healthcarereimagined

Audio Interview

Interview with Dr. David Rosenthal on the effect of the electronic era on physician satisfaction. (7:29) Download

In a past era, the work of the hospital physician was done primarily at the bedside or in the adjacent wet laboratory. Residents had the opportunity to witness the unfolding of diseases (for which we may now have cures) and to come to know their patients over the course of lengthy hospitalizations. The life was grueling and all-consuming — and those who took it up were almost invariably unmarried white men, with teaching hospitals actively discouraging marriage. Medicine was a fraternal order. Doctors’ lounges were central locations where community internists, specialists, and surgeons ate together, socialized, and “curbsided” each other for patient consultations. Charts were kept on paper and were often indecipherable.

Every aspect of medicine and training has since evolved. Progress has been remarkably quick in some areas and painfully slow in others. The past 20 years have seen much debate over the amount of time worked by house staff. As residents’ duty hours have changed, so has the nature of their work.

Typically in our field, internal medicine, residents arrive at the hospital at 7 a.m., get sign-outs from nighttime residents, and conduct “pre-rounds” to see patients they have inherited but don’t know well, before heading to morning report or attending rounds. Attending rounds often consist of “card-flipping” sessions held in a workroom, frequently interrupted by discharge planning and pages, calls, and texts from nurses and specialists. Finalizing discharges before noon can feel more important than getting to know new patients. Increasingly, the attending physician doesn’t see patients with the team, given the time constraints.

No longer are there paper charts at the bedside. The advent of the electronic era, while reducing the time required for tracking down laboratory or radiology results, has not substantially changed the time spent with patients: recent estimates indicate that medical students and residents often spend more than 40 to 50% of their day in front of a computer screen filling out documentation, reviewing charts, and placing orders. They spend much of the rest of their time on the phone coordinating care with specialists, pharmacists, nutritionists, primary care offices, family members, social workers, nurses, and care coordinators; very few meetings with these people occur face-to-face. Somewhat surprisingly, the time spent with patients has remained stable over the past six decades.¹

The skills learned early by today’s medical students and house staff — because they are critical to getting the work done — are not those needed to perform a good physical exam or take a history, but rather the arts of efficient “chart biopsy,” order entry, documentation, and sign-out in the electronic age. When a medical team gets notice of a new admission, it seems instinctive and necessary to study the patient’s record before meeting him or her. This “flipped patient” approach² has advantages, but it introduces a framing bias and dilutes independent assessment and confirmation of history or physical findings.

In short, the majority of what we define as “work” takes place away from the patient, in workrooms and on computers. Our attention is so frequently diverted from the lives, bodies, and souls of the people entrusted to our care that the doctor focused on the screen rather than the patient has become a cultural cliché. As technology has allowed us to care for patients at a distance from the bedside and the nursing staff, we’ve distanced ourselves from the personhood, the embodied identity, of patients, as well as from our colleagues, to do our work on the computer.

But what is the actual work of a physician? Medical students entering the wards for the first time recognize a dysjunction, seeing that physicians’ work has less to do with patients than they had imagined. The skills they learned in courses on physical diagnosis or communication are unlikely to improve. Despite all the rhetoric about “patient-centered care,” the patient is not at the center of things.

Meanwhile, drop-down menus, cut-and-paste text fields, and lists populated with a keystroke have created a medical record that (at least in documenting the physical exam) at best reads like fiction or meaningless repetition of facts and at worst amounts to misleading inaccuracies or fraud. Given the quantity of information and discrepancies within medical records, it’s often impossible to discern any signal in the mountains of noise. Yet our entire health care system — including its financing, accounting, research, and quality reporting — rests heavily on this digital representation of the patient, the iPatient, and provides incentives for its creation and maintenance.³ It would appear from our hospital quality reports that iPatients uniformly get wonderful care; the experiences of actual patients are a different question.

It’s clear that physicians are increasingly dissatisfied with their work, resentful of the time required to transcribe and translate information for the computer and the fact that, in that sense, the work never stops. Burnout is widespread in the workforce, and more than a quarter of residents have depression or depressive symptoms.⁴ In response, health care leaders have advocated amending the “Triple Aim” of enhancing patients’ experience, improving population health, and reducing costs to add a fourth goal: improving the work life of the people who deliver care.

