Our AMA is leading the way to quality medical care

AMA Leader Commentary. By Yank D. Coble Jr., MD. Nov. 18, 2002.

AMA LEADER COMMENTARY

A few words about current events in medical practice

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A message to all physicians from AMA President Yank D. Coble Jr., MD.

In American medicine today, the AMA and the Federation are addressing so many serious issues, such as our disastrous medical liability system and arbitrary payment cuts, that other important initiatives sometimes don't receive the recognition they deserve. One of the less well known but most valuable endeavors that the AMA has undertaken, in partnership with our medical specialty societies and other organizations, is the development of clinical quality improvement initiatives.

Physicians have much at stake when it comes to enhancing medical quality and safety, especially in terms of professional satisfaction, autonomy and self-regulation. The Institute of Medicine's reports, though perhaps overstated, have made it clear that a number of quality and safety issues need addressing. If we, as a profession, don't attend to the concerns raised in these reports, others will do it for us. Judging from what we've seen already, it won't be pretty.

Fortunately, the AMA has a long history of leadership in improving medical quality. Starting 155 years ago, we helped establish standards for medical education, training and accreditation -- standards that have helped make American medicine the envy of the world. Since then, we have also dedicated ourselves to enhancing medical science through the work of our many councils as well as our support of medical research and academic medical centers. We have always held fast to the principle that physicians must play a front-and-center role in enhancing medical quality.

Well before the IOM reports came out, we were anticipating new quality issues. In 1989, we convened a group called the Practice Guidelines Partnership. Composed of representatives from the 13 largest national medical specialty societies, the Agency for Healthcare Research and Quality, the American Hospital Assn. and the Joint Commission on Accreditation of Health Care Organizations, among others, the PGP developed strong, fundamental attributes for clinical quality guidelines.

At the time, generally accepted standards did not exist, and abuses were rampant. The Milliman & Robertson Healthcare Management Guidelines provide a good case in point. These guidelines, which insurers embraced in the name of quality, soon came to be called the "black box" guidelines. Why? Physicians could not verify what scientific studies or medical experts helped shape them. That information remained proprietary. Many doctors believed that the M&R guidelines were being used for economic rather than quality reasons.

The PGP responded to these abuses. It made clear that a consensus of respected physicians or physician organizations must create and publicly endorse clinical quality guidelines. Such guidelines would focus on medical science, best practices and patient outcomes. Not on costs.

The work of the Practice Guidelines Partnership led to a collaboration with AHRQ and the American Assn. of Health Plans, through which we created the National Guidelines Clearinghouse. Today, NGC provides doctors and the public with an electronic repository of current clinical quality guidelines, to be used as tools (not rules) and as guidebooks (not cookbooks). The guidelines are available online Web site (http://www.guideline.gov/).

In recent years, the AMA has also grown in its commitment to physician performance measurement.

The AMA's Physician Consortium for Performance Improvement is a vehicle that allows physicians to shape scientifically based physician measurement tools. These tools are easy to use and allow individual physicians to improve medical quality across systems of care.

The consortium is composed of experts representing more than 50 national medical specialties, as well as AHRQ and the Center for Medicare & Medicaid Services. To date, the consortium has developed physician performance sets for preventive care, type 2 diabetes, coronary artery disease and prenatal testing. It is in the process of developing sets for asthma, major depressive disorder and pneumonia. These tools are available to all physicians over the Internet Web site (http://www.ama-assn.org/go/quality).

While these measurement tools can be used to measure performance across health care organizations, the tools are not to be used in evaluating individual physicians or assigning accountability. They are not to be used in assessing competence, guiding patients in their choice of physicians or determining compensation. The tools simply were not created with these purposes in mind. For example, they do not take into account variables that would skew evaluations, such as patient sample size.

The AMA and medical specialty societies understand the limitations of these physician measurement tools -- as well as the many ill effects of physician profiling. We are committed to seeing the measures used to enhance physician satisfaction and performance -- and to assist in systemwide, clinical quality improvement efforts.

The AMA also recognizes that clinical quality improvement tools must be cost-effective and easy to use, especially at the point of care. At the AMA's recent Clinical Quality Improvement Forum, we focused on how electronic tools can be used to improve quality and efficiency, all with a mouse click or the stroke of a stylus.

For the first time, we have the technological capacity to create effective, integrated electronic medical systems at multiple sites. At the October forum, physicians cited real-world examples of how the newest electronic medical systems can help improve efficiency and enhance quality and safety. Attendees also examined electronic medical systems and ways to implement systems in a large group practice. They also had the chance to learn about the national context in which these technologies are emerging.

It's been said that when it comes to quality, there is no finish line. Like you, the AMA and the Federation believe that this is especially true for medicine. Together, we plan to continue our focus on physician-driven clinical quality improvement measures. We will work hard to ensure that these measures are scientifically based, and that they are used solely for the purpose of improving medical quality. We will make every effort to address ongoing issues with measurement tools, such as ease of use and cost-effectiveness.

Most of all, the AMA and the medical specialty societies will do all that we can to keep clinical quality improvement where it belongs -- in the hands of physicians.

Dr. Coble, an endocrinologist in private practice in Jacksonville, Fla., was president of the AMA during 2002-03.