A recent New York Times article calls attention to the unintended consequences of healthcare performance metrics. (Disclaimer: I am am favorably disposed to cite any piece that quotes Avedis Donabedian, one of the fore-parents of health quality research methods.) With widespread use of the electronic health record, gathering data for performance metrics increasingly overshadows clinical care. A study in my field, emergency medicine, shows that a typical emergency room physician’s electronic health record charting involves 4,000 mouse clicks in a 10 hour shift. The Times piece cites evidence that even superb and motivated physicians
had come to believe that the boatloads of measures, and the incentives to “look good,” had led them to turn away from the essence of their work. In medicine, doctors no longer made eye contact with patients as they clicked away.
The piece notes that policy-makers are retreating from some of the measure-reporting requirements.
Even some of the measurement behemoths are now voicing second thoughts. Last fall, the Joint Commission, the major accreditor of American hospitals, announced that it was suspending its annual rating of hospitals. At the same time, alarmed by the amount of time that testing robbed from instruction, the Obama administration called for new limits on student testing. Last week, Andy Slavitt, Medicare’s acting administrator, announced the end of a program that tied Medicare payments to a long list of measures related to the use of electronic health records. “We have to get the hearts and minds of physicians back,” said Mr. Slavitt. “I think we’ve lost them.”
Other prior reflections and studies of unintended consequences of healthcare quality metrics include
- Mandatory reporting mechanisms lead providers to cherry-pick, turning away the less healthy patients who would make their report cards look worse.
- Pay for performance programs (rewarding or penalizing providers based on their patients’ outcomes) do not improve care.
- Patients who give their providers higher satisfaction scores have an increased risk of hospitalization, higher cost of care, and higher death rates than patients who are less satisfied with their care.
The Atlantic published one of my favorite reviews of the unfortunate consequences of performance metrics, specifically, metrics related to patient satisfaction. The article explains the mechanism for the association between incentivizing patient satisfaction scores and poor healthcare outcomes:
Hospitals are responding to the current surveys and weighting system by focusing on smiles over substance, hiring actors instead of nurses, and catering to patients’ wishes rather than their needs. Then again, perhaps it’s no wonder that companies are airbrushing healthcare with a “Disney-like experience,” a glossy veneer. One of the leading consulting companies now advising hospitals on “building a culture of healthcare excellence” is, oddly enough, the Walt Disney Company.
Marion R. Sills, MD, MPH 
This is a truly fascinating study. Thank you for bringing our attention to it. My first thought is that so many of these metrics are there to “build a culture of healthcare excellence” but are failing and my question is why? How can they refocus these metrics to accurately reflect good clinical work? Are these surveys all based on patient satisfaction or is there another body surveying the doctor’s work?
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