What are the best ways to get physicians the data they want and need?
Profiling isn’t a dirty word at Sentara Healthcare
From internal practice reports to hospital and HMO data, physicians increasingly are burdened by the information they have to provide to a variety of sources, and by the reports that come back to them afterward. Adding physician profiling to that pile would be about as welcome as a mosquito bite. But at Sentara Healthcare in Norfolk, VA, physicians are uniformly happy about a new profiling effort.
"Our physicians were hungry for information that was reported to them in a meaningful form," says Rod Hochman, MD, the chief medical officer for the six-hospital system. After a bevy of requests, Sentara created a portfolio of reports that debuted in January 1999.
"Our internal departments communicated with each other; the HMO we owned had its reports; and there were disease management reports and others, too," explains Deb Anderson, director of planning for Sentara. "Rather than being bombarded by one report after another, we decided to centralize it in one document."
What has value?
The first step, says Doug Thompson, vice president of decision support and reinventing, was to determine what reports had value for physicians, what reports didn’t, what reports duplicated information, and what reports were confusing in their presentation. "This provided us with the opportunity to sit down as a group and talk about the issue of data," he says.
Hochman adds that appropriate information can help to change behavior. "A lot of times you get information dumps; it goes into a pile or into the garbage," says Hochman. "We wanted to make sure that didn’t happen, and we wanted feedback from users to make sure that we provided information that makes a difference to them."
To facilitate communication about the reports, Sentara created a fax-back form. "Each time, we have distributed 800 copies of the report, and we have calls, e-mails, and faxes coming in with comments," says Anderson. The number of responses has been about 30 to 40 for each of the four issues of the report released, she adds. The goal is to respond within two business days to all requests for clarification or discussion.
That figure of 30 to 40 responses may be misleading, though, Thompson says. "One recent response was from a 70-member obstetrical practice, which responded as a group. We get responses from maybe 200 physicians in all."
"We thought at the start that if we had 800 people calling, that would be a bad sign," Hochman adds. "And if no one called, that also would be bad. We are pleased with the feedback and the constructive comments we get."
Over time, the comments from physicians have resulted in modifications, Anderson says. "It is more concise and understandable now. For instance, we include an executive summary that pulls together some of the information we think is most important."
Among the information included:
• MEDSTAT outcomes data that look at severity-adjusted length of stay and charge comparisons among peers within a hospital for a specific time period. Comparisons are made on a DRG basis. The reports include inpatients only and are based on the attending physician.
• MEDai Pinpoint physician data that contain severity-adjusted clinical indicators, length of stay, cost, and other treatment and financial comparisons among peers within a national database.
Reports include inpatients and observation patients and are based on attending physicians for medical-related conditions, and on primary procedure physicians for surgical conditions.
• Disease management data that are not severity-adjusted but include selected utilization indicators for a physician’s panel of members and offer comparisons among peers within Sentara health plans. Comparisons are made on a disease or condition basis for asthma, diabetes, essential hypertension, and depression and are made between primary care physicians and Sentara goals or national benchmarks. Only physicians with at least 10 patients diagnosed with a condition have data reported, except depression, which has a minimum patient load of three patients.
• Dartmouth Atlas of Health Care in Virginia released by the Virginia Hospital and Healthcare Association each July. A brief article about the atlas and a summary of its highlights are enclosed in the profile report.
One of the benefits of the MEDSTAT data, in particular, is that they are fairly current, Thompson says, and physicians can get them for any and all facilities at which they work. "If a doctor works in three of our hospitals, he gets three reports." Physicians also can choose specific areas they want to track in their own reports. For instance, a family practitioner may want to see how she compares in managing diabetic patients with others in the system and with others in the nation.
Hochman adds that group practices also can get group data on special request, which can provide insight into how well they, as a group, manage patients.
Data result in meaningful action
One reason physicians responded positively to the idea of internal profiling is that the contract with physicians stipulates that the data collected and reported cannot be used for retribution or deselecting, Hochman says. "That helped alleviate the fears they have of profiling. It was simply an exercise in clinical improvement."
The idea of collecting and reporting meaningful data got an added push from something published in the business press in Virginia, Thompson explains. "A local magazine used information from the Dartmouth Atlas that was old to create a story about physician quality. It instilled a real hunger among our physicians to look at data in a meaningful way. They kept wondering how [that magazine] could base a story on such old data."
Another way Hochman says he was able to get buy-in from the doctors was to promise them that data would result in meaningful action. "We tied the information to our medical practice committees and performance improvement groups," he says. "They, in turn, can use these data to create a useful project. We use the information we generate to see how we are doing as a health system. But unless we turn that into clinical improvement projects, there really is no point."
One of the most outstanding projects undertaken as a result of the profiling program concerned the use of beta-blockers among patients with myocardial infarction. "The improvement in their use has been spectacular," says Hochman. Other areas of improvement include a dramatic decrease in hospitalizations among patients with asthma, and a clear demonstration that hospitalists have a positive impact on the outcomes of hospitalized patients.
There have been additional improvements, too, from shorter lengths of stay to reductions in charges, Thompson says. "Physicians are competitive, and they realize that there are people out there doing the same things that they are but getting different outcomes and better results. They want to find out why and what these others are doing differently."
The upshot is an increase in dialogue among physicians, adds Thompson. "There is sharing between the physicians so they better understand what creates improvement."
Hochman agrees. "Even inside group practices, you can see discussions among the physicians as they go over their data. That, to us, is a real sign of success."
Involvement a key to success
Getting the physicians to agree to profiling wasn’t difficult once the doctors knew they would be in on the process, Hochman says. "If you want to do something like this, make sure they are involved from the start. And make sure it isn’t a punitive program."
Another tip, he adds, is not to bite off too much at once. "All of us are compulsive data jockeys, so we started off putting out more information than our physicians wanted."
The less-is-more philosophy includes understanding that, at most, Sentara management has three minutes to attract physicians’ eyes to a report and get them interested. "We have to use formats that they understand easily and simply." Bubble charts and other graphic presentations of data are one way to accomplish that, says Anderson, as well as executive summaries. It doesn’t hurt that the report is just big enough that it doesn’t fit in most traditional wastebaskets, Thompson adds.
Most importantly, make sure you have commitment from the top, says Anderson. "If we didn’t have [Hochman] channeling this through the organization, we wouldn’t have gone beyond the first issue," she says. "This takes a really strong commitment to follow through."
A commitment to clean data also is vital, says Thompson. "We have had two years to get this right. We have had to fight battles for coding specialists and had to be nondefensive about implementing the kinds of changes that will improve the quality of the data. And you have to constantly remind the physicians that . . . we can share valuable data with them faster than any outside organization can collect it and get us a report back."
[For more information, contact: Deb Anderson, Director of Planning; Rod Hochman, MD, Chief Medical Officer, and Doug Thompson, Vice President of Decision Support and Reinventing, Sentara Healthcare, Norfolk, VA. Telephone: (757) 455-7975.]
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