This Visit May Be Recorded

flying cadeuciiIn their 1993 book, Reinventing Government, David Osborne and Ted Gaebler entitled a section “what gets measured gets done.” Unfortunately, when it comes to improving health care quality, safety, and costs, we often fail to observe the real work of care, and miss the chance to get it done better. To make a real difference, we need to begin measuring care when and where it happens – behind the curtain.

Why We Must Directly Observe Patient Care

For the last 10 years, our work in research and quality improvement has used concealed audiorecorders to capture what actually happens during patient-physician encounters, and to provide feedback to physicians about their performance. Much of our focus has been on demonstrating the importance of appreciating the patient’s life context and showing how encounters in which physicians elicit patient context and incorporate it into care planning have better health care outcomes and lower costs from inappropriate care. We’ve found such contextual factors are relevant to health care in two-thirds of encounters, that physicians ask about them less than a third of the time, and when they are discovered, they are incorporated into the plan less than 60% of the time. Contextual errors—inappropriate care due to failure to contextualize—are pervasive.

Records Don’t Record

Only direct observation of care reveals these errors. The medical record, currently the source of most data in performance improvement, does not and cannot identify mistakes that the physician doesn’t already recognize. The medical record, at best, shows that the physician rendered the care they believe the patient needed, which can be the “right” care for the wrong patient.

Moreover, studies comparing the accuracy of the medical record to the care actually provided suggest both that care is documented that is not provided and that care is provided that is not documented.

Patient care surveys, another source of quality improvement data, are helpful but also limited. Patients know the complexities of their own lives, but frequently don’t understand how that context relates to their health care. A patient may be stretching out an expensive daily asthma inhaler to reduce the cost of refilling the prescription without understanding that the medication’s effect depends on daily use. Just as the physician doesn’t know the problem to treat without exploring the patient’s life, the patient doesn’t know that his problem is one of access and knowledge, rather than lung function.

Mystery Patients and Focused Improvement

Another important technique for direct observation of care is the use of the unannounced standardized patient, an actor trained to visit a physician incognito and portray a particular patient case with high fidelity. This “mystery patient” approach, like the use of “mystery shoppers” to improve customer service or evaluate racial disparities in customer treatment, allows a practice to manipulate features of the patient presentations and evaluate performance while controlling for case mix. In our largest such study, physicians planned appropriate care 73% of the time when the case did not include a complicating medical or contextual factor, 38% of the time when the case included a complicating medical factor, and only 22% of the time when the case included a complicating contextual factor. In a recent quality improvement project, we trained actors to present as diabetic patients and record whether the physician conducted a proper diabetic foot exam; comparing the directly observed care to the charted care reveals preventable errors in care, charting, and billing. The use of unannounced standardized patients, particularly with the prior consent of physicians to receive such visits (at an unspecified future time), can meet ethical standards for research, as well as quality improvement.

How to Move Forward

Although much can be improved in medical education settings, directly observing care is an especially important step toward measuring physician performance in the natural setting of practice. Providing ongoing audit and feedback to physicians about their performance can improve contextualized care (Weiner, et al. 2015 June. The Joint Commission Journal on Quality and Patient Safety) and suggest specific quality concerns that can be tested in detail with unannounced standardized patient programs. Practices may adopt direct observation as part of their commitment to improve quality improvement and patient safety; payers and regulators may also reap the benefits of reduced costs by encouraging these efforts through performance incentives.

Alan Schwartz, PhD, and Saul Weiner, MD, are co-authors of the forthcoming book Listening for What Matters: Avoiding Contextual Errors in Health Care (Oxford, January 2016).  They write about contextualized care and direct observation at http://contextualizingcare.org.

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5 replies »

  1. Riffing on the auto-attendant phone call tree and NFL “instant review” process…

    – “This patient exam may be recorded for quality assurance purposes.”

    – “The previous patient encounter is under further review.” … “The ruling on the exam table is confirmed.”

    I have long referred to clinical documentation as “lossy compression,” (think .jpeg or .mp3 files) an analogy particularly apt with respect to EHRs. e.g., see my post “Are structured data the enemy of health care quality?”


    Might patients be accorded an “opt-in” to have their clinical encounters A/V’d? Yeah, I know, a host of problems with that idea. YouTube “99213 exam porn”?

    Nonetheless, a written or digital record is a “lossy compression” historical artifact of a prior event. No way around it.

  2. Mom’s in her late 80s & lives in an assisted care “facility”. We’ve had the same kind of health care experience. While clinicians and health system executives are certainly partly to blame, our legal system contrives to treat anyone presenting as an authorized advocate first with suspicion & then as an adversary. “Durable” power of attorney? Don’t make me laugh. The social ‘conventions’ we’ve codified in law work vigorously against anything like collaborative care. HIPAA is only the most high-profile example.

  3. Adrian, same experience with my wife’s 88 year old mother. Terrible access to qualified geriatric PCP or hospital doc – even in Florida. Last bout in hospital was only solved by concerned Infectious Disease doc. Meds were wrong, diagnosis was wrong even with daughter advocate and my nurse wife. Finally got a head-screwed-on-right PCP. We have found that elderly in Florida are just a conduit for Medicare/Supplemental billing.

    As usual we claim best medical system in the world for feel good flag waving but the reality is we’re just getting world class prices.

  4. “physicians planned appropriate care 73% of the time when the case did not include a complicating medical or contextual factor, 38% of the time when the case included a complicating medical factor, and only 22% of the time when the case included a complicating contextual factor.”

    physicians planned INAPPROPRIATE care 27% of the time when the case did not include a complicating medical or contextual factor, 62% of the time when the case included a complicating medical factor, and 78% of the time when the case included a complicating contextual factor.

    Not good odds.

  5. This is a very important conversation. I try to help care for my 89 yo mom who still lives in her home with a live-in caregiver. I live 200 miles away and depend on the context for my mom’s care to include me, her live-in caregiver, and all of her various clinicians and practices. (I really dislike the word “provider”). Although elderly and not as sharp as she used to be, my mom’s health is good and she complains of nothing.

    I have 6 years of experience now. With one significant exception in an academic geriatric practice that is inaccessible to my mom due to distance and schedule, not a single clinician or practice is willing to interact with my mom in a context that centers on her and her situation. Every system and every practitioner is focused on their institutional context, their EHR, and a process that actively blocks information flow to and from her personal context.

    This is the reality in US healthcare today. We talk about patients and technology from an institutional perspective as if this is the way it has to be. We need to envision a patient-centered health information architecture and start down that path.