The Data Files

Physicians Can Help Ensure the Truth Is Out There on Hospital Discharge Data

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Medical Economics Feature -- June 2000

By Johanna Franke
Associate Editor

After a hard day's work, you arrive home in time to catch the evening news. The talking head on the screen announces that one of the hospitals you practice at has the highest mortality rate in the state. This does not surprise you, since the hospital has a trauma center that takes in seriously ill or injured patients.

But reporters line up on the hospital lawn the next morning, waiting to shove a microphone in your face as you sprint to the door. Once inside, you see the hospital's public relations department working furiously to clarify that you and your colleagues are not killing patients.

Physicians can't live in denial anymore. For better or for worse, Texas hospital discharge data will be released for public consumption in December -- not September, as originally planned. The good news is this postponement gives physicians more time to ensure the quality of the information before it is consumed.

The "conspiracy"

"Medical staff coordinators and chief executive officers of hospitals are telling us that physicians assume this is some kind of plot created by the hospitals," said John R. Holcomb, MD, a San Antonio pulmonologist who is a member of the Texas Medical Association Council on Socioeconomics and chair of the Texas Hospital Association's (THA's) Committee on Quality Indicators and Patient Information.

In actuality, three legislative sessions' worth of effort has led to the collection and reporting of hospital discharge data. A 1995 legislative act created the Texas Health Care Information Council (THCIC), composed of 19 members representing employers, labor, physicians, hospitals, consumers, health maintenance organizations (HMOs), and quality assurance experts. The legislation, sponsored by Rep Glen Maxey (D-Austin), charges THCIC with "developing a statewide health care data collection system to collect health care charges, utilization data, provider quality data, and outcome data to facilitate the promotion and accessibility of cost-effective, good quality health care."

THCIC began publishing data on Texas HMOs in the fall of 1998 and continues to make annual releases. Discharge data on 450 Texas hospitals will be released quarterly.

The original legislation was amended in 1997 and 1999, in part due to efforts by TMA and THA to ensure that all data are presented accurately and will be meaningful for consumers.

Discharge data provide information about a hospital's performance, including quality and effectiveness of health care, and charges and rates of change in charges for health care services.

But Dr Holcomb, also a member of the Quality Methods Technical Advisory Committee of THCIC, says patients won't find much use in these data.

"The problem is that THCIC, as most other legislatively created councils, is severely underfunded, so it's not clear to me that there will be any dollars available to format these data in any kind of meaningful fashion to consumers," he said.

This is not a new problem, according to study results published in the April 12, 2000, issue of The Journal of the American Medical Association . The results show that consumers don't use performance data because of difficulty in understanding the information, disinterest in the nature of the information available, lack of trust in the data, problems with timely access to the information, and lack of choice. Instead, consumers rely upon anecdotal evidence from family and friends to choose where they obtain health care services.

Debugging the system

An 10-hospital pilot project, considered a success by THCIC officials, was created to test the proposed certification process, identify challenges faced by THCIC and hospitals, correct system process weaknesses, and make the certification process smoother for all reporting hospitals.

"Even the worst of problems discovered in the pilot test could be taken care of with a one-time fix," said Jim Loyd, THCIC executive director. "So we really do have a process that works and is functional. We can see the light at the end of the tunnel, and it's not a train coming at us."

Only 450 Texas hospitals will be required to report discharge data. Federal hospitals and charity hospitals do not have to report data. Hospitals in counties with fewer than 35,000 people and certain other hospitals may apply for exemptions through THCIC. But hospitals linked to hospital systems are required to report data even if they might otherwise qualify for an exemption, Mr Loyd says.

Hospitals collect the data for THCIC through the UB-92 billing form, also known as the HCFA 1450. This form contains more data elements than the HCFA 1500, used for Medicare billing. It is used to submit changes to all payers. For charity and cash customers that don't call for a UB-92, THCIC requests a similar "alternative" data set. The UB-92 form provides a readily available data source, and offers the most cost-effective and efficient form of submission, a THA spokesperson said.

