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Quality Commitment


Ehab Hanna, MD, MBBch, FHM, understands better than most why hospitalists are frustrated with all the grand plans to utilize information technology (IT) for streamlining admissions, medical reconciliations, and the discharge process. As assistant chief medical information officer at Eastern Maine Medical Center in Bangor, he spends half his time scouting and assessing the value of new IT platforms and the other half as a front-line hospitalist.

Dr. Hanna and his colleagues are frustrated that software systems promise to deliver electronic medical records (EMR) but freeze up too often, take too long to download files, or can’t handle the functions for which they were developed. But he also knows the future of healthcare hinges on IT as much as anything else—and that done correctly, and probably expensively, it can be a savior.

“Every time we want to come up with a quality-initiative project, we want to ask, ‘What can IT do for us?’ ” Dr. Hanna says. He also acknowledges that “it’s all types of money, whether it be resources, funding, or people to implement [the system]. And there’s physician resistance to it.”

The link between quality and cost is paramount to healthcare and HM. As evidence, the keynote theme of HM09 in Chicago was quality improvement (QI)—defining it, making it a priority, setting up analytical metrics to measure it, and the most difficult step: implementing it. QI projects vary in size, shape, and scope. On one end of the spectrum: hand-washing compliance systems and simple programs to increase the prescription of pneumococcal vaccines. On the laborious and expensive end: EMR system integration with ambulatory care and pharmacy.

New SHM President Scott Flanders, MD, FHM, speaks at HM09. MATT FENSTERMACHER

New SHM President Scott Flanders, MD, FHM, speaks at HM09.

Industry leaders agree QI projects must include measurable goals and incentives for success. The flip side is that failure to reach those goals has to include a level of accountability.

One thing is for sure: The choice to focus on patient safety no longer is a choice, it’s a mandate. Patient-safety advocates are barking louder than ever, and the public and politicians are taking note. Medicare reimbursements are increasingly tied to performance measures, a trend that is likely to accelerate in light of recent news that Medicare will sink into the red in just eight years. Many expect that threshold to keep moving closer, too. President Obama has pledged to push major healthcare reform legislation—including a focus on EMR—through Congress. He wants to sign it into law by Labor Day.

On the other hand, there still is a relatively small sample of data on the effectiveness of pay-for-performance contracting in relation to overall patient health. There is a recurring call from many outside the HM field for more independent, empirical data that can pinpoint the quantifiable value of hospitalists. Discussions based on those values could satisfy group leaders, hospital administrators, and government regulators who still use the tried-and-true HM formula: value equals quality divided by cost.

“I see about as many challenges in QI as I do opportunities,” says SHM President Scott Flanders, MD, FHM, director of the hospitalist program at the University of Michigan Health System in Ann Arbor. “Is the horse before the cart? We have spent a lot of time and effort putting in place … programs before understanding the clinical effect.”

Dr. Chassin calls for a collaborative QI effort between researchers, government, and trade groups like SHM. MATT FENSTERMACHER

Dr. Chassin calls for a collaborative QI effort between researchers, government, and trade groups like SHM.

Can IT be EZ?

Dr. Hanna says hospitalists would embrace new IT initiatives immediately if they were easier to use. Many hospitalists are frustrated that in their pocket sits a handy, portable device that works in real time as a computer, a phone, a CD player, a GPS tracking device, and a scheduling secretary, yet they can’t use their E&M coding system without encountering constant hiccups, interruptions that take valuable time out of an already crowded 12-hour shift.

“Why isn’t it working like the iPhone?” is a complaint Dr. Hanna says he hears all the time.

One answer is that a number of medical software programs are limited in nature and don’t automatically network well with other systems already in place. User errors and other problems crop up regularly; plus, there isn’t a repository for people to measure different systems against each other. Some SHM leaders are considering a plan to create an online resource for IT vendors, but the society is leery of making recommendations because of potential conflicts of interest.

The Joint Commission, which accredits and certifies more than 15,000 healthcare organizations and programs, has been asked—by Dr. Hanna, among others—if it intends to regulate EMR vendors, which would let hospitalists know which systems are most reliable and useful. Commission President Mark Chassin, MD, MPP, MPH, said after his HM09 keynote address that his agency has no intention of doing so.

I see about as many challenges in QI as I do opportunities. Is the horse before the cart?

—Scott Flanders, MD, FHM, SHM president

“We don’t see [that] as a good message for us to give,” Dr. Chassin said.

IT also can be used in creative ways to spur patient-safety improvements. As hospitalists struggle to increase compliance with hand-hygiene standards, several hospitals have resorted to using video cameras above sinks to track whose hands are clean and whose hands are not clean, Robert Wachter, MD, FHM, said during his plenary address to conclude HM09. Real-time tracking runs through a software program and is displayed on a small, LED screen that hangs from the ceiling. Positive results are praised, while low rates of compliance result in pages to HM and hospital leaders to address hygiene issues. Dr. Wachter, professor and associate chairman of the department of medicine at the University of California at San Francisco Medical Center, chief of the division of hospital medicine, former SHM president and author of the blog “Wachter’s World” (www.wachtersworld), said UCSF hospital executives are considering the video system.

