The United States spends more per capita on healthcare than any other country, yet ranks low on quality metrics. Healthcare costs and quality also vary among states. Finally, as discussed earlier, the Dartmouth Atlas of Healthcare shows dramatic sub-state variation based on healthcare referral regions. Although these macro-level studies are important for policy makers, consumers face the immediate problem of choosing high quality providers in their local area (or choosing to travel for healthcare). There are two important ways that people find information on the Internet about the reputation of their healthcare providers—organizational report cards and word-of-mouth. Although government agencies and other organizations publish quality information about physicians, plans, and hospitals, many consumers seem to prefer word-of-mouth (or Internet blogs) to select providers.
First, lets consider report cards that are produced by many government and non-government organizations to help consumers make better choices. These reports use administrative billing data or sometimes clinical data to create objective performance measures that are usually presented as events (e.g., mortality, misadventures) per procedures performed or conditions treated. For example, the Center for Medicare and Medicaid Services have a website to help consumers evaluate the quality of hospital care. In California, my organization, the Office of Statewide Health Planning and Development, produces quality ratings for hospitals and for surgeons performing specific heart operations such as coronary artery bypass surgery. Interestingly, the California Hospital Association working with the University of California also publishes hospital ratings. This site, called calhospitalcompare.org, is much more consumer friendly than our state website. Almost every other state has numerous organizations that publish such report cards, and a great deal of energy and money are put into creating performance ratings. Given all this work, is there solid evidence that consumers use this information online to make better decisions when selecting healthcare providers? No.
An article in the prestigious journal Health Affairs by David Bates and Atul Gawande describe that few patients use organizational report cards (though this might be changing), and there is little evidence to date that the report cards alter consumer behavior. There are many other complaints about these reports such as too much reliance on poor quality data and too little attention paid to the multiple processes that lead to outcomes of interest. However, given the recent attention to the transparency of healthcare, and the fact that the reports are becoming more scientific, it seems that report cards will only become more important in the future. Meanwhile, patients are using the Internet in different ways to evalate quality. The Bates and Gawande article, as well as a number of more recent studies, provide evidence that consumers prefer to seek providers with high quality reputations based on word-of-mouth communication with friends and family. There is also evidence that more and more consumers are using Internet blogs to both supply and obtain information about high-quality providers. There are numerous sites emerging in which patients can rate their physicians, thus providing some information to others about variation among provider care. Interestingly, there is also some evidence that consumer ratings actually correlate fairly well with more objective performance measured based on hospital data.
How will these two paths of Internet use evolve in the future? It is very likely that the transparency movement will continue to push organizations to produce report cards. More importantly, there is promise that report cards will become more consumer oriented, and provide more opportunity for patients to use health information to select high quality (and maybe lower cost) providers. An interesting website to keep an eye on is published by Consumer Reports. This site does a good job of translating complex scientific outcomes studies into consumer friendly information. Of course, it also seems that the use of health blogs and patient rating sites will also increase in popularity. Thus, it is interesting to think about how these two methods of use could augment one another, and in the end, create an increased opportunity for quality improvement. I list below a two ways that could lead to positive synergy between Internet report cards and word-of-mouth communication.
1.) Report cards might start to offer people a chance to blog about the information that they see. It is unlikely government sites could allow this to happen, but the non-profit sites could do this easily. In fact, the Consumer Reports website for healthcare quality does have some simple ways for people to comment about what they see on the site. It is possible that in the future, some clever health informaticists will find a way to bridge the objective outcomes and process measures with more subjective comments from users.
2.) Organizations that create report cards might try to create their own systems for people to rate their satisfaction with providers, and then publish this along with more objective performance measures. Some sites such as calhospitalcompare.org do present data on patient satisfaction, but these measures are based on pre-collected survey data. Could patients enter ratings directly on the site, and then aggregate their responses in an ongoing measure of satisfaction?
The Internet is not going away, and neither is the drive to improve the quality of US healthcare. Lets hope that patients are given every opportunity to review “objective” report cards as well as document their own personal experiences in some type of positive way.
References
Healthcare Quality and Cost Transparency Using Web-Based Tools, by Jiao Ma and Cynthia LeRouge. In Patient-Centered E-Health (2009) E. Vance Wilson
The Impact Of The Internet On Quality Measurement:
Word-of-mouth advice about providers is gaining respectability through the Web.
by David W. Bates and Atul A. Gawande, Health Affairs vol 19 #6 2000
You Can Lead Patients to Quality Data, But Will They Use It?
HealthGrades
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