Quality at the point of care is crucial in getting the right diagnosis and treatment.

Three years ago, the Rand Corp.’s The First National Report Card on Quality of Health Care in America reported that patients in the United States have a 50 percent chance of getting the right care. The media jumped on the story, calling it “coin-toss medicine,” and it helped spark a national quality improvement movement.

Quality continues to be a hot buzzword in healthcare. But, until recently, the industry had not looked at the issue of getting the right diagnosis and treatment as the fundamental quality metric. A recent report called The Road Ahead: Emerging Health Trends 2007, by the consulting firm Hewitt, shows that this may soon change. Employers are beginning to target the root of the issue and are looking for solutions that influence the interactions between providers and their patients.

This focus on quality at the point of care is long overdue. Patients and their physicians need solutions that help them work together to get the right diagnosis and treatment.

The ‘Fog of Care’
It is a story familiar to anyone who has been or knows someone who has been seriously ill. The patient has doubts about her diagnosis and treatment, but finds it hard to get good answers. She never feels she has enough time with her doctors. And when she goes online to fill in the gaps, she finds as many new questions as she does answers. What may be surprising is that doctors report the same frustrations and uncertainties. It’s really what could be called the “fog of care,” and it’s representative of a healthcare system that doesn’t work.

The results of this “fog” are seen in the high rates of misguided care. Studies show that as many as one in four patients is misdiagnosed, and more than half don’t get the right treatment.

The reasons for this are as complicated as our healthcare system. Doctors see enormous numbers of patients – sometimes 30 or more a day – meaning they only can spend a few minutes with each one. Coupled with all of the new technologies, tests and treatments, there is more likelihood than ever that a piece of information will be overlooked, that an opportunity to treat correctly will be missed. For patients, then, if quality is to mean anything, it must mean that each and every one of them gets the right diagnosis and treatment.

Quality Initiatives
The problem of misguided care has been around for many years, and is the key indicator of deficits in quality. Most quality initiatives, however, seem to focus elsewhere. Hospitals routinely define quality on the basis of the information they report on medication safety, customer service and the number of surgeries they have done.

Health plans have created “high performance” networks, consisting of doctors who comply with certain state-of-the-art treatment protocols. Some of this information is useful to consumers, and gives at least some sense of where medicine is practiced with a high degree of skill and experience. But as “quality” initiatives, the information is too generalized to be of much use to patients trying to get well.  And it does nothing to impact the quality of the care actually delivered to patients. 

The Real World
Consider the example of James Rice (not his real name). Rice, 47, complained of tingling and weakness in his side and went to be seen by his doctor. The doctor ordered a battery of tests, including a full neurological workup, and referred him to a neurologist. An MRI revealed a mass in his brain, which the doctors biopsied. After reviewing the pathology, they delivered some very bad news to Rice: He had a brain tumor. Quickly, they advised that he begin a very aggressive treatment plan, including radiation and other treatments.

Some time later, after undergoing the first round of treatments, Mr. Rice went for a follow-up visit with his doctors. A new MRI was done, and the doctors were surprised to find that the tumor had vanished. Was it a miracle cure? As it turned out, it was not. The doctors ordered a re-review of his original biopsy and learned that, after all, he had never had a tumor. In fact, he had multiple sclerosis, but had been treated as if he had a tumor the entire time.

While this came as a great relief to Rice, it was also quite a shock. How could this happen? By traditional measures, the quality of Mr. Rice’s care had been quite good: Treatment protocols were followed, the right tests were ordered, and he was being treated in an experienced medical center. It was just that the product delivered – his medical treatment – didn’t actually work.

New Quality Trends
Cases like Rice’s are becoming well-known as patients take on increasing responsibility for their own care. As they do this, they are demanding more information and better results. Doctors, who work every day on the front lines of medicine, are among the first to recognize the changing environment. They are starting to ask their patients to be more actively involved in understanding the decisions – and challenges – they face.

In his best-selling book How Doctors Think, Dr. Jerome Groopman describes this issue in great detail, concluding that patients need to be “vital partners” in their care, who can improve their doctors’ thinking by asking a few “pertinent and focused questions [that will] protect me from the cascade of cognitive pitfalls that cause misguided medical care.”

The opportunity for health plans and employers is to create new ways to help patients partner with their doctors. In particular, there is a need to create the tools that patients can use to make sure they are asking their doctors the right questions. What would have happened if Rice knew that pathology results can often be wrong? What if he had asked his doctor to have his pathology reviewed again by someone else before his treatment started? Without question, the quality of his healthcare would have been vastly improved.

A number of services are emerging that give patients information to use to work with their doctors. Even some of the most rudimentary information can be helpful, but when it comes to serious illness the need for focused, detailed information is even more important. The stakes are high and the impact of error is great.

One model for doing this is to move beyond generic disease-based information and provide specific patient-based information. For example, it is possible to have world-class medical experts review each patient’s case, and provide guidance to the doctors treating these patients. Supporting the treating physician with an elite team of experts ensures the correct diagnosis and treatment and improves quality. In this way, patients can truly be effective partners with their doctors.

This kind of approach represents a true strategy for quality improvement. The point of care is where the decisions are made that lead down the right path or the wrong one. The most important contribution anyone can make to the improvement of the quality of care is to make sure that each patient has the right diagnosis, the right treatment and the best chance to get well. If we want to define “quality” as delivering healthcare that works, this is the answer we are looking for.