The Institute of Medicine has designated patient-centered care—care that is respectful of and responsive to individual patient preferences, needs, and values—as one of six domains of quality. Many Americans, however, do not receive such care, despite research showing that it can improve clinical outcomes as well as patients' satisfaction. Commonwealth Fund grantee Sarah H. Scholle, Dr.P.H., assistant vice president for research and analysis at the National Committee for Quality Assurance (NCQA), is currently developing and testing a set of measures to evaluate the "patient-centeredness" of care provided in physician offices. Recently, we spoke with Dr. Scholle about the challenges of defining, recognizing, and advancing patient-centered care practices.
Can you define patient-centered care?
Sarah Scholle: Patient-centered care looks at how patients interact with the health care system and how the health care system supports patients. In our project, we wanted to get right into the nitty-gritty of how a practice can demonstrate that it is patient-centered, so we asked, "What are the key concepts that make sense to patients and health care professionals?" The measures we developed focus on the way practices are organized and the extent to which they support patient-centered interaction, like the scheduling process or the ability to get advice by phone or e-mail. We also thought about measures around patients' experiences of care. We came up with six domains: access to care, communications, quality improvement, coordination of care, care management, and self-management. We included quality improvement because we think it's critical that practices use information to evaluate care and improve, particularly in regard to what patients feel they need.
What are some of the specific elements of patient-centered care that you want primary care providers to measure?
Scholle: Well, in the domain of access to care, for instance, how easy is it to get information from your physician or practice? How easy is it to get into the office if you need help? Does the practice have the ability to do secure e-mail? Are there resources for returning phone calls on clinical matters in a set time period—allowing patients to get clinical information without having to rearrange their lives to get into the office? In terms of care management, do practices have an organized way of communicating with patients about how they're doing? If you're a diabetic, do they tell you about controlling your A1c? Does the practice provide educational support and involve the patient's family members? Does it refer patients to other educational opportunities, like a smoking cessation group, to help them manage their conditions on their own?
We've also worked with a special group of consultants to add cultural competency into the framework. For practices that serve populations with limited English proficiency, you can't have access and communication if you don't have the ability to communicate in a way the patients understand. We also want to look at trust and respect—whether you see different levels of performance with different groups.
Patient-centered care doesn't seem like a groundbreaking idea. Why isn't it the norm?
Scholle: I'm not sure we even know if it is or is not the norm, because we don't have measures to evaluate the health care system from this perspective. Instead, we have focused on measures that look at clinical effectiveness or ones that are based on financials. I don't think doctors set out to practice non-patient-centered care. Some practices really do value and try to adhere to patient-centered principles. But there are a lot of pressures on physicians and staff that make it hard to take extra time to give full explanations of illnesses or treatment options. There are financial pressures that make it hard to do all the steps to coordinate care for chronic illnesses or get patients to do better self-care. Generally, doctors can't bill for an e-mail or phone consultation or for a longer visit to provide more educational materials. Our reimbursement system does not encourage practices to develop resources to support patient-centered care. It is focused on "What did you do?" and "How many times did you do it?"
We also don't have the metrics to help us understand where practices currently are. For hospitals, there's a system in place to help them report patient experience data—CAHPS [the Consumer Assessment of Healthcare Providers and Systems]. But in the outpatient setting, it's more complicated to get survey data, physicians don't learn about it, and there's no incentive for them to collect it. If we have valid metrics, we could begin moving toward a system that rewards physicians and practices for meeting quality standards, for doing a good job, and for helping patients manage their chronic illnesses and care outside the office.
How do you think physicians will react to using these measures? Are there other barriers to patient-centered care?
Scholle: We're going to be talking to doctors to see what they think. We're conducting qualitative interviews with physicians about these performance metrics to find out if they think they're useful in guiding their practices and how they feel about using them as a basis for rewards. Our question is: If you can earn rewards for doing well, would that be incentive for you to institute patient-centered practices and to collect data?
I think physicians want to do a good job. Part of the issue is that we need those who purchase care—like insurers and employers—to demand information about these kinds of metrics to hold plans and providers accountable. We also need patients to demand information. All of these stakeholders are key to moving the patient-centered care agenda forward.