Grading Physician Performance has long been a disorganized and incomplete science at best, more often fraught with inconsistency and biased opinions of the reviewer than actual ongoing hard data comparisons to support the reviewers’ conclusions. Many of these reviews are performed because the hospital or physicians groups are “required” to have them performed for “compliance,” “licensing,” or “unexpected” outcomes, therefore limiting the scope and purpose of a comprehensive performance review.

There are no national standards for thorough physician performance reviews, and in the few areas when the review is performed, there are no regional or national results available for comparison. Because of time and cost reasons, a review of hard medical data is performed mostly in a limited range that looks at only a microcosm of the total performance of a physician. These limited reviews examine hard data such as surgical outcomes, infection rates, patient readmission rates, etc. A microcosmic review does not address a comprehensive or ongoing performance of a physician, and in most cases, any thorough physician performance review requires a physician of the same specialty to conduct the review which is expensive and undoable. Therefore the performance review is limited in scope, and the reviewing physician most often does not have sufficient allocated time or access to all the data required that an algorithmic program would contain.

Future algorithmic systems such as the PhyScore model will discharge the need for human interface in the physician performance review and will have access to databases much larger than any reviewer has the time or expertise to use. These future systems will have the capability to review the performance on every individual patient the physician treats and suggest areas for performance improvement as well as comparing an ED physician’s performance to other physicians within the group and other regional groups.

A Battle is on the Horizon for your Future

Implications of Hospital Resource Utilization for the Emergency Physician

“For the first time ever, imagine employing a program that tabulates actual total ED facility and hospital utilization and physician costs and comparative outcomes of every patient seen and for every disease the physician treats.”

Hospital and ED utilization have exploded over the past 40 years due to innovations beyond our imagination: Imaging, ultrasound, laboratory, ED interventions, medicines; all have contributed to quicker, better, and more precise diagnoses and treatments for our patients, and with no surprise at a much greater cost. A battle is beginning to take place that will change the way we work, think, and act.

The Emergency Department will be on the horizon in this revolution of healthcare delivery because of the tremendous costs that even a simple illness or injury incurs. Emergency Physicians especially will be placed in this forefront and under the microscope, as they will be assessed by their utilization of the hospital’s resources, accuracy of diagnoses, and outcomes. Costs and performance of ED physicians will be compared not only within the group, but as to their ranking among other groups of like physicians. The public and government officials will demand to lower all reimbursement whatever HealthCare system the public and congress elects to utilize.

It will become the reality that hospital administrators will shop for the best price and quality of a group or physician, because they have the data to select the physicians or group they wish to employ. Longevity and relationships of ED physician groups with hospital administrations will become strained if the ED group is marked as “too expensive to keep” or “certain physicians place the hospital at a quality risk”. The group with the most acceptable patient care outcomes and the lowest cost of facility usage will be highly sought after. Algorithmic systems will be implemented to compare your usage of hospital resources and interventions that you currently employ to formulate your medical decision making and interventions. Work performance and cost saving algorithms will become the standard procedure to grade your medical career.

Many of our progressive groups have begun to let loose of the “old thinking” by employing some of the ideas above to stay affront of this inevitable revolution. It is up the individual ED physician and ED groups to resource and measure these matters, build a model that will begin to confront the costs of care as well as measuring the quality and outcome of the patients in their care. For the groups working to be in front of this inevitable horizon showing positive results, they will be watched and followed. These forward thinking progressive Emergency Medicine groups will have a tremendous advantage over those who wait.

PhyScore

Two years ago, PhyCon began developing a patent pending system for the evaluation of physician care, how it affects patient outcomes, and simultaneously the cost to perform it. We realized that the cost of HealthCare is very soon going to become the enormous solitary issue to every patient, insurance company and, government provider, as well as the entire HealthCare Industrialization process. Since the advent of the use of “Big Data” from “Facebook” to “Cambridge Analytical” the world now realizes it affects everyone’s thinking, and it even affects those who choose not to be a part of the social media or web environment. Using this type of large analysis has won elections all over the world, sold trillions of products, made small companies into huge corporations, and driven a multitude of corporations and companies into bankruptcy. It’s real, it’s effective, and it’s coming to medicine!

