Physician Ratings on the Horizon
I’ve heard Zagat is going to start rating doctors. Do you think patients are going to choose their doctor just like they choose restaurants?
D. Ricketts, Houston, Texas
Dr. Hospitalist responds: You are correct. The Angie’s List Web site, www.angieslist.com, which is famous for home improvement contractor reviews, is doing the same. Zagat also is planning to review hospitals and other healthcare providers. Rating services are commonplace (e.g., RateMDs.com, Vitals.com and DrScore.com).
Many of us routinely check out a review before buying a camera, a big-screen television or a new automobile. The World Wide Web makes this information readily accessible.
Hospital ratings have been commonplace for years. Who hasn’t heard of the U.S. News and World Report Hospital Rankings? Even Consumer Reports is preparing to launch a new hospital rating service.
Doctors, however, are not accustomed to reading reviews about doctors. I’m sure I would be thrilled to read a fantastic review about myself. The problem lies in the possibility of bad reviews. Rating services tend to attract “very good” or “very bad” comments. Most of the silent majority typically avoids comment.
I also suspect these rating services are less applicable to hospitalists than elective-care physicians, such as dermatologists and plastic surgeons. Most patients with chest pain won’t be going online to check out their hospitalist before they head down to the emergency department. Even if they were going to look up the hospitalist’s Zagat review, what is a layperson going to learn? They might be able to read comments about “bedside manner.”
I don’t want to underestimate the importance of communication, but it is only one part of what makes a good doctor. These rating services won’t be able to provide information about a physician’s diagnostic skills or surgical technique. I think we have a long way to go before consumers will be satisfied with the information they can glean from physician ratings, but don’t for a second think it will dissuade companies from publishing ratings.
I am the director of a hospitalist group and I have been catching grief from our quality officer because of the poor legibility of our hospitalists’ signatures and their continued use of unapproved abbreviations. I have spoken with our hospitalists repeatedly but with minimal success. Have you found anything that works?
C. Macleod, Simi Valley, Calif.
Dr. Hospitalist responds: All of us have heard the jokes about physicians’ poor handwriting, but as you and your hospital quality officer recognize, illegible handwriting is no laughing matter. Each of us is aware of examples of how illegible handwriting has resulted in medical error. Some abbreviations result in error because of misinterpretation. The Joint Commission has pushed hospitals to eliminate illegible signatures and the use of some abbreviations. This is easier said than done. Changing old habits is difficult, if not impossible.
Undoubtedly, education is important. Providers must understand why poor handwriting and the use of prohibited abbreviations can result in medical error and patient harm. Education is necessary, but rarely is it sufficient. Requiring adults to write legibly is difficult, especially when they are in a hurry. This also is the time they are more likely to make mistakes.
I believe the illegible signature problem and the use of prohibited abbreviations requires a systemic solution. You might contend the poor penmanship issue would go away if hospitals adopted a comprehensive electronic medical record (EMR) system. This might be true, but few hospitals have an entirely electronic process to enter inpatient medical information. An investment in EMR requires a significant capital investment. Also, recognize EMRs are not a panacea. You could be replacing one problem with another because typing notes and orders would require increased physician time and effort, which might not be acceptable. Transcriptionists and voice recognition software are potential alternatives to asking physicians to log inpatient notes and orders. Voice recognition software has come a long way, but additional improvements are necessary for widespread acceptability for this purpose. Use of transcriptionists for dictation of all inpatient notes could be cost prohibitive and an unrealistic workflow option, as transcribed notes might not be available in a timely fashion.
So what is a hospitalist director to do? One possible solution is the use of signature ink stamps–and requiring physicians use them. Universal acceptance is difficult to achieve. Some stamps are messy and physicians tend to lose them. Others give them up the first time their stamp runs out of ink. I don’t view stamps as an acceptable long-term solution.
The most acceptable solution I know of involves the use of pre-printed paper templates. For example, I have more than 30 providers in my hospitalist group. We print each of their names at the bottom of our paper template. There is a checkbox next to each name. A doctor still might scrawl their illegible signature, but as long as they check the box next to their name, we know who filled out the order and this satisfies the Joint Commission’s mandate for legible signatures.
Pre-printed text with elements of the history, review of system, and physical examination on the template not only saves time, but also minimize legibility and prohibited abbreviation issues. Templates allow providers to document the necessary information and minimizing handwriting. Then again, I don’t think we can eliminate handwriting altogether. Consider printing the prohibited abbreviations at the bottom of each page of your template. This will serve as a daily reminder. Also require intermittent updates of these templates to keep up with changing documentation requirements. When the time comes for EMR, change your template into a macro file. Using a template in the EMR will minimize typing and the use of prohibited abbreviations. TH