A 2013 study commissioned by the American Medical Association highlights some of the factors associated with higher professional satisfaction. Perhaps not surprisingly, the investigators found that perceptions of higher quality of care, autonomy, leadership, collegiality, fairness, and respect were critical. The report highlighted persistent problems with the usability of electronic health records as a “unique and vexing challenge.”⁵

These findings underscore the importance of reflecting on what our work once was, what it now is, and what it should be. Regardless of whatever nobility inhered in the work of physicians in a bygone era, that work was done under conditions and quality standards that would now be unacceptable. We practice in a safer and more efficient system with measurable outcomes. Yet with the current rates of burnout, our expectations for finding meaning in our profession and careers seem largely unfulfilled.

We believe that if meaning is to be restored, the changes needed are complex and will have to be made nationally, beginning with a dialogue that includes the people on medicine’s front lines. Perhaps the greatest opportunity for improving our professional satisfaction in the short term lies in restoring our connections with one another. We could work on rebuilding our practices and physical spaces to promote the sorts of human connections that can sustain us — between physicians and patients, physicians and physicians, and physicians and nurses. We could get back to the bedside with patients, families, and nurses. We could get to know our colleagues from other specialties in shared lunchrooms or meeting spaces.

In addition, we believe that in the coming years, the U.S. medical community will have to rethink the human–computer interface and more thoughtfully merge the real patient with the iPatient. We have an opportunity to radically redesign electronic health record systems, initially created for fee-for-service billing, as our organizations shift toward bundled payments, capitation, and risk sharing. Perhaps virtual scribes and artificial intelligence will eventually reduce our documentation burden.

But technology cannot restore our professional satisfaction. Our profession will have to rebuild a sense of teamwork, community, and the ties that bind us together as human beings. We believe that will require spending more time with each other and with our patients, restoring some rituals that are meaningful to both us and the people we care for and eliminating those that are not.

Solutions will not be easy, since the problems are entangled in the high cost of health care, reimbursement for our work, and obstacles to health care reform. But we can start by recalling the original purpose of physicians’ work: to witness others’ suffering and provide comfort and care. That remains the privilege at the heart of the medical profession.

Performance measurement in the U.S. health care system has expanded dramatically over the past 30 years. The National Quality Measures Clearinghouse now lists more than 2500 performance measures. These measures are used in various quality-reporting, accountability, and payment programs sponsored by commercial payers, government agencies, and independent quality-assessment organizations. The Centers for Medicare and Medicaid Services (CMS) aims to base 90% of Medicare fee-for-service payments to clinicians on “value” by the end of 2018 by using performance scores.

Although most physicians view the delivery of high-quality care as a professional imperative,¹ performance-measurement activities face increasing resistance from physicians and some policymakers who believe that current measures are not meaningful.² In a recent survey, 63% of physicians said that current measures do not capture the quality of the care that physicians provide.³ Yet U.S. physician practices are spending $15.4 billion each year — about $40,000 per physician — to report on performance.³

In response to these concerns, the Performance Measurement Committee (PMC) of the American College of Physicians (ACP) developed criteria to assess the validity of performance measures (see box). Using a modified version of the method developed at RAND and UCLA for evaluating the benefits and harms of a medical intervention, we applied the ACP criteria to the measures included in the Medicare Merit-based Incentive Payment System (MIPS)/Quality Payment Program (QPP). We hypothesized that if most of the MIPS/QPP measures assessed were deemed valid using this process, physicians could have more confidence that adherence to the measured practices would result in improved patient outcomes. Conversely, if some substantial proportion of the measures were deemed not valid, the results would suggest the need to change the process by which MIPS measures are developed and selected. (For further details, see the methods section in the Supplementary Appendix, available at NEJM.org.)

Of 271 measures in the 2017 QPP measures list, we identified and rated the validity of 86 that the committee considered relevant to ambulatory general internal medicine. Among these, 32 (37%) were rated as valid by our method, 30 (35%) as not valid, and 24 (28%) as of uncertain validity. We also determined the proportion of the measures that had been developed by the National Committee for Quality Assurance (NCQA) or endorsed by the National Quality Forum (NQF) that were rated as valid by our method. As compared with measures that were not endorsed by these organizations, greater percentages of NCQA-developed and NQF-endorsed measures were deemed valid (59% and 48%, respectively, vs. 27% for nonendorsed measures), and smaller percentages were deemed not valid (7% and 22%, vs. 49% for nonendorsed measures). (For further details on the measure review results, see the tables in the Supplementary Appendix.)

