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Patient Engagement I

The Patient as Consumer and the Measurement of Bedside Manner

Blog Post · March 20, 2017

The field of patient experience has emerged over the past decade. Like patient safety in its infancy, this field has not been fully embraced by the health care industry. While measuring customer experience in order to improve may seem like a noncontroversial standard practice in most other industries, the practice is not entirely accepted among physicians. The mere mention of this term can induce a feeling of intense anger — “I am a physician, not a barista asking for your order.”

The larger question is, is health care a service industry? Many physicians do not believe that patient satisfaction is a legitimate pursuit. In this viewpoint, enhancing patient experience offers no value to medical care.

Is there common ground between patient and physician perspectives? When approaching an encounter with a patient, the physician goal typically is to make the correct diagnosis and provide an evidence-based, efficacious treatment plan. Consumer surveys show that patients value the correct diagnosis, a proper treatment plan, and the doctor’s medical knowledge. However, patients also value whether the doctor treats them with respect and dignity, listens and cares, takes time, and takes them seriously. The ideal patient experience merges excellent medical care, high-quality outcomes, compassion, and empathy that address the emotional needs of patients. Can physicians deliver all these things given the other constraints of practicing modern-day medicine?

Research demonstrating the correlation between service and quality is mixed. Some studies find a correlation between service and medical outcomes, yet other reports show no linkage between patient experience and outcomes, and some show a negative correlation. Study in this area, and the controversy, is ongoing.

Physicians have numerous concerns with performance measurement in this area. First of all, is it really their performance that is being graded? If a clinical team member provides a negative experience, will the doctor be held accountable for factors outside his or her control? How can a patient with no medical background have the sophistication to be a judge of medical quality? Physicians worry they are being pressured to do something medically inappropriate to make the patient happy — “Should I prescribe antibiotics to a patient with a viral infection, or order a CT scan for a patient with a headache?” As Dr. James Merlino, the doyen of patient experience, says, enhancing patient engagement should not be about improving happiness, but rather be about safer care with better clinical outcomes.

Concerns About Patient Satisfaction Surveys

In 2017, the U.S. government will withhold $1.7 billion in Medicare reimbursements from hospitals with poor performance on the HCAHPS survey. This patient satisfaction survey has a response rate of about 30%. Many physicians and statisticians ask how decisions can be made based on data with such a low response rate.

Yet the hospitality industry treats customer survey scores and comments like treasure. They use this information to drive improvement, despite their own low response rates. They understand that 96% of consumers who have a negative experience never lodge a complaint. In health care today, we do not value survey data and patient feedback with the same intensity as other industries that serve people.

The more cynical among physicians feel that the patient experience movement is just another cottage industry within medicine that enables consulting companies to thrive, while detracting from the real practice of medicine. It has become another charged administrative issue and another bully club for administrators to use against their doctors. The fact that many physician bonuses depend on the results of these survey scores drives further embitterment.

The emergence of transparency has also inflamed some physicians. Consumer metrics in health care are chaotic and not user friendly. CMS posts HCAHPS data on the Hospital Compare website, but many consumers are unaware this data is available. Leapfrog compiles hospital ratings based on patient safety reporting. ProPublica reports surgeon complication rates for a small number of procedures. The methodologies of Healthgrades, Consumer Reports, U.S. News & World Report, and Truven Health Analytics all came in for criticism from the Healthcare Association of New York State. A few health systems post their data. Yet all of this information is piecemeal, and the savviest of consumers would not be able to find all the information they need when choosing a doctor or a hospital.

When Health Care Consumerism and Big Data Merge

Despite the limitations of these data sources, the fact remains that consumers crave information whenever they purchase products or services. Much of our economy today is based on search engines that offer crowdsourced rater reviews, such as Yelp, Product Hunt, and TripAdvisor.

Health care start-ups are emerging from the consumer desire to see information before making what can literally be a life-or-death decision. Amino collects different categories of data on doctors, such as the number of cases a surgeon has performed, and it recently added a new feature on cost data transparency. Crowd Clinical mines the Web for positive and negative comments about hospitals, drawn from Twitter and other social media sources. NarrativeDx developed a natural language processing software platform. It processes patient comments and reviews to provide hospitals with deeper insights into their patient perceptions.

Many industries improve their performance when their data are shared transparently. Health systems, too, that are posting their patient satisfaction data on the Internet are seeing improvement in their scores and comments.

Yet I believe the chief motive for health care to join the transparency movement should not be to raise scores but to help patients make important decisions. We must acknowledge that medicine is at once a vocation, a profession, and a service.

For many physicians in training, the importance of patient engagement seems obvious. The medical students I teach ask, “Why wouldn’t I want to engage my patients?” Health care is in need of redesign so that doctors can again enjoy practicing and so that patients get what they need and deserve. Pursuing the “quadruple aim” — which encompasses delivering high-quality, reliable outcomes for patients and populations with value and engagement — provides a hopeful path for the future of health care.

 

This blog post originally appeared in NEJM Catalyst on August 2, 2016.


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