A couple of experiences that I've had recently got me thinking about quality. Then the other day Medscape offered a CME activity on Clinical Quality Measures (CQM) which got me thinking some more.
First, my experience as a patient: My physician is a member of a large group. When he tells me that something needs to be done, I'm sure that he has every intention of doing it but that never seems to happen. He may tell me that an office assistant will call me within a day to schedule a test or that an appointment will be rescheduled and then — nothing. If I don't keep after the office, his plans come to naught. I don't know what gets charted or whether they use an EHR, so I have no idea how they will do on the government's clinical quality measures. If a practice is managed in such a way that intended actions never get carried out, is that quality?
Second, two patients that were referred to me for consultation: Both were children suspected of having tuberculosis because of positive skin tests and histories that included cough. Each child had seen several doctors in the past. None had diagnosed or adequate, managed, and obvious cases of poorly controlled asthma. The positive skin tests were coincidental. There was no tuberculosis disease. They were over-treated for something they didn't have and under-treated for their real problem. Some of the CQMs address asthma but, if you can't recognize that your patients have asthma, the denominator for those measures will be zero. As Dr. Goodrich of CMS explained in the CME material, when reporting, “[p]hysicians ... have the option to attest that their EHR output for any measure is 0:0 patients who meet that CQM. So even if you don't have any patients in your practice for whom [the] measures apply, you can still report even though your denominator, or your population number, is going to be 0.” If patients have problems that their doctors cannot recognize, is that quality?
When reporting, in order to achieve a non-zero denominator, someone must be able to detect the presence of the medical condition in question and document it in a computer system in some way that can be tallied later. To have a non-zero numerator, i.e. the practice took the appropriate action, practitioners must remember to perform specified actions and that usually requires effective coordination. I suspect those practices that do a good job at coordination are those in which the practitioners are committed to the goal of effective coordination and are able to recruit their office staff to share the goal. I see very little evidence that any practice ever improved its ability to coordinate effectively simply because a computer system was installed. Even if the computer can report on items that need to be done, it's the physicians and the office staff who must do them.
As attractive as the idea of quality measures is, having a computer spit out reports does not create quality. Do CQMs even measure quality? The only real quality measure is the percentage of medical problems that are identified and treated appropriately — and documented. At present this measure is unknowable. The computer is not omniscient. It cannot automatically detect and document those situations in which something of relevance is transpiring. It lacks intuition. It cannot detect anomalies for which no detector exists. People, the limiting factor, must do the detection and document the care. Someone has to imagine potential defects, devise detectors and capture the data. Those who implement the detection scheme must anticipate every possible defect scenario in order to enable collection, categorization, and analysis. At present this is not do-able.
Zenith's famous slogan, "The Quality Goes in Before the Name Goes On," applies equally to medicine. If there is no intrinsic quality, there is no quality to measure. The best you can do is grope for defects, tally them, and fix what you can. Using a computer to keep the tally, even if the tally is accurate, won't affect quality nor will it describe the true magnitude of the problem. Quality care is achieved by quality doctors working in practices that use quality patient care processes doing something, as yet poorly understood, to achieve the level of coordination necessary to insure that every patient gets what they need and needs everything they get.
Quality of care at the national level will only be improved when we have figured out how to fairly and objectively identify those physicians and practices that are sub-standard and either get them to improve or stop practicing.
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