The Physicians Practice Profile: a piece of the quality puzzle.

In the controversy that preceded passage in 1985 of New York State legislation aimed at reforming medical and dental malpractice litigation, the medical profession had repeatedly emphasized the provision of high-quality health care as its primary goal. It is not certain if there was a cause and effect relationship between the imminent passage of the legislation and this expressed goal, but it is now clear that high-quality health services are legally required in New York. As part of the package has also come greater scrutiny of physicians and dentists prior to the granting of hospital privileges. This latter requirement is now manifest in the Physicians Practice Profile as produced by the New York State Department of Health.

The New York State physician profile represents a departure from profiles currently described in the literature. Koska's report [1] of a recent survey of approximately 650 hospitals found 52.1 percent had physician-specific profiles, with another 7.6 percent having them under consideration. They were described as being used for tracking DRG performance, for physician recruitment planning, to plot strategies for the development or expansion of specific clinical departments, and to flag inefficiencies in the use of resources. The typical profile outlines the total charges per patient or per physician, or perhaps an average of these charges, and then follows up with what the DRG paid for that case.

Horn and Horn [2] described a computerized severity index to be used to adjust physician practice profiles for accuracy of utilization of DRGs. Feinglass et al. [3] discussed the use of severity-adjusted physician practice profiles to identify cost-effective patterns of care. Because of the discretionary nature of medical decision making and geographic variations, their study of the literature indicated variations in illness rates, demographic or socioeconomic characteristics, insurance coverage, and access to services. Appropriately, they also commented on differences in patient expectations, values, and capabilities. Zuckerman et al. [4] had earlier noted that states with mandatory hospital rate-setting programs have significantly different practice patterns.

All of these conclusions are valid, but they do not bear directly on a practice profile with the components listed by the New York State Department of Health. The New York system is intended to be utilized in credentialing as part of the process of legalizing quality health services.

Genesee Memorial Hospital, an acute care community hospital with 70 certified beds, is now in its fifth year of maintaining physician practice profile as part of an ongoing quality assurance activity. The hospital had a medical records department, a staff of utilization coordinators, and an infection control nurse before the profile system was established and added a quality assurance/risk management coordinator shortly after it began to develop the physician practice profiles. The cooperation of these individuals has been essential to the development of the profiles.

Because these profiles are about the medical staff, the first step was to involve the medical staff in defining the categories that were listed in the regulations. This set the limits of study and allowed medical staff participation in the development and subsequent modification of profile content. There is no doubt that the most important decision was to include in the profile only physician performance data that were derived from decisions and judgments made in peer review and duly recorded in committee and department minutes. Any other data have been limited to objective items, such as the number of patient discharges.

A decision was made to utilize computer capability in recording data for ease of review and analysis. For completeness of the study, categories were added to address pertinent demographics. The original list had 32 categories (figure 1, above). The current list has 41 categories (figure 2, page 18). The differences between the two lists are significant both as to the number of categories and to show the content of categories has been modified.

Category Changes

Transfer for acute care was added to enlarge patient demographics.

"Unimproved" had been on the diagnostic front sheet of the medical record for years, but no physician would admit to this possibility unless there was a mortality. The category was also ambiguous in terms of chronic conditions. It was therefore dropped.

"Unexpected morbidity" was not accepted by the medical staff and was changed to "Infections." This change was followed by protests from physicians that they did not cause infections. Now there is a record of "Patients with infections," and the accompanying data are coded to indicate physician, hospital, or undetermined cause of a nosocomial infection, as decided by physicians on the Infection Control Committee. This code is now modified to recognize the immuno-compromised patient as well. Physicians found this necessary when the hospital had its first AIDS patient, with resultant infections.

The "Complications" category has been challenged but is required by the state to cover morbidity not included under the infections category.

The "Medical case review," "Medical case evaluation," and "Surgical case review" categories led to confusion as to where to place the cases. In an intermediate phase, committee, department, or executive committee reviews were noted. Currently, reviews are being recorded as four varieties of case study. In the next phase, instances of unexpected outcomes, with varying degrees of preventability, may be noted.

