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Rapid Responses: Rapid Responses published:
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Abuse of information system
- David J Brookman (7 April 2003)
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Shifting the goal posts in performance in Canadian primary care – whither physician performance?
- Carmel M Martin, William Hogg, Professor, Family Medicine, University of Ottawa (14 April 2003)
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David J Brookman, Senior Lecturer General Practice Australia
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There is a major defect in logic which determines what a practitioners records is a measure of the quality of care. Practitioner use records for different purposes from institions, and lawyers. For many it is a memory aid, some only record abnormality - there are only about 10 -15% of us who obsessionally record data in order to maintain a continuous record for monitoring progress of disease. To now claim that what is recorded reflects the quality of care is ludicrous. Applying evidence based practice requires three essential elements: 1. The ability access up to date clinical information
There is no information system which permits the analysis of adherence to evidence based practice that is exercised by an external reviewer because they are not privy to the third element. Hence any quality assurance information system while it can record adherence with current clinical evidence, and it can test the clinical judgement and skills it cannot possibly declare that non adherence with evidence is indicative of poor quality - only the practitioner who makes the judgement can do that. The concept of external review of practitioners by funding bodies claiming to be a quality measure is a direct attempt at coercion of practitioners, undoubtedly intended to reduce expenditure. This information system abuse will alienate the profession away from using such systems for their own benefit by imposing the "big brother" effect. Providing a clinical audit system using the data collected by practitioners electronically which the practitioner then uses for self review is probably effective in produing behavioural change - it has not as yet been tested in a controlled trial. This abuse by "profiling" will probably prevent development of potentially productive improvements in quality of care. Competing interests: Research on developing informations systems for self directed clinical audit |
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Carmel M Martin, Associate Professor, Department of Family Medicine University of Ottawa, I Stewart Street, Ottawa, K1N 6N5 Canada, William Hogg, Professor, Family Medicine, University of Ottawa
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We agree with Goldfield, Gnani and Majeed(1) that it is important to measure physician performance in a way that will improve the effectiveness and efficiency of primary health care delivery. As primary care physicians we have a responsibility to ensure such measurements of our performance will actually drive our care in a positive direction, although the generalist, longitudinal and team based nature of primary health care makes this a complex exercise.(2) In addition, different patient disease, socioeconomic and cultural profiles make comparisons difficult to interpret and release of this information to the general public of this information is potentially unfair. In Canada, there is much discussion about Family Physician performance at a national level, but little action to date. At a local and regional level, however researchers from the University of Ottawa have had considerable success. Our model(3)is practice-based rather than physician profiling and run by the University, independent of government, payers and medical organizations. Clinical performance measurement is confidential and not released to the public at any level that could identify individual practices or physicians. Performance results of detailed repeated chart audit and patient survey are supported by feedback from facilitators. Such feedback is emotional, complicated and takes skilled people several visits before it is integrated fully and accepted by physicians.(4) The practices are helped to use the information to set targets and create a plan to improve service delivery. Physician and practice patterns do change.(2) Currently we are funded to implement this research program at a provincial level in Ontario. Other developments in Canada are noteworthy. The current Primary Health Care Transition Fund (PHCTF) program is shifting the emphasis from physician performance to the performance of an interdisciplinary team or practice. PHCTF is mostly about promoting improved team performance in its goals of access, comprehensiveness, quality and accountability with less focus on individual physician performance. This is appropriate and fair; however, completely ignoring the primary care physician leadership role in responsibility for clinical care outcomes will not best serve the population either. We should not shy away from true physician accountability that is based on fair and scientifically valid appraisal, but recognizes different roles and responsibilities in the complexity of primary health care delivery in different populations. There is an urgent need to collaborate internationally on how to measure such performance with well validated indicators and to improve care delivery. Such measurement should be conducted at arms length from the payers whether they are private or public in a way that is empowering and formative and not punitive. Carmel Martin and William Hogg, Department of Family Medicine, University of Ottawa, Ontario, Canada 1. Goldfield N, Gnani S and Majeed A. Primary care in the United States - Profiling performance in primary care in the United States, BMJ 2003;326:744-747 5 2. Martin C, Douglas R. "Getting Value for Money". Measuring the outcome and quality of general practice care. MJA, Vol 159, 16 August, 1993. 3. Lemelin J, Hogg W, Baskerville N. Evidence to action: a tailored multifaceted approach to changing family physician practice patterns and improving preventive care. CMAJ 2001; 164(6):757-763 4. Baskerville NB, Hogg W, Lemelin J. Process evaluation of a tailored multifaceted approach to changing family physician practice patterns improving preventive care. J Fam Pract 2001; 50(3):W242-W249. Competing interests: None declared |
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