Wednesday, July 18, 2007

Electronic Medical Records - EMRs and Pay For Performance (P4P)

A Response to One of My Blogs

One of the joys of blogging is the comments and dialogue you have with fellow bloggers. In one of my recent blogs, July 15, “Doctors Go Haywire with EMRs, A Critic Says,” I received the following comment from Vijay Goel, MD, a Los Angeles-based management consultant and author of www.consumerfocusedcare.

I really like the framework you used of force vs. persuasion. I think too many in the health policy field rely on force-- leaving us with a group of highly talented and dedicated, yet frustrated and demoralized group of physicians.

Where I would like to hear more is the purpose for physicians offering EMRs. There have been some studies where offices using EMR have been less effective than those without.

Ultimately, we should incent the outcome desired (i.e., better outcomes for diabetes care, better sugar levels, etc) over the process we think could help get us there-- and show how proper use of the desired process helps to achieve the desired outcome.

Having been a consultant for many Fortune 500 companies (and smaller ones), I fear that with process metrics people focus on form, not function-- installing an EMR becomes more important than designing a great clinical pathway to engage diabetics-- which takes us only partially toward the outcome we hope to achieve.

I discuss this on my blog:”

Here’s what Dr. Goel said in his blog:

Metrics: Be Careful What You Measure For--You Just Might Get It
“Quality is a buzzword in medicine today--unfortunately, its application is anything but a high-quality, well-designed approach.

There are many reasons why quality is hard, and many reasons why defining quality well may not be fair to existing players who are trying hard to do the right thing. In settings like these, there is no one right approach that fits everyone. Ironically, by having quality efforts led by the government (P4P) and major payers, we're less likely to get it right than by having a number of smaller players seek to play objective, third party roles that maximize benefits for specific constituents.”

”Structurally, quality is hard because:

1.There are no established benchmarks

2.The only metrics that matter--morbidity, mortality, and patient experience-- are complicated and seem largely uncontrollable

3.There is significant money at stake for the "chosen"

4.Politically, no doctor believes they are inferior

5.Society favors heroic intervention over statistically avoided event”

“I'll deal with the first 2 below:


”The medical profession likes to think that all of its practitioners are better than average (of course a statistical anomaly). While licensing and training make all quite good, some will be better than others-- and recent evidence shows there is a strong correlation to better quality with a minimum volume of procedures done, by hospitals and by surgeon. There is also strong evidence that physicians differ significantly in rates of treatments recommended, with few added benefits to societal health. Where benchmarks have been applied and evidence of high and low performers made transparent (not the case in recent hospital mortality rankings), low performers quickly adjusted to close the gap with high performers (see NY state cardiac surgery rankings)”


”There are two types of metrics, process and outcome metrics. Process metrics are seen as means of getting to desired results, with outcome metrics being the desired results. Outcome metrics are the things that really matter-- in medicine this would be rates of morbidity and mortality, with good patient experience also potentially a desired outcome.

The issue we have with quality reporting today is that most of the metrics available focus on process: did they use an EMR, did they give pill X in Y time, did they check body part A for B sign. While process is important, process metrics often forget about context and they forget that there are many roads to the end-goal. Unfortunately, process can only incorporate disease features we think we understand-- and as with drug-eluting stents, we may be maximizing to solve intermediate steps but creating a worse end outcome.”

”Outcome metrics, while politically less viable (everyone wants a reason why they're not #1--and will complain they need to stop seeing sick patients), are truly measures ensuring that treatments work as well as promised. Risk adjustment will never be perfect and segmentation will always be a rough estimation. This is where a single approach linked to payment will get tremendous pushback, whereas a few third party approaches (e.g., Morningstar for financial products) can be triangulated to determine appropriate risks and risk-payments. At the same time, spending a ton of resources on sick people who die soon is ultimately not a great use of society's funds if its not benefiting research-- or coming out of that individual's own wallet (yes, its not fair to the poor--and nothing else in life is fair to the poor either).”

