Informed decision making: the new paradigm.

Clearly, the sentinel issues for medical management today are accountability, appropriateness testing, and awareness of clinical outcome. A partnership with physicians is required to discern these features of health care.

This, however, represents a significant shift in paradigms.[1] As evolutionary as Hertzberg's Theory Y (encouragement) was to Theory X (inspection), the new paradigm has more respect for the worker, in this case the physician. In brief, the method relies on our ability to evaluate process, correlate it to outcome, identify "best practices," and close the "feedback loop" to providers about their performance. "[A]cademic and professional organizations and maybe even managed health care plans must explicitly alter the physician's role in society to include their responsibility in the production of new knowledge about what does and what does not improve health."[2]

Continuous Quality Improvement

Continuous quality improvement can help us understand the complexity and depersonalization of our health care system, because it focuses on customers - physicians, patients, and employers. Customers define success when we have met or exceeded their expectations. Quality management and improvement assumes that the worker is competent and earnest. It is a focus on process. "What" becomes more important than "who." We begin by respecting the physician - an approach more likely to succeed than is policing or doctor-bashing. Whatever action we take, the reaction is studied for clues for further improving our behavior.

The health care industry has been "ignoring information technology's potential for three decades. While most industries spend up to six percent of revenues on data systems, health care devotes barely one per-cent.[3] For example, one of the shortcomings of managed care has been the lack of useful customer reporting and statistical forecasting. This is important not only for planning and market positioning, but also for continuous quality improvement and cost reduction. Feedback to employers and other payers, patients, and providers is essential. Delivery systems that cannot produce meaningful performance information will be squeezed out of the market.

The Need for Information

It seems incongruous that there are so few comprehensive data about the process of health care. The approach to information management must change. It should be based on what works best and is most economical. Constant attention to this information, especially in terms of outcomes measures such as access, appropriateness, and acceptance (customer satisfaction) encourages early intervention and illness prevention. In brief, this kind of managed care combines patient advocacy with efficient health service, proper and timely payment, and effective insurance risk management.

Modern computer techniques, such as relational database management, can translate data into information that will be available to physicians across the country. Data comparing best practices fosters both intellectual and moral support and perhaps ways to avoid malpractice. The only goal should be what works best for the health of the patient.

How do we get the information we need to evaluate the cost benefits of a procedure? There are two ways - passive and active. The passive method is to associate diagnoses with requests for payment for services rendered and then reconfigure these data. This transformation of data into information establishes the clinical context and episode of care. The active way is to extract a database of the clinical and cost picture and present this information concurrently (i.e., in real time) to those who need to know. The medical record is a clinical database. It can be divided into past medical problems, present medical concerns, and items that have the potential to cause disease. Cost and production data from claims and encounter forms constitute other databases. In either case, we must protect the confidentiality of this information whenever it is made available to authorized users.

With more knowledge, we will make better decisions. Knowledge-based systems help relate outcomes to the antecedent care, i.e., the medical process. They relate quality, efficacy, and cost issues in a value equation, taking into account disparate data, both qualitative and quantitative. They answer questions of quality, cost effectiveness, and acceptability. They may even help redesign our treatment of groups and individual patients by referring to our past experiences, both effective and ineffective.

Knowledge-based systems should be dynamic, applying rules that enhance learning (heuristics), reminding us what works, how well it worked, when it is critical to act, or when we or the patient fails to follow-through. Clearly, we must continuously gain new knowledge and improve our information systems as we help others to manage care.

Knowledge-based systems also generate a variety of reports that can ferret out inconsistency. They allow physicians to monitor their own performance and standards and to compare them to those of their peers. These reports are valuable because they address specific products, business risks, and the overall health of the patient or system.

Informed decision-making and knowledge-based systems do not have to be intimidating or awkward to use even at this early stage of development.[3] Operating on a micro- or minicomputer network, the systems' capabilities can be used to enhance decision making.[4] For example, documents, reports, databases, and text files of varying file structure can be made available in an interactive mode. This is what is meant by online support of the practice of medicine. It helps establish perspective and organize complex tasks and serves as a communication technology for groups. When the systems are used for executive information, access is allowed or restricted on the basis of the audience and purpose.[4]

Summary

It is our responsibility as health care managers to maintain or improve the quality, appropriateness, and cost effectiveness of the services we provide or arrange. When we make recommendations, however, we must be certain that salutary change is both wanted and effective.

Informed decision making is the principal tool or method we will use to accomplish these objectives. It becomes a reality when the needs of customers - payers, providers, and patients - are addressed and when they have achieved a co-destiny relationshi with the institution.

The tool is fashioned as follows: Data are translated into information as they are being accessed, managed, analyzed, and presented. The information loop is closed. The customer is informed, empowered, and involved in the care, facilitating change.

In meeting or exceeding customer expectations, informed decision making represents a new imperative in health care. In this new paradigm, we will finance more sensitive, efficient, cost-effective, and efficacious health services. We see this as the beginning to the end of the health care crisis. Indeed, we see ourselves as suppliers of quality and information, first determining and then communicating what does and does not work in our methods.

References

[1.] Kuhn, T. The Structure of Scientific Revolution. Chicago, Ill.: University of Chicago Press, 1970.

[2.] Brook, R. Quality of Care: Do We Care?" Annals of Internal Medicine 115(6):486-90, Sept. 15, 1991.

[3.] Rifkin, G. "New Momentum for Electronic Patient Records." New York Times, May 2, 1993, p. 8.

[4.] Kaplan, J., and others. Quality Improvement and Information Systems. Tampa, Fla.: American College of Physician Executives, in press.

[5.] Davidson, W., and Malone, M. The Virtual Corporation. New York, N.Y.: Harper-Collins, 1992, p. 222.

Jeffrey G. Kaplan, MD, MPS, is a health care consultant in Cortland, N.Y. Joseph Brophy is a health care consultant in Hartford, Conn. Dr. Kaplan was previously Vice President for Medical Management Information and Mr. Brophy was President, Travelers Insurance Companies, Hartford.