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This page created April 2000 by Michael Wynne
This page examines the difficulties of
collecting suitable information from the marketplace. Market models
such as that proposed by Graeme Samuel to the World Bank depend on
collecting information and monitoring the care given. This is
extremely difficult because of the commercial sensitivity of such
information.
Experience in gathering information:- Gathering clinical information is a major problem in the competitive marketplace and I will address it thoroughly.
Information is commercially sensitive. Information is of value to the corporation if it improves their profits, their image or can be used in marketing. Adverse information is very threatening. As a consequence they guard it and control it. There is very little objective data about care. Almost all of the useful information about care in the USA comes from outside the corporations.
Getting Information:- One of the major problems in the corporate marketplace is the difficulty in obtaining anything other than government regulatory oversight inspection data and legally prescribed disclosures. There is even pressure to limit the latter and present it in a distorted positive light. One has only to read reports submitted to the Security and Exchange Commission (SEC) in the USA by health care corporations and then follow the thread to its source to appreciate how language and public relations experts can redefine the situation while still making the disclosures required by law. Effective outside oversight over the full range of care would be too cumbersome and costly to contemplate.
How Corporations Handle Data:- Corporations secure their clientele by marketing and the larger the marketing budget the more successful.. Columbia/HCA and Tenet/NME considered this their most important activity, ranking it above patient care. The very last thing these wealthy corporations want is the availability of reliable information which can be used to challenge the content of their advertising or even used in negative advertising by competitors. They certainly do not want to supply information to the sort of discerning customers Dr Wooldridge, Australia's minister of health and Graeme Samuel, chairman of the National Competition Council envisage. These customers might reach sensible conclusions. Some of them have dealt with used car salesmen before.
The bottom line is that corporations will not cooperate in monitoring the sort of health care information which is really needed for care. If they were required to do so there would be strong pressure to fudge the data.
Problems in Collecting Data:- The ongoing collection of medical data is a subject which has been dear to my heart for many years. While the collection of data and its evaluation is the basis of modern scientific medicine there are major difficulties in collecting reliable data, being sure that it is representative and interpreting it correctly.
Clinical research is bedevilled by these problems because the interpersonal relationships between doctor and patient have a profound impact on the way in which both experience facts and how they interpret them. These are resolved whenever possible by double blind trials and when this is not possible by evaluating the data very critically. It is not possible to conduct ongoing monitoring of care as a double blind study, even if we had the money. Nevertheless collecting the best possible information is very important. Another difficulty is that data is so often used without recognising its limitations. Those of us who have worked in academic medicine frequently encounter the claim that "the figures show" when quite obviously the inferences drawn cannot be correct.
Measuring Outcomes:- Advocates like Graeme Samuel will point out that you can measure outputs such as death rates and a number of clearly defined end points. Obviously we can and should do so. By doing so we only collect a limited subset of the information available. In a poor care system for example some units or individuals inappropriately doing procedures will be picked up as giving substandard care. In a good integrated system the unit with the most experience will be referred the most difficult cases and the poorest risks. Their results will be worse and patients accessing the data may elect to go elsewhere. Only those working in the system will interpret the figures correctly and these are unlikely to be corporate directors. It is of course possible to collect more data recording the risks and then adjust the assessment but this hypothetical example illustrates the problem. It is usually cheaper to understand what is happening
Bias in Collection:- The other problem is that money and resources are always limited so that the information collected is always that which is easy to collect and not costly. This information can be very valuable but it can distort understanding if it is used out of context. It may give a partial picture.
How for instance do you measure outcomes and assess the way in which staff interact with nursing home patients, stimulate their interest, and involve them in the activities of life. This is one of the most important activities in increasing quality of life and also life expectancy. How does it get factored into deliberations about efficiency and productivity.
The revelations from nursing homes across the USA and Australia show quite clearly that it has not been a consideration for corporate owners, for government regulators or for the politicians who make policy in either country. Understandings like this are as foreign to modern marketplace policy makers as the idea of probity.
Corporations and Data:- Data collection then is difficult and prone to misrecording and misinterpretation and more so when there are pressures in the system. There is a strong tendency to prematurely publish and publicly proclaim positive information and delay then down play adverse information.
The interpretation and the spin put on data is important. I have read numbers of reports of adverse information about corporations. I cannot remember a corporate spokesman accepting the data and addressing it. Adverse information, even government studies are routinely denied, their validity questioned and the people who generated them attacked. A few representative examples may help. It will give some idea just how threatening accurate data is in the marketplace.
Unwelcome Data -- Examples:- A Consumers group in the USA made a study of the nursing home data collected by state surveillance and published this in 1994. For profit nursing homes had performed very poorly when compared with not for profit facilities. Sun Healthcare was one of the poorer performers. The article was aggressively attacked in regards to its methodology and the motives of the group. It was claimed that this was old data, the methods of collecting data had been upgraded and were now more accurate and so on. During the last 3 years these findings have been confirmed in study after study across the USA.
A scientist working in the USA produced evidence which showed that a product on which a large sum had been spent in development and which was about to be marketed was valueless. The company made every effort to attack his integrity and discredit him. They tried to block publication and they used their influence with politicians to terminate his government research grants.
Dr Olivieri was a well trained researcher in Canada. She was funded by a company to test a new treatment for children with a blood disorder. The treatment was successful in making life very much easier for the children and she published positive findings. She then began to observe unanticipated problems which threatened to shorten the lives of the children. She advised the company of this and urged them to issue a warning. Instead she was dropped from the project and her work attacked. Attempts were made to stop her publishing. The hospital and the university received large amounts of research funding from this company and both took the company's side. Some doctors rallied in support of Dr Olivieri and a long bitter public dispute was reported in the press. While Dr Olivieri was vindicated her research career will be over.
I could find another dozen or so examples. Problems like this are commonplace. Many are not prepared to risk careers and the financial future of their families by opposing corporate interests and publishing unwelcome data.
Patient Care Information:- Much more information is required and it needs to be properly handled and interpreted. Samuel compounds his difficulties by defining a "clear separation of this role from those of purchaser and provider". How is this "role" going to get accurate information from other separate roles, each consisting of groups who are more interested in controlling that information for their own competitive purposes?
Surely we can do better- Contrast the marketplace with my hypothetical model - an integrated and cooperating community based health system where clinical and other information is kept in a digital form. Programs scan the data base continuously collecting data and collating it. This is continuously reported to the sections responsible for care. Any trends can be studied more closely and where necessary the actual situation can be reviewed face to face and resolved.
Lest the very idea of patient data on a network stirs up an outcry about privacy I stress that the patients confidential data would be stored on the protected computer of each doctor or service. None of it would be stored on any other disk and no one else would have access. Collated data only would be stored on the computers of each medical service group. Data at another level of extraction would go to central administrators computers. The benefits for the care of patients, as opposed to government or insurer of an integrated digital data system are so great that methods must be developed to protect patient confidentiality.
CLICK HERE -- for a page about collecting information about the market