How Patients Use the Internet to Find Quality Healthcare Providers

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

Why the Geography of Medicine is Important

As we hear more and more information about health reform efforts, it is very easy to become confused about what needs to be changed and why. Health is a very complex topic, and the organization and finance of medicine adds more layers of complexitiy. As a result, it can be a daunting task to understand how to improve our health services delivery system in the US.

The purpose of this blog is to focus attention to the human ecology of health and medicine by looking at medical outcomes on a map. Most people are good at reading maps, and maps put complex issues in our own backyards. Most importantly, we can compare our areas, or where our friends and family live, to other areas. Recent efforts to map healthcare outcomes as described below allow people to quickly make comparisons and then think about why these differences might occur (assuming the differences are meaningful and real).

I believe the variation in healthcare costs and quality as illustrated by maps is often real variation. This means that some places have better medical care than others. Once more people look at health in this way, they will be less likely to be confused by biased media and "noise machines". I think they are more likely to say, "Hey wait, the data on the maps show huge differences in costs and quality, so lets focus on the real problem."

The Geography of Healthcare

For more than twenty years, the Dartmouth Atlas of Healthcare has shown variation associated with the costs and quality of healthcare across geographic areas of the United States. Some areas are much more costly than other areas, and there is little evidence that high-cost areas provide better quality of care. Indeed, high-cost regions seem to provide lower quality care. The reasons for this variation are complex, but evidence is growing to support the hypothesis that specialist-driven medicine leads to fragmented and uncoordinated care. Moreover, many medical conditions and treatments are not guided by scientific evidence, and practicing physicians often do not adhere to guidelines when they are available. A popular article in the New Yorker by Atul Gawande is based on some of this research.

Managing the finance of healthcare is important for increasing access to healthcare for uninsured Americans, yet high costs and variable levels of quality must be addressed before any sustainable solution will be reached. In my opinion there is a strong need to transform the culture of medicine that is currently based on physician autonomy to a system in which medical providers work as a team to provide patient-centered care. The Internet may be the force that will empower patients to learn more about their own health, and then motivate them to work together with their providers to achieve the best outcomes possible. Once patients have more information about their health, and are better able to understand risks and benefits of their options, it is likely that they will select less costly treatments that lead to higher quality outcomes. It is likely that once physicians embrace these changes, they will enjoy working with patients who have the capacity to understand more about complex health issues.