Dr. Wachter also says hospitalists can’t lament the rise of QI and the stricter standards that are attached. Nor can HM complain too loudly about the burdens QI places on them. As hospitalists argue that their value is partly defined by their contributions to hospital quality, they have to expect to be accountable to the claim. “We have positioned ourselves as being leaders in quality and safety,” he says. “This is not going out and being branded. We bring this in. We often say we have two sick patients; one is in front of us, the other is our organization.”

Proven Path to Improvement

Long before he took over at The Joint Commission, Dr. Chassin was a believer in business management systems such as Six Sigma and the Toyota Production System. One of the philosophies he touts for QI projects pushes physicians to “Trust, Report, and Improve.”

  • Trust. Put faith in your colleagues and patients. Work toward a mutual goal instead of pitting doctors against administrators or physicians against patients because of financial pressures.
  • Report. Accountability and publicity force physicians to confront the warts of HM and the entire healthcare industry. However, it’s only through categorizing and tallying as many processes as possible that data can be generated, analyzed, and made useful.
  • Improve. Get it right. This should be the ultimate goal of patient care, not just because it saves money or creates revenue, but also because it’s the right thing to do.—RQ

Pay for Performance?

Another largely unanswered question is how valuable pay-for-performance will be in improving patient care, safety, and satisfaction. While most HM contracts include additional compensation based on volume, bonus pay often ignores such measurable outcomes as readmission rates and length of stay.

“Does incentivizing healthcare quality actually improve health?” asks Susan Freeman, MD, chief medical officer at Temple University Hospital in Philadelphia. “It’s really hard to measure things that don’t happen—the myocardial infarction that didn’t happen, the stroke that didn’t happen.”

Active pay-for-performance programs numbered 160 in November 2007, four times the number of programs four years earlier.1 Yet as the concept catches on, the average physician incentive was 2% or less, and it seems to play a small role in how care was delivered.2

A more recent look at the issue concludes that if insurance companies and private employers worked with hospitals and physicians, attitudes toward pay for performance might change. “The amount of incentives available to physicians strongly affected their rate of participation,” say the authors of a May study in the American Journal of Managed Care. “Our analysis suggests that all stakeholders—health plans, physicians, and patients—would benefit from health plans collaborating on their pay-for-performance efforts to maximize physician participation.”3

Russell Holman, MD, FHM, chief operating officer of Cogent Healthcare, says another pay-for-performance concern is that improved quality is not always something that translates quickly into bottom-line savings. In today’s economic environment, in which every dollar spent has to be justified, it can actually be tougher to sell the upfront costs and long-term savings associated with investment in QI projects. “Improving quality is going to take a long time to see the advantages to the healthcare system,” says Dr. Holman, a former SHM president. “It is delayed gratification.”

Dr. Wachter

Is HM Ready?

Dr. Holman says the pay-for-performance solution might end up as more of a hybrid of two reimbursement models, incentive-based pay and the controversial notion of billing bundling. Most hospitalists and HM groups are not entirely comfortable with the bundling idea, in which the hospital receives a lump-sum reimbursement for all services performed for a patient, then shells out payment to the surgeons, hospitalists, nurses, etc. The concept of hospitals as payment intermediaries adds an extra layer of bureaucracy, but the bundling concept appears to be gaining momentum.

While QI projects are the trendy way to measure value, Dr. Chassin points out that physicians need more detailed thresholds to exceed. Such measures as prescribing beta-blockers after myocardial infarction were good first-generation concepts, but better care requires better benchmarks, he says. Dr. Wachter echoes the sentiment, telling HM09 attendees that relying on past successes in QI won’t help hospitalists demonstrate their value or answer the “What have you done for me lately?” demand from hospital administrators.

Dr. Chassin compares healthcare to other high-pressure industries that do much better at controlling mistakes. Some estimates show nearly 100,000 people a year die from medical errors. Why? Many high-risk industries—airlines, nuclear energy, mining—have better quality and safety processes to protect against routine errors that continually plague healthcare (e.g., hospital-acquired infections, operations on the wrong patient).

The responsibility to get better doesn’t belong to one medical group, either. Dr. Chassin says researchers, the Centers for Medicare and Medicaid Services, and trade groups like SHM have to work collaboratively to design benchmarks that can be measured quantitatively. Once those measuring sticks are in place, though, Dr. Chassin believes hospitalists are the first responders who can best identify and solve problems.

“You have to understand the causes of the problems you’re trying to fix,” he says. “Hospitalists are on the front lines.” TH

Richard Quinn is a freelance writer based in New Jersey.


  1. Baker G, Delbanco S. Pay for performance: national perspective. 2006 longitudinal survey results with 2007 market updates. MedVantage Web site. Available at NationalP4PStudy.pdf. Accessed May 17, 2009.
  2. Pearson SD, Schneider EC, Kleinman KP, Colin KL, Singer JA. The impact of pay-for-performance on health care quality in Massachusetts, 2001-2003. Health Aff (Millwood). 2008;27(4):1167-1176.
  3. De Brantes FS, D’Andrea BG. Physicians respond to pay-for-performance incentives: larger incentives yield greater participation. Am J Manag Care. 2009;15(5):305-310.

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