Metric Movement

Has the metric movement gone too far in Medicine, as Robert M. Wachter suggests in a New York Times Opinion Piece?

“… the measurement fad has spun out of control. There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a “top 100,” “honor roll,” grade “A” or “best” hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.”

Or in the words of Dr. Don Berwick, former head of the Centers for Medicare & Medicaid Services:

“Stop excessive measurement: I don’t mean that we should stop measuring. Indeed, I celebrate transparency in every form. How else can you learn? But we need to tame measurement. It has gone crazy. Far from showing us our way, these searchlights training on us, they blind us. …. I vote for a 50 percent reduction in all metrics currently being used.”

A HealthAffairs Blog post that discusses the call for measures that matter asks a key question about that movement:

“Yet defining the measures that matter is complicated because we often gloss over an important question — measures that matter to whom?”

At Doctors Council we have noticed that debates over metrics are often debates over power and control.  It is not the idea of measurement that offends doctors–Dr. Berwick is right: “How else can you learn?”—rather, it is the fact that the measurements feel separate from the work of doctoring.  They feel disconnected from the healing process, and are often experienced as an add-on that takes time and energy away from the work at hand.

This feeling that the patient and provider are there to serve the metric  is captured by Craig Bowron, MD who writes in KevinMD

“Without a hint of hyperbole, it’s clear that many physicians feel that their primary task is to satisfy the electronic chart, so as to satisfy the system. When you’re done with that, you might see if you can figure out what’s wrong with the patient and how to fix it. All these “innovations” in the business of medicine have made direct patient care much more difficult.” 

As we noted in a previous Doctors Council blog, while there is value in reporting the numbers, the question is debated if  the practice of medicine has become too focused on numbers and as a result, the autonomy of doctors is being eroded or lost.  In addition to doctor autonomy, there is also the concern if the medical profession has become good at quality assurance as opposed to quality improvement.

Rather than the doctors serving the metric, the metrics need to serve the patients and doctors.  Therefore the solution is not some sort of technical fix; rather it is a question of involving patients and physicians in the creation of the metrics.  This is hard for doctors to do on their own, and gets to a key question: How can doctors come together collectively to shape the institutions in which they practice?