Can Bulk Reporting Really Improve Patient Care?
In my role as medical director of our practice, I get a ton of different reports from different sources, slicing and dicing the ways different people look at our patients. Lots of reports on individual performance of different practitioners, as well as global indicators of important measures of the quality of care we provide. We get reports that are generated internally, directly from our electronic health record (EHR), across all aspects of our practice, by disease and by healthcare maintenance items, as well as from insurance companies, the hospital, and other vested entities. And, of course, each patient's chart contains flags for missing healthcare maintenance items, unanswered questionnaires, disease specific interventions, and best practice alerts. Take for instance, our reports on the control of hypertension in our practice. These reports are generated on a monthly basis, and report on how many of our patients seen in the past month have a blood pressure that is at goal. All of us who take care of patients know that there is often more to an office blood pressure reading than meets the eye, more than just a set of numbers. Sometimes our patients forgot to take their medicines that day. Sometimes they don't take them intentionally so they can see how their blood pressure was without their medicines. Sometimes they're afraid to tell us that they can't or won't take them, that they can't afford them, that they can't tolerate the side effects, that they're scared about being dependent on a medicine. Sometimes we've just picked the wrong medicine. And each of us, in our interactions with our patients, respond differently to these values, the snapshot of their blood pressure in the office that day. Some practitioners are incredibly aggressive, responding to any elevation with an increase in dose or an additional medicine. Some are more lenient, letting things slide, giving someone another chance. Let's work on those nonpharmacologic interventions, cut out the salt, and exercise more, and make sure you're taking your pills every day. Sure, we could build the system such that any reading above normal would lead to a series of interventions, dose escalations, checks on compliance, remote monitoring, and enrollment in care management programs. Another example is our monthly opioid use report, which has come about partly in response to the opioid crisis and the ofttimes over-prescribing of these medicines. As we've all heard, part of this opioid crisis was of our own making, a response to mandates that we control pain -- the "fifth vital sign" -- a number that needed to be driven to zero, for patient satisfaction and for bureaucratic personnel looking at our charts and telling us we were not doing a good job. Now the pendulum has swung the other way, and we are being monitored on how many milligram morphine equivalents we are providing per patient per day per refill. When this bulk report appears for our practice, even if we distribute it to the individual providers, they look at themselves and their own practices and maybe they say, "Perhaps I could do better." But with a particular patient sitting in front of them, it's hard to remember that that patient was on the report and that something needed to be done about it. Each of our patients has a story, so much of their lives that we don't understand, that sometimes it's easier to not push back and insist on change. Efforts that should be fairly easy and obvious, like using breast cancer screening registries to improve completion, just haven't seemed to make that big a difference. We don't trust the data; it doesn't reflect internal versus external reports; it can't capture mammograms done at an outside radiology facility; no one has time to update those health maintenance fields; my patient doesn't want to get the test done; they're scared. I wish we had a system that allowed us to fill all the gaps, to see what our patients were missing individually and globally, to help us see where we could do better. I also wish that we had the resources to pour onto our patients to address what's keeping them from getting to these best states of health. In the past, we've assigned individual partners at our practice a different intervention, a different type of reporting, so that one person became the colon cancer screening czar, one person was for diabetes, one for hypertension, one for depression screening, one for pneumonia vaccines, one for falls screening. Even incentivizing these roles, even building up infrastructure around them, just didn't seem to do much in terms of increasing compliance. As we dive deeper into the available reports built into our EHR, and we get more institutional support for these projects, perhaps we can do a better job of using these to make a difference, for individuals and for populations. Let me know, in the comments below, if there are ways that you found to better engage, to fill in the gaps, to overcome the barriers, to help dot the i's and cross the t's. I bet you all have a lot to report. Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what's going on in the world of primary care medicine from the perspective of his own practice.