Quality as a business plan…Caring and compassion as our mission.

In this rapidly shifting healthcare business our mission remains my top priority, but we can no longer count on that to lead to a sustainable medical practice….sadly!

Quality has always been hard to define in medicine and particularly in my field of primary care.

So often when people ask “who’s a good doctor?” the answer is usually based on if people like him/her. Looking at an individuals actual quality as a provider is very challenging in primary care as there are so many gray areas. It is much easier with say a surgeon and gallbladder removal as an example. You can compare outcome data among surgeons and hospitals based on complication rates, infections, length of stay and time to full recovery. Although even this can vary based on regional economic and racial health disparities that we need to address ( I’m writing this at 35k feet on my way to a meeting in Chicago on this very topic as well as quality).

So back on topic.

When I see a 60-year-old patient there is no clear-cut parameter that determines my actual quality except in certain cases such as abdominal pain where I need to choose the right diagnostic test to confirm my diagnoses or the patient may die. This is just using your training and years of experience.

For the routine healthy patient it is much harder for everyone to judge quality from insurers to doctors there is no clear definition.  Why? because so many of the interventions we make may not have a positive outcome for that patient for many years. As an example if I hadn’t talked that patient into a colonoscopy and a polyp is found would he have developed colon cancer if we hadn’t done the test?  Who knows for sure, science does guide us some here and suggests a higher likelihood that he would have.

The quality that we are judged on now is based on a set of ever-changing standards set by the NCQA (a private entity known as the National Center for Quality Assurance).  These are known as the HEDIS criteria.

In my practice we decided to try really hard to hit these HEDIS goals. In fact it became a key component of our business plan and is really the driving reason we made the difficult switch in our NEW Electronic Record systems  ATHENAHEALTH (www.athenahealth.com) last year. We needed one that would help us track recommended screenings and hit quality goals as well as enable us to manage our population of patients.These include such things as mammograms, colonoscopies, and immunizations.

The above does not actually prove you are a good doctor. I personally consider my definition of a good doctor is the one who can rapidly figure out what is wrong with me when I’m sick and successfully guide me to a cure. Hitting the HEIDIS goals make you an effective doctor in the eye of Medicare and the insurance companies.

However, these criteria are what we are being judged on so I decided let’s run with it and try to be the best at hitting these goals. Much to my surprise as we started having a quality tab on each chart I soon realized I wasn’t as good as I thought. Many of my patients were lacking key preventative services such as tetanus boosters. Now I have never had a patient die of tetanus, but none the less that’s a public health recommendation. So as I order more preventive services, screen more people for depression and immunize more patients I have the hope I am having a positive impact on their long-term health. I actually do think I am!!

So when you come to our office and get screened for depression, alcohol abuse and get asked about pain. We are trying to follow quality guidelines. 

We will never hit 100 percent of any of these HEDIS goals as many people don’t want colonoscopies, mammograms or immunizations.  Another factor that isn’t included in the “numbers”, patients do have a choice and we are held accountable to their actions as well.

Finally I think another key component of quality in healthcare is timely access. As my practice has moved more towards team based care with a walk in clinic and same day visits as well as a vigorous patient portal my number of hospital admissions has dropped dramatically. Indeed so much so that my hospital thought I was being disloyal and using other hospitals. I invited them to come visit. They found that we were not using another hospital, but rather were keeping people out of the hospital by seeing them early in their disease process and intervening to prevent a hospitalization. In fact, my mindset is that every hospital admission should be looked at as a plane crash. Why did it happen and what can we do to prevent it in the future.

Until next time be Well!!!

John W Farley, M.D.