178 measures.

This is what we’re up to — the collected compilation of quality and performance metrics for our ambulatory care network, across all the different divisions.

Where did these come from, who decided this is what we should measure, does anyone really have any idea if measuring these things reflects the true quality of the care our patients receive?

That’s a lot of questions all at once, and I’m not sure we’re ever going to get the answers to all of them, but it is reflective of the environment we are practicing in. Here are some examples:

• Behavioral health, ADHD medication management, follow-up care for children prescribed ADHD medicines — initiation phase, continuation phase. So someone’s going to have to review the charts of children with ADHD, and make sure that there is follow-up. Whatever that means.
• Disease management, chronic, HIV/AIDS, engaged in care. So someone is going to have to read through our charts and make sure that our patients with HIV/AIDS are engaged in care. Whatever that means.
• Disease management, chronic, congestive heart failure, medication management, ACE inhibitor or ARB or beta-blocker therapy for left ventricular systolic dysfunction.
• Patient experience of care, access, length of relationship.
• Disease management, chronic, pain management, use of imaging studies for low back pain.
• Disease management, chronic, rheumatoid arthritis, medication management, antirheumatic drug therapy.
• Disease management, geriatrics, medication management, medication review.
• Disease management, chronic, high blood pressure, screening, high blood pressure and follow-up plan documented.
• Patient experience of care, wellness, health promotion and education.
• Preventative care, immunization, influenza immunization.

The list goes on and on like this, page after page of tiny type in a lengthy Excel spreadsheet, bringing together all of the different initiatives, including our accountable care organization, DSRIP [New York state’s Delivery System Reform Incentive Payment Program], patient-centered medical home, meaningful use, and countless metrics mandated from insurers.

Who decided that getting these boxes checked for all of these things would really lead us to better care, to a better health care system, to happier, healthier patients and happier, saner health care providers?

In the current world, we are pouring endless effort and energy and the work of all the people who used to help us take care of patients, into creating an electronic documentation behemoth, this huge space that used to be called the patient’s medical record, that is now becoming a lumbering collection of boxes that needed to be clicked to satisfy a never-ending thirst for compliance and unproven metrics.

Are all these things, these metrics, really just the things we used to do, the things we were trying to do, the actual taking care of patients, the actual providing of care to our patients, that we want to happen in every interaction with our patients?

As we’ve done more and more of these things, required the health care team on the front lines to respond to mandates from above, we end up doing things that we are not so sure are really in the best interest of our patients.

Is the patient associated with a completely compliant electronic medical record truly better off? Are they healthier, safer, and have they been provided the highest quality of care?

There has got to be a better way to make sure my patient gets their flu shot, takes their medicines, becomes educated, is on the best treatment, gets healthy.

Some studies have shown that shortening length of stay and decreasing readmissions may not always the best thing for patients, and may, in fact, cause more harm than good.

Just because we’ve clicked a box that says whether or not a patient has fallen in the past year, whether or not I have documentation of their high blood pressure treatment plan in the chart, whether their depression screen is negative, whether they are overweight or underweight, are we really changing the outcome?

If all the effort that can possibly fit in the office visit or hospital stay, or any health care encounter our patient has, all goes towards satisfying a metric, is the patient healthier?

We have questioned whether figuring out which of these things really impact the lives of our patients will lead to us getting more resources to actually take care of the things we discover are really in our patient’s best interest.

If we discover that food insecurity, lack of access to healthy food options, obesity, unmet mental health needs, poor compliance, low health literacy, are the things that our patients really need addressed, is our institution, and the health care system of our society as a whole, prepared to give us what we need to get them to get these problems addressed, fixed, cured?

I’m not saying that I want my patients to fall; I know that’s not a good thing. I don’t want them to smoke — that can’t be good for them. I want them to take their medicines, eat healthy, exercise, overcome the barriers in their lives that are preventing them from getting to the healthiest state they can.

But the entirety of our interaction with the patient can’t just be lip service to health care, it needs to be real, it needs to be actionable, and it needs to have resources and muscle standing behind whatever we find to be the problems.

Just because patient experience of care, satisfaction, stewardship of patient resources, is listed as something we need to do, help us do it.

Maybe we need one visit for patient care, and one visit for the care of the chart.

Don’t just make it a metric we need to meet.

Make it about the patient.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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