Why online doctor reviews are good medicine: Tom Lee makes the case for transparency

Patient-centered care isn’t about looking good on consumer scorecards.

It’s a mindset, an organizing principle and a means to a greater end:  high-value health care, says Tom Lee, Chief Medical Officer for Press Ganey, the nation’s leading provider of patient satisfaction surveys.

 “Everyone realizes that health care has to reorganize. It has to become different. It has to organize around meeting the needs of patients,” said Lee during a visit with University of Utah Health Sciences CEO Vivian Lee (unrelated).

Like Yelp for restaurants or TripAdvisor for hotels, patient surveys give consumers a forum for grading hospitals and doctors in areas such as, wait times, professionalism and communication skills.

The concept can be a hard sell with some arguing it will cause doctors to bend to patient demands for unnecessary drugs, tests and treatments. Giving patients what they want isn’t always good medicine.

“[Doctors] are afraid that patients won’t understand the complexity of the data. They’re concerned that the data won’t be robust enough, that it won’t have risk adjustment. And they’re afraid that maybe they are worse than average, or just average,” said Lee, a practicing internist and cardiologist on leave from professorships at Harvard Medical School and Harvard School of Public Health.

But satisfaction scores have become an important gauge of quality; Medicare is tying them to hospital reimbursement. And as institutions like University of Utah Health Care – the first hospital system in the country to post online physician reviews and comments – embrace transparency, physicians are realizing that they have more to gain than to lose, said Lee. 

Q: You travel all over the country and have a unique perspective on what’s going on in the transformation of health care. You’ve also been a real champion of transparency. Tell us examples of where you think transparency is driving change.

A: It is a time of amazing change. I will say this, I haven’t seen any organization I would categorize as happy or feeling like they’ve got everyone nailed and everything is going beautifully according to plan. It is a time of turmoil and transition and everyone is under stress. That said, there are things happening all over the place. Everyone realizes that health care has to reorganize. It has to be different. It has to organize around meeting the needs of patients as efficiently as possible. It’s really hard, but people are doing some fabulous care and it feels like better care. 

People are changing the way they actually try to get our colleagues to work together. University of Utah is a national, and really I would say international, leader in understanding how transparency can not just shape what consumers read about us, patients read about us, but actually change the way that clinicians look at themselves and work together. You know you’ve created a performance framework that frankly the rest of the world is very interested in. 

When I was working at Partners [Healthcare System] I was always pretty careful about pushing transparency because I felt like it was the right thing. But if your colleagues don’t come along then you know it’s obvious it can be a very destructive thing to be pushing things before people are ready. 

But I have always felt that the arc of history is clear. It is toward transparency. It’s impossible to make an argument against transparency. 

Q: How can we justify keeping information away from the consumer, and what are the downsides to transparency? 

A: Everyone in health care is for transparency for everyone else. They just get very nervous when it’s applied to them. But then as organizations like University of Utah has gone out there and put data out there they find that the things that they really worry about, they don’t really happen and many good things happen. …It’s kind of like having kids. I’ve always said that having children, you know, all the bad things are true, all the good things are true. But the bad things aren’t that bad and the good things are better than you imagined possible. 

But it’s not just transparency about patient experience. There’s transparency about costs and prices that I think the arc of history is toward that as well. And then there’s transparency about what we do, giving patients full access to the notes that physicians write. Several organizations have led the way with that, the open notes project; Geisinger, Group Health, Beth Israel Deaconness. Others are going that way. Of course my colleagues are nervous. I would be nervous. At the same time, does anyone doubt that that isn’t where we’re going? 

Q: It seems implicit in everything you’re saying that it’s critical to have that patient education piece. If you’re going to make your patient satisfaction data and notes transparent then there needs to be some patient education as well. 

A: I think that’s true, and of course, we know we can’t educate everyone and everything and have them get 100 on the test. But we should certainly try. The flip side is also true. 

One of the healthiest things I see organizations doing around the country is bringing patients onto committees, onto groups within the care delivery system. And when patients are actually at the table, it doesn’t even matter who the patients are, it doesn’t even matter if they say anything, just their very presence reminds our clinical colleagues of what it is we’re supposed to be doing. 

