Monday, 20 June 2016
Dashboard medicine is a term that I had never come across until I came to Canada. The concept however, is one that I was well versed with as a GP in the UK. It refers to a function on the electronic medical record (EMR) that gives a summary of various measures for multiple patients. It could be all the patients rostered to one doctor or the whole practice or a region or even an entire country. It ties in with a theme I would like to touch on today; feedback for doctors.
I heard it said recently that doctors typically fall into one of two camps when they are given feedback that has negative connotations. The first type of reaction is one of abject horror: “I can’t believe I did something wrong”. These doctors feel devastated that they let their patients down and vow to never make the same mistake again. This can lead to being over cautious and requesting unnecessary tests and investigations that can in turn lead to more harm than good. The second type of reaction is basically denial. “Those figures are wrong”. “My patients are older/sicker/different in some way”. “It has been taken out of context”. Clearly what is needed (and I suspect what most of us aim for) is a middle ground. This is where dashboard medicine comes into play. When evidence-based best practices demonstrate improved clinical outcomes or efficiencies of resources without impacting on clinical outcomes, then it is absolutely right that doctors should be adopting those practices. This holds true even if it means changing years or decades of established practice. Lifelong learning should be a reality and not just a snappy catch phrase.
In the UK, the Quality Outcomes Framework (QoF) led to EMRs providing this dashboard of summarised information about various chronic diseases. QoF set standards for best practice that GPs were incentivised to achieve. It then evolved into something else. Many of the current targets leave GPs scratching their heads looking for the evidence base behind them. The regular amendments and additions make it impossible to plan sensibly and adopt new methods to improve outcomes. Moving the financial goalposts with alarming frequency has left a sense of intense frustration, with some doctors stating that they have lost control of the viability of their practices.
In Canada, the concept of dashboard medicine is only really just starting to gain ground. In the province of Ontario where I now live and work, we have a handful of targets such as pap smears and childhood immunisations (targets that have a solid evidence base for improved clinical outcomes) and we receive small financial bonuses for meeting certain thresholds. I believe that a sensibly managed dashboard concept can be an excellent way to provide meaningful feedback to doctors. If you don’t know what sort of results your peers are achieving, it is difficult to know if a) you are in a group that need to make changes to improve outcomes or b) you are in a group that is getting fantastic results and you should be sharing your practice methods with colleagues in order to drive standards up across your local area, region or country. I think the key to successful feedback to doctors is that it is done in a positive manner. The primary role should be to identify high performers in order to develop systems for sharing their best practice and drive standards up across the board. It should never be driven primarily by a desire to name and shame low performers, whilst leaving the vast majority content with mediocrity. The key to the success of a dashboard is that it contains a focused, evidenced-based set of markers that are clearly aimed at improving outcomes for patients. I hope that the drivers of change in Ontario can learn from the mistakes of QoF whilst taking the best bits for use here.