Public Reports for an Uninterested Public

Jaz-Michael King

Jaz-Michael KingHere at IPRO, the Health Care Transparency team has been working on producing publicly available comparative health care reports since 1999, and we launched our first Web-based report in 2001. Back then everything was highly experimental and consumer engagement was next to nil. Over the following years we’ve experimented with numerous visualisation techniques and consumer language approaches, and watched many other folks around the country and the world push more and more data on an unsuspecting – and largely uninterested – public.

Compared to other developed nations, the United States poses a unique problem for the health care consumer. Instead of a single payer in the form of government-purchased health care, the US health care market is composed of independently-operating heath care providers, even though the government ends up paying in nearly half the cases. These practitioners or facilities compete for private and public insurance dollars in a somewhat free market environment, but due to the nature of insurance agreements the same freedoms are rarely passed on to the insured. The insured individual may be locked into a network of available providers, or be allowed to choose beyond the network in return for cost-sharing.

Tools to help consumers spend their insurance dollars wisely have been steadily growing, but the very reason for the existence of such educational tools is still subject to slow adoption; few public reports generate much in the way of significant consumer interest and to date even fewer studies have been performed to gauge either these reports’ usefulness or impact. (IPRO is participating in an AHRQ-funded national survey of hospital reports – more on this later.)

So why build public report cards if the public doesn’t use them?

Well, we have first-hand evidence that the public does use them. We receive emails thanking us for making the information available and our less-than-scientific user surveys demonstrate at least a portion of consumers actively engaged in searching out this type of information. We have Web traffic reports showing millions of hits to individual reports, demonstrating that for someone, somewhere, these things are useful. We also believe strongly that the publication of comparative data stirs competitive juices and drives quality improvement. Most importantly though, we believe that a true, data-driven health care marketplace is impossible to achieve without good quality data, and that good quality data is driven by reporting the best we have to offer and searching for more.

Ten years ago, acquiring health care data to produce a public report was nearly impossible. These days, we’re drowning in it. Between a transparency-focused White House, Web 2.0 technologies and social media, and a slow but steady digitization of health care, we can barely keep up with the flood of data becoming available. As purveyors of this data, we try to find the right way to tell the right story to the right people.

Not all our tools are intended for public consumption. The work we produce for the Commonwealth Fund’s Why Not The Best? site, for example, is specifically intended for providers and quality improvement professionals.

Yet, as part of the team that has launched dozens of such reports, my experience has been that no matter the intended audience for a report card – consumers, policy makers, providers or purchasers – the first audiences through the door judging a given tool are the press and the providers being reported on. The press usually want a couple of quick-fix highlights showing one or two providers failing miserably at their job, and the providers usually want to tear the report’s foundation to shreds by demonstrating how on any given Tuesday the numbers used for indicator “x” are wrong because of convoluted reason ”y.”

Nonetheless, interest in publicly available data is growing by leaps and bounds, and the topic of health reform has stimulated interest from many newcomers with considerable skills to add to the universe of health care reporting. One way we are telling different stories is with the use of Web-based interactive maps. “Health care is local” is an oft-used maxim when talking about disparities in quality, and nothing says “local” like a map.

Last year we found ways to let visitors on the Illinois Department of Health site explore county-level data with several goals in mind. First we had to produce a complex map tool that allowed public health workers and policy folks to zoom in from the state level to the county level to urban areas easily and intuitively. Next we had to provide a tool that was not off-putting to the general public. Third, we had to show different types of indicators in the same general interface without losing the user in complex instructions.

The result – after many months of painful experiments – is the Illinois Public Health Community Map. Produced in conjunction with our partners at Axis Maps, we have delivered a unique tool that not only takes complex comparative data and presents it in what we believe to be a visually pleasing and intuitive fashion, but also allows your average health wonk to bite more deeply into the data by combining it with census data or jumping between the available indicators with ease. Additionally, users can quickly highlight outliers or segment the reported regions by simply dragging a pointer across the available histograms.

“So how does publishing county-level data help me?” I hear you ask. Or, at least, I hope you’re asking.

Applicability and actionability have been major hurdles. Remember 2001? No YouTube. No iPhones. Google was still just a search engine. Friendster hadn’t opened yet, let alone burned out and been replaced by the now ubiquitous Facebook revolution. I learned early on that reporting the differences in quality of care across various providers was practically pointless because nearly everyone believed that all health care was roughly equal. In fact, as I heard it, all health care delivered to anyone else was awful, while all health care delivered to you personally was the best in the world.

So we changed our tack. Instead of “compare this provider to that provider”, we went back to basics with “health care quality varies.”

We’re still trying to educate consumers that the quality of health care varies. Sometimes by a lot, and sometimes by a little. But it varies. Consumer-centric reporting tools will remain almost useless until this basic fact is at the heart of our consuming habits, but I’m buoyed by the caveat that the Web has changed how people consume everything. Just as we have all changed how we shop for travel, mortgages and cars, we will surely catch up in how we purchase health care – even more so as more of our personal dollars supplement the monopoly money that we call health care insurance today.

When that happens, we and our peers will be ready, having tested our reports on the early adopters who are shopping that way now. Of course, at some point, all of us Web-savvy young’uns will start getting older, become AARP members and start shopping for our own health needs and by then you can guarantee we’ll have figured this all out. It’s hard to report on a system you have little daily use for.

So this county-level report squarely illuminates variation in the delivery of health care, without pin-pointing specific deficiencies in a given provider or even a given county. Most reports, when done well with a broad set of data, will show that entities perform better at some things, less well at others. Again, variation.

This is our first tool aimed squarely at a public health audience. The good folks at the Illinois Department of Health worked tirelessly to guide our efforts and they have already found new uses for the tool. We are extremely interested to watch how it gets used and who uses it. Over the coming year we will be building additional map interfaces for other audiences using other indicators and a broader set of data. We will begin exploring how consumers can interact with this data to find facilities or providers near them, and to quickly ascertain differences in cost and quality. We’d love to hear how you or your colleagues are using this or other tools at their disposal, so please leave a comment and let us know your thoughts.

Mr. King oversees the eServices team at IPRO, where he most recently directed the production of the nation’s first publicly accessible clinician assessment portal, and the construction of Pellucid™ – a global database of publicly reportable health care data.

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