Ratings for a Sample of Measures.

For each measure, the committee rated validity with respect to five domains: importance, appropriateness, clinical evidence, specifications, and feasibility and applicability. Examples of the overall and domain ratings given to individual measures judged to be valid, not valid, and of uncertain validity are shown in the table.

Notably, among the 30 measures rated as not valid, 19 were judged to have insufficient evidence to support them. For example, MIPS measure 181, “Elder Maltreatment Screen and Follow-Up,” requires the completion of the Maltreatment Screening tool on the date of an encounter and a documented follow-up plan for all patients 65 years of age or older. Although elder abuse is a serious problem that physicians should appropriately diagnose and report, the U.S. Preventive Services Task Force has found insufficient evidence to warrant routine screening. We believe the substantial resources required to screen large populations of elderly patients for maltreatment and to track follow-up would be better directed at care processes whose link to improved health is supported by more robust evidence.

Another characteristic of measures that were not rated as valid by our method was inadequately specified exclusions, resulting in a requirement that a process or outcome occur across broad groups of patients, including patients who might not benefit. MIPS measure 236, “Controlling High Blood Pressure,” for instance, requires that a blood pressure of 140/90 mm Hg or lower be achieved in the clinic setting for all patients. Forcing blood pressure down to this threshold could harm frail elderly adults and patients with certain coexisting conditions.

We also identified measures that were directed at important, evidence-based quality concepts but had poor specifications that might misclassify high-quality care as low-quality care. For example, MIPS measure 009, “Anti-depressant Medication Management,” assesses whether patients who started taking an antidepressant medication continued taking one at 3 and 6 months after initiation. This measure does not consider patients’ reasonable preferences for switching to alternative, evidence-based interventions such as psychotherapy or electroconvulsive therapy after experiencing side effects of antidepressants.

Our analysis identified troubling inconsistencies among leading U.S. organizations in judgments of the validity of measures of physician quality. Although the ACP assessment was limited to a defined set of measures, that set was large and included the vast majority of measures that will be applied to ambulatory care internists as part of the United States’ largest physician quality-assessment program for the purpose of accountability. Our findings are striking given that the criteria we used were similar to those used by NQF and CMS. Why the disconnect?

Possible explanations include the methods used to assess measures and the characteristics of the experts who did the assessing. The RAND–UCLA appropriateness method does not classify measures as valid when there are significant disagreements among the panelists. In contrast, the NQF threshold for endorsement is close to a simple majority of panelists (60%). The ACP method thus sets a higher standard for validity. In addition, we would argue that the RAND–UCLA method can be considered more evidence-based than other methods, since favorable clinical outcomes have been demonstrated for patients treated according to standards developed with this method.^4,5

It is also possible that the perspectives of the groups doing the rating contribute to differences in validity ratings. Specifically, NQF convenes multistakeholder groups, whereas the ACP committee is composed exclusively of physicians with expertise in clinical medicine and research. However, analyses of the RAND–UCLA method in which multiple panels were convened to rate identical criteria have demonstrated high levels of agreement across panels for necessary care. Hence, although changing the panel composition might result in some differences in ratings, we would not expect the variation to be large enough to explain why so many NQF-endorsed measures were rated as not valid by the ACP committee.

The fact that only 37% of measures proposed for a national value-based purchasing program were found to be valid with a standardized method has implications for physician-level performance measurement. The use of flawed measures is not only frustrating to physicians but also potentially harmful to patients. Moreover, such activities introduce inefficiencies and administrative costs into a health system widely regarded as too expensive. If developers, assessors, and public and private payers adopted a more rigorous method of assessing measures’ validity, potential problems could be identified before the measures were launched. It makes sense for practicing clinicians to participate in the development and review of measures. At the same time, a single set of standards (like those put forth by the National Academy of Medicine for clinical practice guidelines) could be developed that would allow others to evaluate the trustworthiness of performance measures.

We believe that the next generation of performance measurement should not be limited by the use of easy-to-obtain (e.g., administrative) data or function as a stand-alone, retrospective exercise. Instead, it should be fully integrated into care delivery, where it would effectively and efficiently address the most pressing performance gaps and direct quality improvement. For now, we need a time-out during which to assess and revise our approach to physician performance measurement.

Article link: https://www.nejm.org/doi/full/10.1056/NEJMp1802595