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Big Brother medicine

May 2010

When I called my mother recently, I was a little surprised to hear the following message before she picked up: “This conversation may be recorded for quality improvement purposes.”

Whether we like it or not, we have entered the era of “Big Brother” (or in my case, Big Mother). That recent conversation with her only serves to remind me just how true that has become in medicine. Look no further than the operating room where many states are moving to require video monitoring of surgical procedures to help monitor “never events.”

Handwashing is another great example; it’s simple, cheap and effectively saves lives. If only that was the end of the story. Many institutions struggle to push compliance rates anywhere near perfect, which really is the only acceptable goal when it comes to hygiene.

Frustrated by low buy-in from health care providers, some hospitals are using video surveillance to ensure compliance. My group is piloting a technology that monitors clinicians entering and leaving a room via an infrared signal and linking these events to the activation of the hand dispenser. Bring in a little Big Brother and problem solved.

The big question: Is Big Brother better medicine? (Just to be clear: I’m not talking about government surveillance but any form of surveillance or monitoring.) The big answer: probably. Perhaps painful to admit, but it’s no surprise that we do a poor job policing ourselves.

This isn’t for lack of motivation or, for the most part, intent. It’s just that measuring quality is a very illusive process when it comes to deciding what makes a “good” doctor. Getting it wrong often has more than trivial consequences. And none of us really believes we’re making errors until we go to the videotape.

As an example of what currently passes as medical oversight, type “Physician Quality” into Google. The first two links you find are HealthGrades and ABIM.

In the time it takes me to write this blog, I could use the Healthgrades physician rating platform to give myself five-star rankings many times over. As for the ABIM, while I believe board certification is important, I am not sure board certification improves quality.

For me, the true value of certification lies in its being a means to an end. The means–forcing us to refresh our knowledge–isn’t a bad concept, even it much of what we learn proves to be too esoteric for any hospitalist’s day-to-day practice. The end–a six-hour test that 95% of all takers eventually pass–may not really indicate any substantial improvement in the quality of care.

Which leaves us still searching for some way to change behaviors that bring quality down. If we still want proof that medicine needs better oversight, look no further than the recent case in which a cardiologist was accused of stenting hundreds of normal arteries. As Dr. Wachter so deftly argues, the great tragedy is not that this fraud happened, but that no system was in place to prevent it. While this is an extreme example, the mere fact that it occurred speaks volumes about our current process of peer review.

So, where does that leave us? Well, back to Big Brother. Data mining is a technique that the pharmaceutical industry has used for years to track every prescription physicians write. That gives the industry the ability to peer into a physician’s practice. While having that access seems a bit questionable, no doubt many who employ hospitalists wish they had the same reach.

In fact, I suspect many already do. In my experience, information technology greatly increases my ability to examine an individual doctor’s practice in much more meaningful and accurate ways.

In the not-too-distant future, it will be common to speak of doctors in terms of their “cost per case” or “discharge to follow-up visit ratio.” Similar to batting averages and WHIP ratios in baseball, physician statistics in a bundled world will be increasingly important. And a good CPOE system will feed those data in real time to your iPhone. Yes, there will be an app for that.

I suspect that for hospitalists, the era of more big brothering will only further prove our worth in a reformed health care system. Unfortunately for sons, at least in my case, it may not turn out so well.

Informed that I forgot to wish my mother a happy birthday, I mortified said, “Roll the digital tape” (or, really, binary code). She was right; despite every intention of doing so, the proof was in the recording.

The upside for me? Now, each day starts with a checklist. Similar to the Provonost venous catheter bundle, which prohibits placing a line without completing a safety list, I can’t begin my day unless I have confirmed, “Right Relative, Right Birth Date.” If Big Brother means I never again have another catheter-related bacteremia or forget another birthday, who am I to complain?