Vivian Lee, M.B.A., M.D., Ph.D.
N Engl J Med 2017; 376:197-199January 19, 2017DOI: 10.1056/NEJMp1610136
After years of academic debate over the role and value of patient-satisfaction scores and reviews of health care providers,1,2 Yelp, the online powerhouse of documenting customer satisfaction, is forcing the issue. With more than 102 million customer reviews to date, 6% of them in the health care arena, Yelp easily dwarfs longer-standing commercial physician-review sites such as Healthgrades and Vitals. A recent analysis used natural language processing tools to evaluate 17,000 Yelp reviews of 1352 hospitals and showed that they revealed information similar to that covered by 7 of the 11 categories of patient satisfaction included in the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS), along with 12 categories not included in the HCAHPS, such as costs, billing, and scheduling.3
Although this free and familiar platform can generate an impressive volume of feedback data, physicians do not always respond positively to the sudden exposure of sometimes negative reviews. Recent reports describe doctors and dentists who have felt compelled to post retaliatory and revealing responses that not only violate the Health Insurance Portability and Accountability Act (HIPAA), but also threaten to undermine the fundamental trust between patients and clinicians.4
So what are the goals of transparency efforts regarding patient feedback? How can those aims best be achieved? Whose responsibility is it to provide and share these data? And what are the best media or venues for such sharing?
I believe patient reviews and feedback can serve three main goals. First, like the peer-level perspectives on consumer products and services posted on Amazon, TripAdvisor, and Yelp, reviews of physicians or hospitals can help patients make more informed consumer decisions. Publicly available reviews can help address information asymmetry in the health care market and increase patients’ confidence in their own decisions. Collectively, by making clear their preference for higher-performing systems, patients can become a market force driving quality and value in health care.
Second, patient reviews offer clinicians valuable performance feedback for learning and improving, both individually and across a system. Receptivity to performance feedback, which depends heavily on physicians’ acceptance of the data’s validity, facilitates a culture of continuous learning and patient-centeredness.
Third, health care systems and physicians who voluntarily share patient-review data visibly foster a spirit of trust with patients and the community. Patient reviews offer the opportunity to improve health care delivery while strengthening the provider–patient relationship.
With these goals in mind, various approaches to enabling and supporting patient feedback can be evaluated in the context of several key principles that are necessary for effectiveness. One principle is that data need to be trusted and considered legitimate by both physicians and patients. Existing online doctor-review websites, such as Vitals, Healthgrades, RateMDs, and Yelp, may fall short because reviewers need not have received care from the clinicians they critique. Anyone — a disgruntled neighbor, an ex-boyfriend, even a random stranger — can post a negative review of any clinician. The limitations imposed by HIPAA restrictions on the ability to verify the identities of patients posting on social media platforms may reduce the perceived validity of the reviews. Nevertheless, the sheer volume of reviewers and reviews on websites such as Yelp can mitigate this concern.
In addition, data need to be relevant and actionable. Patient-satisfaction questionnaires can cover a wide range of attributes of care, from the clarity and effectiveness of communication and shared decision making to amenities such as parking and food service. Manary et al.1 found that when metrics are designed correctly, patient surveys provide a “robust measure of quality”; they determined that characteristics of a well-defined survey include specificity about a visit, a focus on patient–provider interactions, timeliness of responses, and risk adjustment of the cohort. In sum, feedback should be specific, relevant, timely, and fair.5
Data should also include benchmarks for comparison to peers,5 which can provide some degree of the risk adjustment that Manary et al. cite as critical. Large databases of patient-satisfaction survey results, whether commercial or otherwise, make it possible to translate absolute scores from patient-satisfaction data to percentiles that reflect comparison with the appropriate peer group.
Patient feedback, like any performance feedback, influences physician behavior most effectively when it is disclosed for the purposes of educating and motivating improvement.5 In our experience, first sharing benchmarked feedback with physicians privately, providing opportunities for learning and improvement, and then increasing transparency, is effective.2 As the Yelp experience reveals, sudden, broad distribution of performance data can trigger defensiveness and undoubtedly exacerbates problems with physician morale and well-being.4
Finally, patient-satisfaction data can be an effective driver of patient-centeredness in a delivery system. Any patient-satisfaction initiative should be tracked in the context of other important metrics of delivery-system performance, such as measures of access, quality, and costs of care.
Of all the parties that are collecting and sharing patient feedback — government agencies, insurance companies, not-for-profit foundations and organizations, hospitals, for-profit rating systems, and others — health care systems are best positioned to meet these goals and to abide by these principles. Data that a health care system collects directly from its patients are considered more valid than those collected through commercial physician-rating systems and are readily amenable to benchmarking.2 They can be developed in the context of performance-improvement systems. They enhance patient trust and can inform delivery-system reform. Yet for most health care systems, transparency of performance data still represents uncharted territory.
Social platforms such as Yelp seek to define a new norm in performance-data transparency in health care and provide valuable lessons. These platforms have the strong advantages of ease of use, accessibility, and widespread familiarity. In addition, unlike most structured health care surveys, online review sites collect feedback primarily through free-response answers, which Ranard et al. have shown can broaden the scope of feedback and the domains of potential improvement.3
Over the past 4 years, several health systems have begun to share patient reviews online, applying lessons learned from existing social platforms. In late 2012, after 4 years of developing a system for data collection and feedback, my organization, University of Utah Health Care, posted its patient-satisfaction survey data and free-response comments online, adopting the five-yellow-star format that’s easily recognizable by a public familiar with Yelp and TripAdvisor (see image). For 3 consecutive years, nearly half the physicians receiving at least 30 reviews per year have scored in the top decile and a quarter of them in the 99th percentile in patient satisfaction among their peers nationally.2 In early 2014, Piedmont Healthcare became the second health system — and the first one that’s not an academic medical center — to post reviews online, followed shortly thereafter by Wake Forest Baptist Health, Northwell Health, Stanford, Cleveland Clinic, University of Pittsburgh, Duke, and more than 20 others.
Beyond patient-satisfaction data, some health systems are also championing transparency of other information, such as patient charges and performance on quality measures. Who will take responsibility for sharing these data is an open question. For example, even as the Centers for Medicare and Medicaid Services recently released its much-anticipated overall Hospital Quality Star ratings, Yelp announced a partnership with ProPublica to adapt publicly available quality data for inclusion on its website, thereby continuing to advance its goal of becoming the comprehensive data source for consumer decision making.
Ultimately, transparency of validated data about delivery-system performance has the power to change the culture of health care. What sorts of data are collected, how they are shared, and whether they’re used effectively to improve performance and quality will depend on how health care professionals and patients value and use this information. The question is not whether there should be public disclosure of information on patient satisfaction, outcomes, and costs — it’s how and by whom it should be done.
Disclosure forms provided by the author are available at NEJM.org.
From the University of Utah School of Medicine and University of Utah Health Care, Salt Lake City.