Although the concept of quality improvement is not new, very little is known about physicians' views on and experiences with quality improvement tools and principles. In 2003, The Commonwealth Fund conducted a National Survey of Physicians and Quality of Care to explore physicians' use of quality improvement tools, including information technology (IT) tools; future plans to initiate quality improvement activities; and views of potential solutions, as well as barriers. Because information is at the core of quality improvement, the survey explored physicians' access to data on their practices and performance, as well as their willingness to share such data.
In its 2001 landmark report, Crossing the Quality Chasm
, the Institute of Medicine (IOM) stressed the importance of care coordination to providing high-quality care. To examine the issue from a physician-level perspective, The Commonwealth Fund survey asked physicians about the problems that patients encounter as a result of poor coordination, as well as the problems that physicians themselves experience, like the timeliness or availability of referral information.
While research has demonstrated that hospitals and health systems may take financial risks by making quality improvement a priority, little is known about similar risks physicians might face. To address this gap, the survey asked physicians about the role quality plays in determining compensation and about other financial factors they may have experienced in striving to improve quality. Finally, the survey explored physicians' opinions about various solutions and approaches to improving quality.Information Technology: Current Use, Future Plans, and Perceived Barriers
Results from the survey indicate physicians' use of information technology (IT) is growing, albeit slowly. Electronic billing is the IT tools used most routinely, despite the reported benefit of other IT applications. For example, providers who use electronic medical records (EMRs) reported more efficient clinical operations, due to better accessibility and organization of information. EMR use may also increase billing revenue as a result of more accurate tracking of service provided, more accurate coding, and more timely collection of payments. By reducing the need for transcription, data entry, reception, and medical record management, EMRs may also reduce physicians' office operating costs. Despite these benefits, only 27 percent of surveyed physicians reported using EMRs either routinely or occasionally, with an additional 20 percent saying they plan to use them in the next two years. Another innovation—electronic access of diagnostic test information—allows results to be viewed earlier, facilitates more timely intervention, decreases the ordering of unnecessary tests by 10 to 15 percent, and decreases the amount of time spent charting. Although 58 percent of surveyed physicians say they routinely or occasionally access test results electronically, only 37 percent say they do so routinely.
Similarly, more than one-half of the physicians surveyed generate patient reminders, but only 21 percent have automated the process. Clinical decision support systems (CDSS) have also been shown to improve clinical practice and patient outcomes. Such a benefit was demonstrated in 43 percent of the studies reviewed by Dereck Hunt and colleagues. Yet less than one-quarter of surveyed physicians say they use CDSS routinely or occasionally.
The most significant barrier to IT use is cost, with financial burdens greatest for solo and small-group practices—the settings where most U.S. physicians practice. The initial costs of acquiring EMR capability have been estimated at $15,000 to $50,000 per physician, excluding the cost of decreased productivity that can occur in early stages of implementation. Studies have found that IT can have financial benefits. However, these benefits vary by practice, from no reported gains to gains of more than $20,000 per year.Practice-Level and Performance Data: Availability, Sources, and Willingness to Share
According to the survey's findings, physicians are not using data about their practices in a comprehensive way. More than one-half of physicians find it difficult or impossible to get basic profile data on their patients. An even greater percentage (85%) are unable to identify or have difficulty identifying patients who may require closer attention because of abnormal laboratory results or medications that need to be monitored or changed. Physicians who can easily access such information are more likely to practice in larger groups and work full-time in clinical care. Collecting and analyzing data requires knowledge, special technical tools, staff, and time. Large physician groups, due to their financial flexibility and organizational culture, are more likely to engage in these kinds of activities.
Physicians also do not routinely use data to monitor the quality of their clinical practice. Thirty-three percent of surveyed physicians say they have access to performance data, most relying on external sources of information. One-quarter of surveyed physicians identified insurers and health plans as the most common source of quality-of-care data. Only 14 percent said they generated performance measures themselves. Salaried physicians and those who work in larger groups are more likely to generate performance data internally.