But Dr Holcomb questions using billing information to produce performance data.

"I think the integrity of the data is a real problem," he said. "A bill might not be the most appropriate technique for identifying quality and cost. Traditionally, coders, medical records personnel, and hospital chief financial officers of hospitals have only studied those documents to make reimbursement decisions -- not to consider elements that impact other kinds of judgments."

The council will not release provider quality data for at least a year, because, by law, THCIC must evaluate methodologies for assessing provider quality. This will not preclude other entities from using the public data file to develop their own quality reports, THA says.

On top of those headaches, hospitals are required to collect more data than they ever have before to comply with the new law, says John Anderson, MD, senior vice president for clinical integration at Baylor Healthcare (BHC) System in Dallas and another member of THA's Committee on Quality Indicators and Patient Information.

"The problem with this is the state has come along and said, 'We want all your hospital discharges, and it really doesn't matter to us that Aetna requires the UB-92 to be filled out one way and Blue Cross wants it done another way, and, by the way, nobody collects race and ethnicity information, but we want that data as well.' We've got to figure out how to fit that into the data submission," he said.

This increase in data collection literally crashed the processing system at Parkland Memorial Hospital, says Jackie Mutz, RN, quality management associate director of outcomes resource there.

Besides fixing technical difficulties, hospitals must weed out human errors in their systems before sending data to THCIC. These human errors sometimes are caused by poor medical documentation on the physician's part, Ms Mutz says. Physicians should know how the data are coded so they can document the data accurately. "The better they document, the better the information the coders have," she said.

Physician detectives

Even though more than 400 items of data are being collected, only 60 are included in the official public data set, which must be certified by hospitals -- and physicians -- before being released, says Stephen Turner, MD, THCIC immediate past chair.

During his tenure, Dr Turner pushed the council to create this subset of "the bare essentials." These essentials include hospital identification, demographic information, length of stay, type of admission, discharge status, payment source, up to nine diagnoses, significant comorbidity, and diagnosis-related groups.

As required by statute, the public data set also includes a risk and severity adjustment factor developed by 3M to prevent institutions from being dubbed "hospitals with the highest mortality rate in the state" when they care for a larger number of critically ill patients than other facilities do.

During the 60-day certification process, hospitals are required by law to give physicians a chance to review their data and make comments. Because the certification process has just begun, it remains to be seen how many physicians take advantage of their hospitals' making the data available for review.

"We have conveyed to physicians that the data are not physician-specific, so they have not had a lot of interest in it," Dr Anderson said. "But that doesn't mean that if tomorrow the data were published in leading newspapers across the state, they wouldn't suddenly wake up to it -- particularly, if their hospital didn't look favorable based on the data."

Dr Turner believes physician denial is contributing to the lack of interest in the certification process. "Frankly, some of the physicians have had the attitude that this whole process is going to go away."

Because of this, he urges physicians to be involved in the process. "Physician involvement will deliver a superior product while protecting physician interests," he said. "If doctors participate, we'll create something that is more palatable to everyone than something imposed upon them by third parties."

Lewis Foxhall, MD, a THCIC hospital representative and associate vice president for health policy at The University of Texas M.D. Anderson Cancer Center in Houston, agrees with Dr Turner. He encourages physicians to touch base with their hospital administrators to learn about the process. "If we have to do it, we want to make the data as useful as we can so we can actually get some good out of it."

In the long run

To ensure the release of two quarters of solid data, THCIC has pushed back the release of the public data set to December. "We're going to take an upfront delay so that down the road, the data will be submitted in a much more timely and user-friendly manner," Dr Turner said.

Once the kinks get worked out, these data may be useful to public health researchers tracking patient demographic trends as well as large employers and insurance companies, who will use this information to determine which hospitals are providing more cost-effective, quality services, Dr Turner says.

