Report Card Tyranny - Getting report cards on patient care may make doctors too disease-centered

I don't give a shit if doctors don't like report cards. In stroke they would point out that every doctor and hospital in the world would be flunking. And that would be a good thing. Those failures might concentrate the minds to actually fix the problems in stroke.
http://www.medpagetoday.com/PatientCenteredMedicalHome/PatientCenteredMedicalHome/54123?
This month we've started a transformation of one of our practice transformation projects.
One of our projects, which used to be called our "Diabetes Report Card," is now being called something entirely new -- "Panel Management Improvement Project -- Diabetes."

The reports, generated for each provider based on their patients who carry the diagnosis of diabetes, list disease-appropriate guidelines in a large paper packet, containing all the goals and other measures that are being monitored in the name of "quality."
They include the usual suspects for diabetes: hemoglobin A1c less than 7.0%, cholesterol at goal, microalbumin, dilated eye exam, flu shot, pneumonia vaccine, dental exam, foot exam, and more.
All of this information is retrieved as a data dump from our electronic health record (EHR), presented in tabular form to the residents and other providers for them to review, and hopefully work toward trying to improve.
Each item listed for each patient is accompanied by a little "thumbs up" or "thumbs down" icon, and global averages for the entire group of patients are also given.
The project is designed to have them look through their data, think about their patients, and come up with some target interventions they can do to globally improve the care of their diabetic patients.

So, for example, a resident may review her panel of diabetic patients, and get an overall gestalt that she's not being as aggressive as she should with cholesterol management in these patients. Or she may notice a pattern of missing vaccines. Or that the system is simply not correctly capturing the fact that they had an eye or foot exam or had seen a dentist.
As with many EHRs, much of this information is retrieved automatically, from the lab results that pull in the hemoglobin A1c or their lipid panel, or an ophthalmologist's note that satisfies a previously placed order for an ophthalmology consultation. But many of these things need to be manually entered by providers, increasing the burden to get these things complete, accurate, and up to date.
Documenting in your note that you examined someone's feet or that they have a podiatrist they follow is not enough. You then need to go to the health maintenance section of the EHR, find the podiatry/foot exam field, and enter the date that this occurred.
Now, as we all know, the push is on for us to be measured (and rewarded/penalized) on quality, so it may simply be a necessity that we're going to have to get all of these fields filled in and up to date.
But at the same time, it's important to keep an open ear, open eye, and an open mind.

Not all diabetics need to be at a hemoglobin A1c under 7. Not all of our diabetics will take a statin -- nor should they all. Not all of our diabetics want to see an eye doctor. Not all of our diabetics even believe they really have diabetes.
Recently, an elderly patient with advanced malignancy and severe heart failure came to me, along with his family, for a second opinion about his diabetes control. The family has noted in the past few months that his fingerstick glucose readings have drifted upward -- from their usual 110s into the 140s, occasionally spiking to 170 after meals.
Distressed, they had taken him to see his doctor, who had done another hemoglobin A1c, which came back at 6.8%. His doctor had reassured them that he was fine, but he demanded a change of all of his medicines -- "They must have stopped working." He and his family said, "We don't want the hemoglobin A1c to come back over 7 next time; we want to do something about this now!"
This has the potential to cause nothing but harm. Guidelines can sometimes guide us (and patients) down a bad path.
I worry that improvement projects like these take us away from being patient-centered, and back to being disease-centered, or even worse, provider-centered. I feel that somehow the tyranny of these report cards forces us to line up our patients in neat rows like ducks. It shouldn't be more important that they achieve some number, but that they actually feel better, our goals are aligned with theirs, and that they are healthy and do well.

While it is obvious that some oversight, guidance, and monitoring are important, we've become fettered by the need to fill in boxes, and unable to freely practice the care we want to provide our patients.
I think there is a certain value to this kind of process, these exercises. The residents doing them will hopefully learn a little bit more about diabetes, learn about things that they may have neglected to attend to in a more global sense for their practice panel, and some individual patient may benefit from an intervention. Who knows, maybe this step will lead to somebody getting a flu shot that prevents a hospitalization or death.
The residents also will have the opportunity to learn about panel management, disease management, practice improvement, and all the new ways of evaluating systems that are happening in the world of healthcare today.
But I think we need to find a better way to remind these providers that each line on that "report card," or whatever we are calling it today, represents an individual, one person different from all the others in so many ways, with their own specific personal issues, ideas about health, challenges that we've yet to explore, and barriers we need to help them break down. And we need to remember that none of them are a checkbox on some Excel^© spreadsheet.
Otherwise we get a failing grade.