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Is your hospital ready for radical transparency?

Posted Apr 05 2012 10:34am

by Kent Bottles

It is easy to focus on the trials and tribulations of the Patient Protection and Affordable Care Act as it becomes a political football tossed back and forth among President Obama, Mitt Romney, the Supreme Court justices and members of Congress.

Like everyone interested in healthcare reform and the federal government budget deficit, I am keenly aware of the upcoming June Supreme Court decision, the November presidential and congressional elections, and the 2014 date when many of the provisions of the ACA--if it survives--will become operational.

However, no matter what happens in 2014, or in June and November of 2012, hospital leaders will have to deal with more transparency in everything they do. The Internet has increased the public's demand for greater transparency in healthcare, and influential groups such as The Commonwealth Fund have called for transparency and better public information on cost and quality.

They base their recommendations on three reasons : "1)To help providers improve by benchmarking their performance against others; 2) to encourage private insurers and public programs to reward quality and efficiency; and 3) to help patients make informed choices about their care. Transparency is also important to level the playing field. The widespread practice of charging patients different prices for the same care is inherently inequitable, especially when the uninsured are charged more than other patients."

Transparency is related to, but different from accountability. Accountability implies that a judgment about the wisdom of the decision will be made after the results are evaluated, and responsible parties may be penalized for poor outcomes. Transparency, on the other hand, requires open and public discussion during the entire process of decision-making; improvements and mid-course corrections can in theory be implemented before a final decision is made. Daniel Goleman, in his book "Ecological Intelligence," provides an overview of what he terms radical transparency; although he does not focus on healthcare, much of his analysis can be applied to hospital systems.

Three recent developments have strengthened my conviction that transparency is here to stay in healthcare: the recent federal court ruling in favor of a physician rating site, the call by physician societies for limits on medical testing and the popularity of the website HealthTap.

1. A U.S. District Court in Seattle recently ruled that Avvo has the right to publish its lawyer and doctor ratings on its website . Florida attorney Larry Joe Davis, Jr. sued Avvo for libel because of its online rating system. Avvo uses search algorithms to publish publicly available information and to create a profile for every doctor and lawyer in the United States. The company also has created a rating system based on awards, publications, number of years in practice, sanctions, discipline and censure. The profiles also include patient and client reviews.

In a recent blog post , I explored the tensions associated with this trend toward transparent physician rankings. Doctors have sued patients over online criticisms, and some medical offices have tried to have patients sign away their right to post evaluations online. Ironically such tactics can backfire; they have been called the Streisand Effect, which refers to the actress's lawsuit trying to remove a picture of her house from the 12,000 photos available on the Internet that documented the entire California coast. By calling attention to her house with her legal action, she made the photo of her house an Internet hit.

2. In early April, nine medical specialty societies representing nearly 375,000 physicians announced lists of commonly ordered tests for low back pain, sinus headaches, annual checkups, cervical cancer screening, pre-operative evaluation, fainting and appendicitis that may not be cost-effective or medically useful . The Choosing Wisely campaign is calling for more transparency in the shared decision-making between physician and patient. Eliminating unnecessary testing could save an estimated $200 billion to $250 billion a year.

But the difficulty of changing such test ordering practices is illustrated by the experience of Steven E. Weinberger, CEO of the American College of Physicians, which is participating in the Choosing Wisely campaign. When Weinberger had arthroscopic knee surgery, he underwent a pre-operative chest X-ray, an EKG and blood work that was listed as medically unnecessary. "I should have been the person to say no, but you don't like to argue with the person who's providing your care. You don't want to be seen as the difficult patient," he told the Philadelphia Inquirer .

3. Through radical transparency and community rewards, HealthTap hopes to become the best place for patients to connect with high-quality doctors who can accurately diagnose and treat their specific ailments.

"HealthTap, a medical social network for users seeking personalized, public advice from registered doctors ... is releasing an eBay-like rating system for its more than 10,000 participating doctors and their relevant expertise," according to Fast Company . "We spoke with Gutman about how his system has incentivized doctors to go against the taboo of criticizing their peers, how transparency brings credibility to online medical advice, and how HealthTap translates conversational descriptions of symptoms into medical language their doctors can respond to."

Hospital executives need to realize transparency is a trend that is only going to accelerate in the years ahead, no matter what happens to the ACA. Savvy leaders will examine whether their organizations' cultures are responsive to this public demand.

Dr. Kent Bottles is a Senior Fellow at the Thomas Jefferson University School of Population Health and Chief Medical Officer at Verilogue/

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