Last week, I reviewed my dashboard quarterly report and saw how my “quality metrics” compared to benchmarks as well as my fellow clinicians in our health system. This included our practice’s success rate along with my own individual success rate getting patients to comply with evidence-based guidelines including mammography, colon cancer screening, statin use, and hemoglobin a1c targets.
I was happy to see a few areas of improvement since last quarter yet frustrated by our lack of progress in others. This data influences some of our payer reimbursements, which are value-based and used as a performance bonus incentive for both providers and management.
Metrics is a relatively new term in my professional life. It begs the question: what had I really achieved? I succeeded in improving the likelihood of detecting more breast and colon cancers at a treatable stage. Some of my diabetic population had improved glycemic control. However, in order to get engaged in trying to improve our metrics success rate, I needed to reflect on how to reconcile this with my own sense of what constitutes high-quality care.
I thought it might help to start with a list of what I value as my most important professional duties. First and foremost, I strive to offer my unhurried presence and take in my patient’s concerns. There must be space, both temporal and emotional, to get at the deepest worries, which may not be the first ones mentioned. I consider it high-priority to evaluate life context and allow myself to imagine suffering. I need to consider social determinants, such as financial stability and access to food and home safety in all of my recommendations. Next, I ask qualifying questions and perform an examination, carefully considering a range of possible diagnoses, while continuing to build a trusting connection.
All of the items on my list so far are true of all medical specialties. Next, I considered things unique to my own specialty focus area of adult primary care. Managing chronic illnesses, often many concurrent ones, for me is at the foundation. I pay close attention to changes in symptoms, physical examination, and laboratory data, using that information to adjust treatments. This requires the frequent review of evolving best practices and new drug profiles, as well as collaboration with clinical sub-specialists.
To list all of my high-value physician duties into 15-30 minutes per office visit would be quite challenging. Therefore, how and where do these quality metrics fit in? How do they really rank in determining the quality of care?
We are fortunate to have opportunities to prevent or limit the impact of diseases, so quality metrics must be part of my long-term conversation with patients. However, I know I am not alone in feeling like the focus on performance metrics, on top of other distractions from face-to-face time with patients, has challenged my sense of professional self. Metrics are an element of quality and, therefore, should not have to compete with the less measurable elements of excellence. Perhaps the essential question then ask how can they be most effectively and efficiently addressed while preserving my physician identity?
The answer, which I am beginning to see, lies in seeing my doctor role in the context of a team effort. Providing enough information, engaging in relational communication to encourage evidence-based care is good doctoring. Being a check-box accountant is not good doctoring. Rather than reinventing myself as a task-master, I need to combine my role with others in our practice to help our patients achieve and maintain the best possible state of wellness. It is a work in progress and involves staff-provider collaboration to help our patients achieve quality goals.
Much of this is a supplementary effort, which can occur outside the exam room. Medical assistants can learn effective messaging, perform phone and digital outreach and work in tandem with providers to order appropriate screening and chronic disease monitoring studies. Everyone’s role must be understood and respected.
Active patient participation in this process on this engaged team is also essential. I find it inspiring when a patient comes in requesting an order for mammography or colonoscopy after reading our patient information literature or seeing an advisory email in the patient portal. Many payers and employers are incentivizing patients to follow guidelines by offering substantial discounts on coverage costs.
Everyone must understand their own part in the greater picture of providing great care. Metrics is a method of measuring something, but it is also a term for the study of poetic meter or rhythm. Perhaps the latter use of metrics is the best way to think of it — a way of evaluating whether our care team is “in sync” essentially. When we are, both patients and team will thrive.
Jeffrey Howard Millstein, MD is a practicing internist and serves as physician champion for the patient experience initiative at Clinical Care Associates of Penn Medicine. He leads initiatives and serves as a resource for clinicians and staff to help improve patient centered communication skills. You can follow him on Twitter @millstej.