Later this year, THCIC will work with TMA, THA, and local county medical societies to arrange educational programs for physicians about the council and its objectives. In the meantime, physicians should keep good medical records, get some media training (see "Media Tips"), and take their utilization review managers out to lunch.

For more information

To obtain more information on hospital discharge data, call the Texas Health Care Information Council (THCIC) in Austin at (512) 424-6492. You also may contact Helen Kent Davis, TMA director of governmental affairs, at (800) 880-1300, ext 1401, or (512) 370-1401.

SIDEBAR

TMA Advantage: Media tips

Are you ready for your local news reporter to knock on your door when hospital discharge data are released to the public in December? If not, start preparing now.

With the attention the Institute of Medicine report on medical errors received, physicians can be sure hospital discharge data will be high on an editor's list, says Eddie Owens, MBA, director of public relations at Covenant Health System in Lubbock and a member of the Texas Health Care Information Council's (THCIC's) Consumer Education Technical Advisory Committee.

Physicians need to work with their hospitals to be accessible to both hospitals and the media, Mr Owens says. They also should take advantage of the data certification process to learn what the hospital's data mean and understand how the data will look to the media.

He suggests hospital chief executive officers develop formalized response plans for when the data are released, as well as undergo formal media training. Pat Clark, director of speech/media training for the American Medical Association, can help with media training. You can reach her in Chicago at (312) 464-4497.

In the meantime, Texas Medical Association's Media and Public Relations Department offers the following tips for dealing with the media:

The reporter is not your friend.

  • His or her job is not to communicate your message.
  • You must communicate your own message, and you've got 15 seconds of tape or maybe two paragraphs of print to do it.

That said, every time a reporter calls is an opportunity for you to tell your side of a story to the public.

  • Except in rare situations, never let that opportunity slip away.
  • If physicians don't tell their side of the story, no one will.

Be prepared!

  • Make sure your staff members know that media inquiries should be given priority. Don't let requests for interviews get buried under a pile of other phone calls you have to return.
  • Don't keep the reporter waiting all day. The earlier you return a call, the more likely your comments will be used and placed more prominently in the story. Ask the reporter what the deadline is and meet it.
  • Don't go into the interview unprepared. Make sure you know what the topic is and the angle on which the reporter is focusing.
    • If you are not well versed on an issue, don't call the reporter back until you are. Your county medical society and TMA staff members always are available for quick briefings on important health issues.
  • If you are speaking on behalf of your county medical society or TMA, make sure you know their positions on the issue and STAY ON MESSAGE.
    • Determine three or four key message points you want to get across and return to those points at every opportunity.
    • Don't blow off or talk around a question. Acknowledge the question, and then explain why your point is the really important issue.
    • Never repeat a negative statement or assumption. That just gives it more airtime.
    • If you don't know the answer to a question, say so. Offer to find out the answer and get back to the reporter.

Know the ground rules!

  • Find out the reporter's angle in advance.
  • Make sure you know if the camera or tape recorder is rolling before you engage even in idle conversations.
  • Try to give the interview on your turf so you can have more control over where the cameras go, what they tape, and to whom the reporter speaks. Be courteous and cooperative, but don't let reporters push you around.

NEVER SAY "NO COMMENT!"

  • "No comment" makes it look like you are hiding something.
  • If you can't comment, explain why:
    • Ongoing criminal investigation or civil litigation.
    • Confidential patient information.
  • If you are not the appropriate source, refer the report to someone who is.
  • Stay away from off-the-record comments.
    • Assume anything you say is on the record, particularly with a reporter you don't know or don't trust.
    • Most reporters will honor requests not to be quoted by name or to be used for background information only, but you occasionally will get burned.

It's all about relationships!

  • If the reporter knows you, trusts you, and relies on you for accurate information and a prompt response, he or she will come back to you again and again. That increases your opportunities and organized medicine's opportunities to communicate key messages to the public. It also increases your credibility with the reporter and the chances you, your county medical society, or TMA will be portrayed favorably.

June 2000 Texas Medicine Contents
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