”Outcome metrics also seem most out of the hands of providers. However, in the broader sense, providers have done a poor job of managing longer term adherence to therapy and some outcome metrics (blood pressure, sugar levels) can reflect those changes-- and have been linked to significant improvement in outcomes. Perhaps the issue isn't that physicians aren't able to control those metrics, but that we've been asking them to perform instant miracles instead of helping patients understand and control their disease over time.”

Three Questions Hovering Over P4P

Dr. Goel’s comments raises three questions in minds of P4P critics:

1) Should hospitals and physicians be reimbursed for what they should be doing anyway? That, of course, is a political question, viz, “Is pay-for-performance too much of a good thing?’

2)Is P4P worth the price it exacts from the health system? That’s an economic question. In the United Kingdom, since 2004, the national practice of awarding bonuses to practitioners for meeting “quality indicators, “ has worked in meeting those indicators, but in the process it has driven the national health system deeply into debt.

3) Does P4P, until now based mostly on rewards for meeting “process metrics” result in better outcomes in terms of lower mortality, less morbidity, and better patient experience. To date, that remains an unanswerable managerial, genetic, and cultural question because it’s a long-term question, because some of these factors are uncontrollable, and because it may be beyond the power of “ outcome metrics,” now in its infancy, to measure precisely.


1.S. Campbell and Others, “Quality of Primary Care in England with the Introduction of Pay for Performance,” New England Journal of Medicine, July 12, 2007.

2.R. Galvin, “Pay-for-Performance: Too Much of a Good Thing? A Conversation with Martin Roland,” Health Affairs, 2006:25:w412-w419.

3.GP Pay Raise “Was Mistake,” BBC News, June 21, 2007.

4.A. Epstein, “Pay for Performance at the Tipping Point, New England Journal of Medicine, February 1, 2007.


Unknown said...

A couple of observations:

First, P4P, almost by definition, can work to change provider behavior with respect to a defined universe of things they do for particular types of patients for a limited time. If the P4P incentives are built right, everyone will do what they're incentivized to do, and then there will be little or no room for further improvement.

Consider the Premier demonstration project (most providers are trending upward in their performance, since their names are being published and there's some $$ on the table).

Second, if the British NHS paid bonuses on top of standard rates as P4P incentives, then shame on them -- they should have budgeted better, a la the Premier demo. While providers would certainly prefer bonuses on top of standard rates, and everyone talks about expanding the pie vs. talking zero-sum game, the truth is that cash is a limited resource, and we can't just print more money to make incentive payments. That money has to come from somewhere. In P4P-world, it comes from avoided expenses. (I'm not saying that makes perfect sense; it's just part of the internal logic.)

Finally (for now), outcome measures may not be harder to define and measure, but they sure are less palatable. Who gets the financial benefit of the improvement in health status 6 months or 12 months down the road? The doc who's no longer your doc? The surgeon, when a lot of the good done is thanks to your rehab therapist?

At some point, HMOs and docs could capitate and be capitated in part because of the longevity of patient and subscriber relationships. (If you're capitated and you figure the extra preventive care you provide inures to the benefit of the next guy, you have a financial disincentive to offer comprehensive preventive care.) So given the fact that we all tend to flit about across health plans and docs, who should reap the financial rewards of patient health improvement over the long term?

David Harlow

Unknown said...

I think I have a slightly different take on P4P than most...I think its too little and too mandated to really make a difference.

Where some believe that docs and hospitals should be doing a good job anyway, I'm on the side of disproportionate rewards-- Medicare/Medicaid can be a breakeven business for most providers, but I think those saving the health system real dollars through lean healthcare can be rewarded somewhere on the order of 2-3X while still saving the system money.

Lets make amazing performance something people are willing to put capital investment into, rather than the . 1-2% windowdressing it currently is

Of course, for this to work, the focus would have to be on lean outcomes rather than somewhat vague process metrics.

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