"Liability claim" data did not fit in the computer format and are now being kept in a separate file.

"C.M.E." data did not readily adapt to the computer format and are now being kept in a separate file.

Categories for pathology, radiology, and anesthesiology have been added in order to develop profiles on any of these physicians who do not fit in the usual practice patterns.

Drug utilization review is being carried out by the Pharmacy and Therapeutics Committee, now that we have comprehended that this is what was intended by "prescription review" in the regulations.

The identification data entered in the profile record include the code number for the physician, the case number of the patient, and the date of the committee or department review. These entries are now being further modified to identify the source of the entry. Thus, when a medical staff member inquires as to why certain data appear in the profile, the identification data can be printed out, the source quickly identified, and the pertinent committee minutes brought forth for perusal by the concerned physician.

Medical staff members have been encouraged to review their profiles. This step keeps individuals informed and is useful in identifying inevitable data entry errors and making needed corrections.

Multiple entries caused by repeated reviews of the same case have led to incorrect numbers for infections and complications. This has been corrected by listing each infection and complication once and crediting each review as a separate case study. The record room has improved its ability to identify admitting, attending, and consulting physicians who are responsible for the care in question.

The computer program being used is an original creation, designed to meet our needs and then modified to reflect needs developed as a result of our expriences. It allows for the printing of data for any desired period, with a grand total for the entire medical staff and totals for each medical staff member. These data can also be printed out by one or more categories for one or more individuals. Reports for departments of specialties can be prepared. As indicated earlier, the identification data can be printed out to identifying individual cases and to show where these cases appeared in particular minutes.

The data have meaning because they are generated in conjunction with screening criteria that define unexpected outcomes or with the various indicators of JCAHO, which are applied to all cases. Cases with expected results are put in the files and unexpected cases are reviewed by physicians to select those needing full peer review. As a result of participation by the medical staff in the design and planning of the system, physicians have been willing to say that some cases need further evaluation. This has even allowed them to decide that certain instances of care or behavior were "inappropriate." Instead of perfunctory approval of huge stacks of charts, there is now study and appraisal of the small number of charts remaining after the preliminary screening.

Significant improvement in quality of care has occurred as the process of peer documentation of data to be put in the profiles has gone forward. For example, stressing the importance of documentation and communication has resulted in prompt preparation of histories and physicals, daily progress notes, and discharge summaries. Review committees find fewer instances of medical record deficiencies. Suspension of physicians for incomplete records has been minimal and only for brief periods. The hospital now has final diagnoses and signed statements of attestation more promptly and can submit insurance claims more quickly, improving cash flow.

Because the medical staff has been involved in definition of the components of the profile, selection of the screening criteria, and decisions of peer review, physicians have accepted changes. Knowing that there is a profile has made them aware that they are being evaluated by their peers. There has been an effort to keep them informed through free discussion in committee, department, and general staff meetings and through a medical staff newsletter.

The Western New York Hospital Association Credentials Manager computer program is utilized because it allows for retrieval of physician data that are needed for the credentialing process at the time of reappointment. Codes have been developed for a consolidated list of the privileges of all physicians. These codes are also being utilized in a quality assurance computer program that records each admission in our integrated quality assurance effort. The flow chart in figure 3, right, illustrates the integrated quality assurance (IQA) process, which was derived from a program developed by the Hospital Association of New York State.

Utilization review coordinators follow the majority of patients on the medical and surgical services, who are reviewed every week day. The obstetric service compiles comparable data separately because of the short stays of these patients. These data are passed to the next level of review for appropriate action. Everything funnels to the Quality Assurance/Risk Management Coordinator. Collected data are entered in the previously mentioned computer program for retrieval and evaluation as needed.