In order to undertake such a mission, we began with these hypotheses:

1. “Not one single physician performance grading that exists today is comprehensive or conducted in a scientific manner, and no comprehensive physician performance evaluation is compared with other like physicians in the same specialty group.”

1. “All HealthCare spending begins with one keystroke input: The “Physician Order Entry.”

All lab, imaging, procedures, medication, surgery, hospital admission/discharge, hospital administrator’s salary, the physical hospital itself, TV pharmaceutical commercials, and anything that involves a cost in medicine cannot be financially accomplished without the “Doctor’s Order” from a physician. All of the above and more flows back to the doctor as the originator. It’s staggering to think that a physician has all of this power and has little input on what actually happens within his own profession. And now we are targeted by all to drastically control costs of healthcare because we are the originators of these costs and simultaneously we are expected to improve outcomes of patient care. With this, we are faced with a clear and present danger, unlike we have never seen.

To most involved in healthcare, these are simple hypotheses that are easily proven. Many decades ago, the administrators of hospitals respected and understood that it took a physician’s order to bring in enough capital for the hospital and the staff to even be there. Unfortunately for the doctor the authority and prestige of the American physician have been lessened by this slow and grindingly wicked and inexplicable insurgence called: Corporate Profit and Big Data.

There are many reasons for this, but the vast majority of physicians are not corporate or administrator savvy enough to have prevented this from happening. That’s another paper.

Quantification of Emergency Physician Care

Scoring Explanation

Critical Thinking Physician Intervention Resource Utilization Healthcare Cost Tabulation

Patient Outcomes Overall Performance Scoring

Introduction: All physicians by nature are investigators and scientists, and understand information is the most powerful tool for them to use in their practice. Physicians are not provided with what should seemingly be basic practice information such as: All patient outcomes, Exact dollar costs of my medical decision making, the hospital resources I consume, and How do I compare within my own group and outside other groups of the same specialty. How strong is my “Critical Thinking” compared to my associates, and should I take CME courses to improve myself in this area?

All this information is well contained within the compendium of medical record “Big Data” which deserves to be mined and used as the beginning step to develop salient information for the emergency physicians to review and contemplate. In doing this, the doctor will be able to view results from their own data and millions of other patient record results to compare how they are performing. They will discover how they may change or improve their skills and lessen costs to improve their emergency department practice that defines them.

This is why we are developing PhyScore and have developed PhyScore Card; a simpler format sent monthly to all of our physician groups. Our mission is to have the products in place with real time feedback by physicians in the emergency community and to improve continuously the information process flow within PhyScore. This product is for all emergency physicians to help the physician improve the quality of their patient care at the least dollar amount possible. It will only get better through their continued input and the continued advancements in this medical informatics process.

The six categories above in physician assessment scoring are explained in detail below:

1. Critical Thinking Scoring: Forming an objective analysis and evaluation of the possible multiple medical issues to form the correct medical decision, in essence, is the definition of critical thinking. The physician in the ED is often required to formulate immediate medical decisions without the benefit of time or testing and relies on his emergency medicine experience and training. Most often, the ED physician has the time to formulate a plan by considering several differential diagnoses to be verified or deemed incorrect through testing and/or medical interventions. For Emergency Medicine, the critical thinking portion of such algorithms examines both types of these presentations in its multipart algorithms by mining four regions of the medical record. Each of these four subcategories is applied in the formulation of the critical thinking score:

Differential Diagnoses - Emergent Decision Making - Consultation with Specialist Physicians - Documentation of the Time of Treatment of Critical Care Patients

1. Differential Diagnoses: After the physician formulates the differential diagnoses

The system applies its researched proprietary algorithms giving proper weighting to the difficulty of the presenting and final diagnoses presented. Over 268,000 ED specialty, specific diagnosis codes are used in this process.