Q: Most of us realize that patient-centered care isn’t just about patient satisfaction; that there’s a system redesign process that needs to happen. What’s your thinking about how we evolve? 

A: I would say that there are two basic themes. The first is that the overall organization is a valuable, but limited unit of analysis and limited unit of improvement. To go deeper and to really have improvement that feels important and good to clinicians, we have to segment patient into groups with similar needs, because if you’re lumping everyone together, it’s very hard to know what to do with the data. 

But if you’re talking about patients who have just had bypass surgery -- we know what those patients are like and the idea of organizing a team to meet those needs and looking at what they’re going through, that has real meaning. 

And the other thing that is important is asking this question: What are we supposed to become more efficient at? What is the goal of health care? And we know it’s not immortality. And it’s not anything as simple as health. It’s something more like giving people piece of mind that things are as good as they can be given the cards that they have been dealt; helping them live as long as possible, helping to optimize their health. 

Q: What you’re describing, I guess, is the value we should be providing to patients. We think about value as quality and the service piece, divided by the overall cost of care. How do you think about value? 

A: You’re improving value if you’re improving one or more of the outcomes that matter to patients without raising costs, or if you’re lowering costs without hurting any of the outcomes that matter to patients. Ideally we should do both. 

There’s a hierarchy of outcomes, like death obviously is the most important, and functional outcomes, like the loss of a limb. …But assuming you’re in the game on those things, then the disutility of care ­­–– the confusion, the anxiety, the sense that people are not working together –– those things become very important outcomes from my perspective. 

Q: You wrote an influential piece last year in the Harvard Business Review with Michael Porter [Harvard business professor] about measuring outcomes and cost. Which do you see effectively doing that? 

A: No one’s perfect, and I think there’s both measuring and what you actually do with the data, and I think University of Utah is right out front as a leader, if not the leader, in terms of what you actually do with the data. Organizations like Geisinger, Cleveland Clinic, Group Health and Kaiser have made actual measurement-for performance a core value of what they do. But they all feel that they have a long way to go in terms of collecting all the information that matters to patients. 

Q: You just had another paper come out in Harvard Business Review with [Cleveland Clinic’s] Toby Cosgrove about the engagement of physicians. How can we ensure that medicine will continue to attract the best and brightest? 

A: We actually have to change the topic and change the topic from all the things that are upsetting to physicians right now to what we’re trying to create.  And what we’re trying to create is for patients. We have be willing to say it’s going to be better for patients, it may be great for patients, and that is more important that any of our personal agendas. 

The other thing is to help them understand that it’s a team sport today, and functioning like a team, taking pride in what you do as a group. It’s like that’s something new compared to when I was in medical school. Patients are scared that we’re not working well together. 

Q: I think that’s what we’re trying to build into our education programs, more interprofessional training. If we want people to function as teams, we need to train them as teams. 

A: Yes, I was telling some of our colleagues here that when I see every patient I begin by telling them, ‘I read the oncologist’s note, I saw the orthopedist in the hall, I emailed the rheumatologist,’ just to give that message we are working together, to take that issue off the table. It’s bad medicine to be saying anything negative about any of our colleagues, and shaking patients’ confidence that everyone is working together. That’s more than bad manners. That’s really bad medicine now. 

Q: Look into your crystal ball and tell us what health care is going to look like in 20 years. 

A: The progress that’s underway scientifically is breathtaking. I think it feels to me how it must have felt just before antibiotics became available and became widespread. Fleming discovered penicillin, World War II came along they were able to mass-produce it and the world changed. I think we’re on the verge of the same kind of thing scientifically for cancers and genetic diseases.

I think when people, when they look back on our times, they will have limited interest and sympathy for our budgetary issues and the financial crunch, but they will look at the progress and they’ll look at the reorganization of care that occurred and they’ll say, ‘It was a great era.’


By: Kirsten Stewart

Kirsten Stewart is a senior writer for University of Utah Health Sciences Office of Public Affairs.