When problems are noted, they are immediately brought to the attention of the appropriate coordinator. Thus, the infection control person is alerted to investigate each infection, the record room is notified of record deficiencies, special interest or focused reviews are carried out, proper utilization is looked after, and questionable quality care is brought to the attention of quality assurance. For example, if a physician is having some difficulty with the management of a diabetic, the chief of medicine is notified, consultation with the attending physician follows, and corrective action is taken before a more significant problem occurs.

Data are recorded by means of the privilege codes previously mentioned and by codes derived from the original integrated quality assurance manual. This use of codes facilitates record keeping and computer entry. Several thousand ICD-9-M codes have been reduced to a few hundred codes in the IQA list of privileges.

We are still refining the IQA system and related computer programs. At this time, we are able to print out a record of exactly which privileges have beenused by each physician in a given period. We are beginning to enter data from outpatient surgery to complete the recording of all privileges that have been used. This information can be used in recredentialing physicians and can be related to the data in the Physicians Practice Profile, with its summary of demographic data, peer review findings, and outcomes. With the combination of IQA data and the profile data, a more accurate picture of current clinical competence is emerging.

The medical staff has responded to the challenge, and there is less resistance to the thought that care can be improved. But the profile remains a symbol of all that physicians find threatening in the changes that are occurring. One physician is very vocal in labeling the profile a "police record." He is convinced that, at some time in the future, the Commissioner of Health and his forces will descend on the hospital, find one or two notations of inappropriate care in his profile, summarily take away his license to practice medicine, and levy fines and other assorted penalties. He is not reassured by the fact that the present regulations only require that there be a profile and that it be used in credentialing. This same individual is not confident in the protection of the state law and the Federal Health Care Quality Improvement Act, which affords immunity against suits where peer review has been done in good faith and with due process.

With use of this profile, we can proudly point to very positive results. For the 16,927 inpatients from 1986 through 1989, the incident of inappropriate care was 0.23 percent. To restate this as a positive record, the care was of expected quality 99.77 percent of the time.

The medical staff has become proficient in writing minutes to reflect actual evaluations made during review and to indicate the consensus that has been reached in arriving at decisions. They have learned to refer any unresolved problems to the appropriate departments or committees for further discussion and evaluation. The attending physician has then been involved to allow clarification of facts not reflected in records and to give his or her point of view.

Discussion

The law and the attendant regulations were enacted with a belief that medical peer review was ineffective because of a lack of appropriate bodies to act on adverse findings. [5] The intent of the law was to prevent malpractice by assigning a duty to hospitals to scrutinize health care delivery. Hospital employees were encouraged to assist in gathering information by a statutory grant of immunity. Penalties were established for physician failure to provide information, and physician failure to cooperate was classified as professional misconduct. License fees were increased to finance the Office of Professional Misconduct.

Perhaps it is our small size or the basic competence of our medical staff, but the Physicians Practice Profile has not been a significant factor in the process of credentialing and reappointing our medical staff. Reliance has had to be placed on administrative processes that have documented incidents in order to be able to proceed with corrective action. It is, of course, possible to create a detailed profile to satisfy the parameters of the department of health memorandum, particularly when computer programs are used. However, we have found that the addition of the IQA program is needed to give a more complete picture of individual current clinical competence. The Physicians Practice Profile is part of the quality puzzle, but it would appear to be inadequate by itself.

Donabedian's description [6] of the epidemiology of quality is pertinent here. He notes that "the quality of technical care is better when practitioners have better or more training, are more experienced though not too old. When we must depend on reports of morbidity, mortality, and length and use of service, we find that these are extremely difficult to interpret insofar as their implications for the quality of care are concerned."

The use of guidelines in Professional Standards Review Organizations (PSROs) has been evaluated with the belief that community-generated criteria adopted by physicians would be key to changing physician performance. Instead, it was found that the participatory process leads to guidelines that often represent the lowest common denominator of acceptable care. [7] The conclusion was that guideline development appears to be a time-consuming and relatively ineffective approach to diffusing state-of-the-art management into practice.

