TATtle-tales, Paranoia, and Unintended Consequences

My favorite saying of all time is this: "Just because you're paranoid doesn't mean they're NOT out to get you." Truer words were never spoken.

We all know at some level that our PACS stores various measurements, known as physician metrics. Depending on your system, these can get pretty detailed, and may include everything from TAT (turn-around-time) to how many studies you read in whatever time period to how long you spent on any particular study. This is valuable information, if used properly. As reported in HealthImaging.com:

Digital dashboarding uses data mining techniques to continuously, automatically process and visually display custom-set key performance indicators (KPIs) that provide operational data for a practices, departments or group facilities. Paul G. Nagy, PhD, associate professor of diagnostic radiology and nuclear medicine in the department of diagnostic imaging at the University of Maryland School of Medicine(UMD) in Baltimore, says dashboards not only give managers a greater holistic view of their practice, but also reduce costs and can improve productivity.

The majority of this effort seems to be geared to TAT improvement. That of course is a laudable goal, and my group does use data from the RIS to track how fast we sign off our reports once they become available. Hopefully the stopwatch starts at the time the report appears in the queue, and not when the order went in or something, because we would look a bit worse. Still, I think we have pretty good TAT, and that's without Speech Recognition, thank you.

This is all well and good. However, let's get a little paranoid and speculate about what could be done with all this mined data. Can you imagine what might happen if unfriendly types got hold of it?

"Dr. Smith, do you think the fact that you spent only 2.51 minutes reviewing my client's X-Ray had something to do with the fact that the tiny dot you missed turned into a cancer 15 years later? HMMMMM?????"

"Dr. Jones, how could you believe you were doing a good job on the day in question when your PACS system documents that you read 259 examinations without a break? Did you even have time to go to the bathroom? No?"

"Dr. Johnson, the PACS records show that you looked at my client's scan but didn't read it, leaving the life-threating finding for your partner to discover 18 hours later."

"Dr. Dalai, the logs show you were blogging when you were supposed to be helping out with the 368 examinations on the reading list at our seven hospitals."

You get the idea. Well, you say, this just keeps the damn doctors honest. Great stuff. Maybe, but hold your judgement for a moment or two.

Using physician metrics, especially as ratings, is nothing new. Our British friends at the National Health Service tried tying incentives to metrics, and, not surprisingly, the metrics improved:

In 2004, after a series of national initiatives associated with marked improvements in the quality of care, the National Health Service of the United Kingdom introduced a pay-for-performance contract for family practitioners. This contract increases existing income according to performance with respect to 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience.

CONCLUSIONS
English family practices attained high levels of achievement in the first year of the new pay-for-performance contract. A small number of practices appear to have achieved high scores by excluding large numbers of patients by exception reporting. More research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income.

Just what we would expect. Except all may not be as it seems. Here's one analysis:

Really what they showed when they rewarded doctors for maintaining good health metrics in their patients was that doctors that treated the young, healthy, and rich did well, whereas those that served more patients, the poor, the elderly, and difficult patients were paid poorly. Also, those who filed lots of "exception reports" to justify the exclusion of a patient from the data set did the best of all.

Basically, they show that rewarding (and I suspect this will apply to penalizing as well) doctors based on patient health metrics led to doctors serving "easy" populations to do well, and those serving "difficult" populations to do poorly (or try and cook the books). There is no evidence it led to a significant improvement in care. I'm all for getting paid more, but the problem with penalizing or rewarding doctors based on how the patients perform is that it rewards doctors for avoiding difficult patients. ...

The next step will obviously be to make sure that doctors perform the cheapest procedures they can justify, and select the drugs the insurance companies prefer because of rebate deals they make with drug companies.

Here enters both the Law of Unintended Consequences and a bit of paranoia. Alan Greenspan never got it, but the rest of us do understand that people will modify their behavior in ways that benefit them. If you are going to measure something I do, I'm going to change what it is I do so that I look good on the measurement and get the prize. I can illustrate that well with our local TAT problem. As above, my group is monitored for the length of time it takes us to sign off a report. Since our Cerner RIS is a pain to sign on and use multiple times a day, many of us were a bit sluggish about getting this done. But once Big Brother, I mean our friends, started monitoring this, we found ways to improve this problem. My solution, which most of my partners have adopted, is to use a little macro program to keep the RIS window open and in fact flash it in my face every 30 minutes. Thus my TAT never gets much past one hour. Of course, this is a good result. However, with metrics that have more latitude, such as "difficult" patient populations, the practitioner is going to modify his or her approach to fit the metric.

Let's take this to the logical paranoid conclusion. "Meaningful Use" of the EMR is still pretty nebulous, as are most things the government foists upon us, but in reading through the mountains of legalese, one thing about it does become quite clear: for an EMR to be certified, it must be able to transmit data back to the Governmental Mother Ship in Washington, D.C. You can't convince me otherwise. Take the examples above and multiply them by some large fudge factor. The goal is for every doc in the country to report (theoretically anonymously...sure...) on every patient in the country. What a data-mine-field that will be! The potential for abuse is just beyond comprehension. Anyone ready to join me in my paranoia yet?

But I'll conclude on firmer ground with the PACS situation. I think it needs to be determined who owns and who can access the physician metrics stored on your friendly neighborhood PACs. Frankly, I believe this data should be non-discoverable, and available ONLY in anonymized fashion for peer-review and the like. There should be a facility for an individual to see his OWN metrics, but nothing beyond that, except perhaps for how he compares statistically to the rest of the group as a whole.

At this point, I don't know who legally owns this data, the docs, the hospital, the vendor, or the janitor. Also, I don't know if this has ever played a part in any litigation, but I guarantee you, it will someday. Because there are indeed folks out to get us.