Although nearly three-quarters (71%) of physicians agreed that performance data should be shared with their medical leadership, only slightly more than one-half (55%) agreed this information should be shared with patients. Twenty-nine percent agreed that this information definitely or probably should be shared with the public. However, despite physicians' discomfort, there is evidence that sharing medical records with patients may improve adherence to medical advice. Peer comparison and mentoring can lead to improvements in care, and information sharing could help physicians refer patients to the most appropriate specialists.Physicians' Involvement in Quality Improvement Activities
Only one-third of all surveyed physicians report participating in activities designed to change and improve their practices, with the type of practice setting affecting the degree of involvement. Those more likely to be engaged in improvement activities include physicians who work in larger groups, physicians who work in hospital-based or staff models, and salaried physicians. Similarly, a greater percentage of physicians who work full-time (more than 40 hours) are active in redesign, compared with those working parttime (20 hours or fewer) (37% vs. 22%) and a greater percentage of primary care Physicians (PCPs) are involved, compared with specialists (42% vs. 31%).
Collaborative activities that involve public agencies or community groups working together to improve outcomes for patients with specific conditions present another strategy to create system-wide change. However, two-thirds of the surveyed physicians report never having participated in collaboratives. Providers who have used quality improvement collaboratives are more likely to be primary care, salaried physicians in larger group practices.Coordination of Care and Referrals
The most commonly reported quality problems for physicians are issues of care coordination. These issues include disruptions in the process of transferring important patient information and patients receiving conflicting information. Most physicians (72%) reported that patients' medical records, test results, or other relevant information were sometimes or often not available at the time of a scheduled visit. One-third often or sometimes observed that tests or procedures had to be repeated because findings were not available or were inadequate for interpretation, and 28 percent reported that care was compromised due to conflicting information from different health professionals. One-quarter (26%) observed that patients experienced problems following hospital discharge due to information not being released in a timely manner. In some cases (15%), physicians reported that patients often or sometimes did not receive appropriate follow-up, despite test results that indicate the need for such treatment.
The frequency of coordination problems differs somewhat by practice setting and size, with physicians who practice in groups of more than 50 more likely than solo practitioners to report such problems. In addition, PCPs mainly observe issues around follow-up and hand-off (e.g., hospital discharge process), while specialists more often experience test results that are unavailable and need to be repeated.
One-third of physicians said they had problems receiving information and feedback regarding referral in a timely manner. These problems are more frequently experienced by specialists and physicians in larger group practices. In addition, most physicians (64%) say they rarely or never have objective information about the quality of care provided by physicians to whom they refer patients. Quality of care data appears to have little impact on referral decisions, with most physicians using other information, such as patients' experiences with physicians or professional reputation among peers.Quality Improvement Strategies
The survey explored physicians' opinions on the effectiveness of seven potential strategies to improve quality of care. These include: appropriate time spent with patients; patient access to preventive care and health education; treatment guidelines or protocols; information technologies; information about specialists and specialty centers for referrals; team work and communication. Most physicians (52%) cited time spent with patients as an effective strategy in improving quality of care. They also cited access to preventive care (41%) and teamwork and increased communication among health care professionals (35%). Other approaches such as guidelines, electronic medical records and e-prescribing, and performance data, received only limited support from physicians. While most physicians believe that team care results in better decisions, some remain skeptical. One-third (32%) agree or strongly agree that teamwork makes care more cumbersome, while one-quarter (24%) agree or strongly agree that a team approach can increase the likelihood of medical errors. Physicians in solo practice are less supportive of team care than those in larger groups or in hospital settings. Specialty and gender are also significant factors. Forty-one percent of primary care physicians said that teamwork would be very effective in improving care, compared with 33 percent of specialists. Thirty-two of male physicians said that teamwork would be very effective, compared with 45 percent of female physicians.Incentives and Disincentives for Providing Quality Care
For most of the surveyed physicians, productivity remains the major factor determining compensation. Thirty nine percent of physicians reported that board recertification status is a factor in compensation, while less than one-third (27%) cited clinical quality as a factor. Under current payment policies, physicians are rarely compensated for providing certain patient-centered services, like e-mail or phone consultations. None of the surveyed physicians were reimbursed for e-mail consultations and very few received reimbursements for phone consultations (4%) or group patient visits (5%).