B. Emergent Decision Making: Additional critical care scoring for emergent medical decision is applied to the overall critical thinking score such as immediate surgical intervention and/or Cath lab decisions (Neurological and Cardiac), and trauma admissions will be placed in the algorithms.

C. Consultations with Attending Physicians: These consultations allows the physician to broaden his/her critical thinking thru seeking consultations with subspecialists, and it is one area of high importance in the process of scoring critical thinking. The simple fact the physician makes the decision to consult on a patient increases the physician’s critical thinking.

D. Critical Care Time: Documentation of the time taken in delivering emergent care ascribes additional weight to the overall critical thinking score as well. Additionally, this reveals that the physician is using his training and experience to the maximum, and this time is additive and increases the score proportionally to the submitted time documented.

1. Physician Intervention: The physician intervention score is essentially “What the physician does for the patient.” Ordering diagnostic tests, performing surgeries, intubating and resuscitating patients, etc.. PhyScore grades all specialty physician procedures that are performed and applies difficulty ratings to each procedure in an excess of 7, 800 medical procedures.  PhyScore goes beyond procedure scoring by accounting for the work that the physician also performs but is not normally credited in a manual physician review. This program scores all nursing and medication orders, both oral and IV, patient rechecks, oversight of ancillary patient interventions such as respiratory therapy, ultrasound testing, bedside monitoring, reevaluations, etc. By including these items not typically credited during a physician review allows a more complete picture of the physician’s body of work, and triggers a larger separation in the scoring of the sicker and more injured patients by including these items.

1. Resource Utilization: The program accounts for all diagnostic testing a physician uses on each patient. This includes lab testing, radiology, EKG, EEG, ultrasound, imaging studies, and special procedures performed that contribute to the usage of the hospital facility and clinical resource services. Every patient and physician has a resource utilization score, and the software displays these scores for comparison and quality improvement.

Healthcare Cost Tabulation: The financial impact that physicians’ decisions make on the cost of medical resource utilization accounts for approximately 75 - 80% of all healthcare costs. Not surprisingly, physicians have been left in total darkness and to some degree, purposely by the Healthcare Industrial Complex concerning their contribution to the overall costs of their decisions. Recent studies have shown that merely showing the cost of the testing and procedures to the physician prior to the ordering reduced the overall costs by 20%. The study revealed the physicians merely on their own took a few more seconds of critical thinking prior to pushing the order entry button in the computer.

For the first time ever physicians will see what the cost is to every patient they care for including all hospital rooms, clinical studies, lab, radiology, imagining, cardiac, pulmonary, surgical procedures, and medications ordered. The program provides all healthcare and provider costs that are contributed to the individual physician orders and the individual patient. Again cost comparisons are virtually displayed in dollar amounts within the individual physician and group averages.

1. Patient Outcomes: All patient outcomes are displayed in individual and group percentage for comparisons. Again this information is hardly ever given in total to either the individual or group as a part of any standard reporting mechanism, but the system will provide this individually and for the group. In later versions, the system will compare the patient admitting diagnoses to the patient discharge diagnoses between the attending hospital physicians and the ED physicians to reveal the correlation coefficient values between the two groups.

1. Overall Performance: This score is simply not a summation of the previous four main categories but applies weighted algorithmic equations to each of the four categories according to the medical specialty being analyzed. Only after that, the final score is tabulated.

Summary: “Big Data” has come to all hospitals and medical specialties, and it is insidious and indolent because the ever increasing cost of medical care has to be controlled.

Physicians have the power to be involved in this revolution, and if they are diligent this time, they will have the power to be the changers and not the change.

Paul Orcutt MD, FACEP