A prevailing belief in the modern world of health care is that outcomes would be a lot better if people would just do what the best-evidence dictates. In clinical practice, best evidence is incarnate in guidelines and protocols generated by societies, associations, and various empowered committees in hospitals and health care organizations. Concerns about conflicting outcomes in the clinical literature, the extension of the results from the study population to patients in general, and whether the cost of the program is worth the payoff are all safely classified as reactionary obstructionism by the leaders of this revolution. Pay 4 Performance was sold as a way to reward those who conform to ‘best practice.’ While it continues to have advocates, sharp-end practitioners have collectively come to the realization that P4P is a hoax intended to further reduce payments (mostly government) to health care providers.
It is already the subject of caustic irony, published in top-shelf peer reviewed journals:
Finally, it is a dark day when Dilbert is smack-on about the world of health care:
Where does all of this leave us? Well, at the highest levels, the backers of best-practice believe that the problem is that we have not gone far enough. Like the British generals prior to the Somme, their belief is that success requires the same template executed on a larger scale. In this instance, the belief is that practitioners routinely ignore best practice, in spite of whatever the documentation they generate might represent. Hence the only way to verify what happened is to create an enduring, reviewable record.
While the vendor appears to be marketing comprehensive systematic nearly prospective review; in reality such evaluations are certain to be extraordinarily expensive. Worse, performing them on a large scale would require an enormous number of hours, which would only be affordable if the work was done by less-skilled reviewers, or exported ‘off-shore.’ Realistically, this record will be used to ‘look back’ and determine the causes of bad outcomes. Do those who will be using this system for this purpose possess the necessary expertise (e.g. training as the NTSB would require)? I am unaware of any evidence to support this assertion; in fact, I would be flabbergasted if this was the case. Even in their infomercial, it is clear that they are focused on ‘Who are the bad actors?’ rather than ‘Why aren’t these practitioners doing what we want?’ This is not a trivial distinction; it is the difference between mindless, punitive inspection and actually the kind of human factors analysis necessary to improve performance (see The Inspections Will Continue…..). Woe to the ‘bad practitioner,’ this technology provides a mechanism to acquire evidence and levy sanctions.
Beware the briar patch. While many hospital administrators thirst for
information this detailed, most do not realize that it could consume
all of their time, and generate liability on a scale that they
previously have not encountered. Some observations for health care
organizations that are contemplating purchasing this technology:
1. If you don’t sanction practitioners for failure to comply, you’ll have to justify that decision. If you apply sanctions appropriately, there may be no one to do the work.
2. If practitioners comply with all applicable regulations and guidelines, economic failure is certain in any but the most lucrative practice environments. Nothing will get done.
3. Conflicting guidance will create organizational conflict. Where guidelines conflict, practitioners will either act in accord with their best judgment, or worse, compel institutions to generate guidance. This technology requires the organization to have an opinion about best-practice in every domain.
4. Legally, the enforcer assumes all of the risk. Plaintiff’s attorneys will love this: it makes the hospital/clinic accountable for every action of every practitioner. There will be no excuses for either not knowing or not acting.
5. The ‘rules’ you enforce had better be defensible in the face of litigation and continuously up-to-date. Every single one is likely to be tested in the courts.
Of this I am certain: this technology will be a weapon to silence counter-revolutionaries and reactionaries.
This post was written by Mike O'Connor