Our utilization personnel have to use a system in determining DRGs and in reaching all the related decisions, but we did not find any simple means of incorporating severity of illness in peer review decisions and related profile data. Geehr [8] regards severity of illness as an imprecise term and finds risk adjustment more suitable. His description of six different severity systems in indicative of the technical complexity and some of the unrealistic claims that have been made in considering this element in quality care.

Morford [9] says PROs have "a purpose to improve the practice of medicine" but admits the perception is that their primary purpose is to contain health costs and to penalize physicians. Perceiving their tasks to be to improve the practice of those practicing poorly, PROs can require remedial education, limitations on practice, and exclusions from Medicare and can recommend state revocation of licensure. Eisenberg [10] points out that physicians act as patient agents and consider economic factors, the clinical problem, patient demands, the possibility of patient retribution for adverse outcomes, patient characteristics, and patient convenience. He concludes that the failure of PSROs was due in large part to the lack of effective leverage to change physicians.

The plight of individual physicians needs to be addressed. They have reacted with basic responses [11,12] of "fight, fright, and flight." There is rivalry, increased responsibility, and role ambiguity to be noted among physicians. A conclusion is that health care regulators must become more sensitive to the cost and ineffectivenss of relying on inspection to improve quality. The danger lies in a naive and atheoretical belief that assessment and publication of performance data will somehow induce otherwise indolent care givers to improve the level of their care and efficiency.

In consideration of all these viewpoints, it is reasonable to conclude that the Physician Practice Profile is an element in quality assurance, but it is not the endpoint. Other than noting that it is possible to develop and maintain a profile system, and thus to comply with the law and the regulations, it can be concluded that it is no more than another system to assess and publish performance data. In fact, it would appear that we have migrated toward the position of continuous improvements as a result of modifying our peer review process and profile content. We are now ready to formally adopt the approach of continuous improvement. At the same time, the required Physicians Practice Profile is in place and can be easily maintained to satisfy regulatory requirements.

References

[1] Koska, M. "Patient Profile Use in Hospitals Up." Medical Staff Leader 3(19):3, March 1990.

[2] Horn, S., and Horn, R. "The Computerized Severity Index." Journal of Medical Systems 10(1):73-8,Feb. 1986.

[3] Feinglass, J., and others. Using Severity-Adjusted Profiles to Justify Cost-Effective Patterns of Care. New York, N.J.: National League for Nursing, 1987, pp. 99-122.

[4] Zuckerman, S, and others. "Physician Practice Patterns under Hospital Rate-Setting Programs." JAMA 252(18):2589-92, Nov. 9, 1984.

[5] Rosen, B.A. "The 1985 Medical Malpractice Reform Act: The New York State Legislature Responds to the Medical Malpractice Crisis with a Prescription for Comprehensive Reform." Brooklyn Law Review 52:135-81, 1986.

[6] Donabedian, A. "The Epidemiology of Quality." Inquiry 22(3):282-92, Fall 1985.

[7] Ford, L., and others. "Effects of Patient Management Guidelines on Physician Practice Patterns: The Community Hospital Oncology Program Experience." Journal of Clinical Oncology 5(3):504-11, March 1987.

[8] Geehr, E. Selecting a Proprietary Severity of Illness System. Tampa, Fla.: American College of Physician Executives, 1989.

[9] Morford, T.G. "PRO Progress to Focus Efforts on Two Objectives" QA Review 2(2):7-8, May 1990.

[10] Eisenberg, J.M., "Physician Utilization: The State of Research About Physicians Practice Patterns" Medical Care 23(5):461-483, May 1985.

[11] Levinson, H. Executives Stress. New York, N.Y.: New American Library, 1975.

[12] Levinson, H. Psychological Man. Cambridge, Mass.: Levinson Institute, Inc., 1976.

Laurence G. Roth, MD, is Medical Director, Genesee Memorial Hospital, Batavia, N.Y. He is a member of the College's Society on Hospitals and Forum on Quality Health Care.