to look at how a given place differs from the baseline rate in places with similar demographics. And, all hospitals should stive for quality imporvement, and not just feel complacent that they are at the low end of an error spectrum. I guess the endpoint here is that I think quality data should be collected but should be utilized by people trained to interpret it.
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