There is no system in place to financially reward physicians for providing high-quality care. In fact, there appear to be financial disincentives. Altogether, one-half of physicians said that providing the best quality of care often (23%) or sometimes (28%) translates into lower revenues. Physicians in solo practice are more likely than physicians in larger group practices to hold this opinion (58% vs. 46%, respectively).Implications for Policy and Practice
The survey confirms that physicians have not yet fully embraced quality improvement, with a striking gap between physicians in solo practice and those in larger group settings. Although the majority of U.S. physicians work in solo practice or small group (2–9 physicians) practice settings, quality improvement methods have been least adopted in such environments. Quality improvement appears to be institutionalized within organizations that have the infrastructure to support it, but not fully disseminated throughout the profession. Accelerating adoption of quality improvement principles and tools by physicians will require policies that address the following three areas: 1) capacity and infrastructure; 2) education to build knowledge and skills, and 3) professionalism.
It is unlikely that a robust IT infrastructure will be established, and even more unlikely that tools will be adopted by physicians, without federal leadership. Some recent progress has been made on this front. For instance, in May 2004, the Department of Health and Human Services (HHS) appointed a new national health information technology coordinator, David Brailer, M.D. In addition, the Bush Administration set forth a goal for most Americans to have electronic health records by 2014. In Congress, several bills were proposed that address IT, from Senators Judd Gregg (R-N.H.), Hillary Rodham Clinton (D-N.Y.), John Kerry (D-Mass.), and Representative Nancy Johnson (R-Conn.), and most recently, on May 11th 2005, Rep Tim Murphy (R-Pa.) and Rep Patrick Kennedy (D-R.I.) introduced the 21st Century Health Information Act as a bipartisan legislation to address the systemic obstacles and misaligned incentives that have hindered health information technology adoption. In 2005, the President's budget for IT initiatives includes $50 million to AHRQ. In addition, the 2006 budget includes $75 million to the Office of the National Coordinator for Health Information Technology to foster collaboration and develop an interoperable health information technology network. Although this represents a great step forward, more funding and attention will be required in the future. In the United Kingdom for instance, the government invested $10 to $16 billion toward the National Health Information Infrastructure. Future policy options should include federal grants, annexes to the Medicare diagnosis-related group physician reimbursement, and revolving loans (which have been particularly successful in transportation and environmental protection). In the United Kingdom and Sweden, for example, physicians who invest in EMRs receive government subsidies. Fifty-eight percent of physicians in the United Kingdom and 90 percent of physicians in Sweden report using them.
To support the spread of IT, it will be necessary to create and support standardization. The Health Informatics Initiative of May 2004 led to the adoption of 15 standards by HHS and 20 federal agencies. The implementation of local or regional standards using "community-based interconnectivity" models are under way on the state-wide and citywide levels, as well as in local, hospital-based and integrated health care delivery settings (e.g. Massachusetts, Rhode Island, Santa Barbara, Regenstrief Institute in Indianapolis). These systems allow connections to be made and information shared among various providers, including physicians, emergency room staff, and pharmacists. By spreading the cost of the IT infrastructure over a greater number of people, such models may significantly decrease the cost of investment and make it feasible for individual or small groups of physicians to acquire these technologies. Other IT business models will likely require private and public sector partnering to invest in the necessary infrastructure to support and sustain quality.
Quality measurement has not yet been fully embraced by the medical profession, despite its important role in improvement activities. The task of monitoring one's practice and using that information to make improvements should not only be a required skill, but a professional responsibility. In 1999, the American Council of Graduate Medical Education approved a new set of residency program training requirements, under which residents must reach competency in six areas, including practice-based learning and improvement and systems-based practice. The recognition of these competencies is an essential first step in training the next generation of physicians to evaluate and improve their own care.
The 2001 IOM report, Crossing the Quality Chasm, recognized that necessity of aligning payment policies with quality improvement. The IOM called for public and private purchasers to reexamine their payment policies to remove barriers that impede quality improvement and build stronger incentives for quality enhancement. Currently, quality of care determines compensation for less than 10 percent of physicians. Instead, productivity is the main determinant for most physicians. To understand and determine how financial incentives can best foster quality, pay-for-performance programs are currently being tested and evaluated—at Pacificare and the Integrated Healthcare Association in California, among other locations.
Physicians are still cautious about making the quality of their care transparent, but if quality is to be rewarded, data must be measured and shared. Ultimately, the medical profession must take the lead to make care more transparent, with physicians balancing issues of ethics, fairness, accountability, and confidentiality. The public is becoming increasingly worried that doctors are secretive and wary of making full disclosure. Physicians should work to enhance trust between the public and the profession by allowing greater openness about the quality of the care they provide.