What is the stick that can measure the performance of a physician? Is 50 hours a year of attendance in CME (continuing medical education) enough? Would it be better to show instead that they are following national clinical guidelines?
I think now is the time to ask, or at least wonder, how we can objectively measure the performance of a hospital or physician in the Philippines. We now have the technology to keep track of the number of x-rays, CT scans, MRIs, or blood tests that a physician is requesting in a year; the number of patients admitted by a physician to a hospital and the average length of stay and cost; the number of coronary heart surgeries done by a cardiac surgeon; or the number of hospital-acquired infections and complications.
On Dec. 15, 1994, a nurse from a health insurance company in the state of Maine in the United States visited my office. She checked the cleanliness of the examining rooms and toilet and the size and temperature of the refrigerator, randomly looked at dozens of medical records, and talked with the office staff. She was in my office for several hours.
After several weeks, I received a performance “grade” in tabulated form and graphics. My office was given a grade of 92.3 percent, as against the 89.5-percent average of all of the pediatricians in Maine.
In the Philippines, because most hospitals and physicians do not yet have electronic medical records (EMR), errors, injuries, accidents, and acquired infections in a hospital are not yet reported and published. But we should all be concerned about hospital safety because the statistics from the United States are scary.
Many US hospitals have safety records that wouldn’t be accepted in any other industry. Consider the statistics: As many as 440,000 people die every year from hospital errors, injuries, accidents and infections. In a day alone, more than 1,000 people will die because of a preventable hospital error. Every year, one of every 25 patients develops an infection while in hospital—an infection that doesn’t have to happen. These statistics are from the Hospital Safety Score organization, a nonprofit business group called Leapfrog.
To improve healthcare hospitals, public health centers, and private medical offices, we should require an EMR system with relational data fields so research and outcome studies can be done with a few clicks or taps. The pen-and-paper style of record-keeping should be abandoned because of the difficulty and high cost of doing research with this dysfunctional system. Hospitals and physicians should be given tax incentives to have EMR. We can set 2020 as a target year for all. Those without EMR will not be paid by PhilHealth and other private insurances for their services.
The Department of Health should require that all hospitals report the number of hospital-acquired infections, the number of unexpected deaths with root-cause analysis, and the length of stay of patients in hospital for common conditions like stroke, appendicitis, renal failure, pneumonia, etc.
To improve the diagnostic skills of physicians, all hospitals should be required to publish the number of deaths and total autopsies done in a year. This is important because autopsy is still the best tool to find out the true cause of death. Thirty years ago, there were more than 400 autopsies done in a year at Philippine General Hospital. In the past several years, the number was down to 40-70 annually. This downward trend is also seen in other hospitals.
In most hospitals in western countries, the diagnostic error rate is from 5 percent to 15 percent, which is very high compared to other industries. In spite of modern imaging tests like the CT scan and MRI, there is still no significant improvement in physicians’ diagnostic skills. Unfortunately, there is no such study in the Philippines.
Currently, physicians have to report that they have attended 30-50 hours of CME a year for three years before they are recertified. I think this should be changed to show that a physician is following the national clinical guideline in the treatment of hypertension, diabetes, tuberculosis, pneumonia, etc. Those equipped with EMR can, with a few clicks or taps, easily report the number of diabetic patients in their practice and how many have had the standard test for hemoglobin A1C. Similarly, they can easily report the number of asthmatics treated with inhaled steroids (the best treatment).
Since I retired in 2010 and began to stay part of the year in our country, I have been to three medical offices. All of them are still using pen-and-paper medical records. One physician whose office is in a famous large tertiary hospital in Metro Manila was using paper provided by a pharmaceutical house. Another has records on 5×8-inch index cards stored in a shoe box.
With technology getting less expensive and more powerful, there are more reasons for hospitals and physicians to universally use EMR and post their performance on their hallways. My physician in Bangor, Maine, has a bar graph showing the number of asthmatics with peak flow meter recording and number of diabetics with hemoglobin A1C prominently displayed on the wall behind the desk of the receptionist.
Dr. Leonardo L. Leonidas (nonieleonidas68@ gmail.com) retired in 2008 as assistant clinical professor in pediatrics from Boston’s Tufts University School of Medicine, where he was recognized with a Distinguished Career in Teaching Award in 2009. He is a 1968 graduate of the University of the Philippines College of Medicine and now spends some of his time in the province of Aklan.