Medical Directors Corner | Audra Thomas, MD

A Historical Perspective of Peer Review: Why We Do What We Do

Becoming a physician who performs peer review means that you have decided to help your fellow physician improve overall medical care for our patients. Peer review can be challenging for everyone involved. The physician being reviewed is worried about a negative finding and what it might mean for her or his career.  The physician reviewing is worried about judging too harshly, backlash or ruining a good working relationship with a fellow physician at the hospital or clinic. We worry – if you live in a glass house, don’t throw stones. 

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If you are older, like me, you can remember some very painful M&M conferences and the punitive statements against a colleague or fellow resident.  We simply do not want to be part of a punitive process. Our goal in the current peer review process is to enable a positive learning process. That is why peer review needs to be an honest, independent evaluation of care that focuses on educating the parties involved and looking at all aspect of care and not just the physician. Outside of individual judgement, what other forces affected the course of a patient’s care?  The majority of physicians desire a good outcome, desire to maintain their good reputation and have the patient’s best interest in mind. With this in mind, errors are still made, a particular practitioner may lack best practice knowledge, or the malevolent person sits amongst our ranks. Peer review exists for these situations.
 
Evidence of clinical peer review can be found in historical records dating back to 9th century Syrian law, where new physicians had to keep records of their cases and share them with the city’s physician council. In a more modern era, Ernest Codman, MD and his good pal, Edward Martin, MD started two organizations aimed at improving medical care.  When Codman was a medical student at Harvard, he began keeping track of how much ether he gave to patients and its effectiveness of anesthesia along with the patient’s outcome.  He continued this habit of record keeping throughout his career, writing down patient’s demographic data and treatment plans along with the patient’s outcome. He called this record, “End Results Cards” as it was kept on individual cards.  He teamed up with Martin, a gynecologist from Philadelphia, to form the American College of Surgeons (ACS), an organization specifically dedicated to improving outcomes for patients through review of patient care. They expanded and looked at hospital care to see how outcomes could be improved.  At this time, medical records were not routinely kept and attending medical school was not required of physicians.
 
Codman and Martin called for hospital medical staff to be trained at a medical school, physicians should keep written records, and that each physician’s outcomes should be reviewed regularly (his End Results Card idea), which eventually developed into Morbidity and Mortality conferences. This subcommittee of the ACS was called Committee for Hospital Standardization and is the forerunner of the current Joint Commission for Accreditation Hospital Organizations (JCAHO). Simultaneously, state medical boards gained strength during the early part of the 20th century, adding additional checks and balances to the setting of educational standards, discipline of physicians and advocating for peer review.
 
In 1952, JCAHO first required hospitals to have a peer review process of physicians, and it quickly became the standard.  However, in 1986, there was a significant court case regarding unethical use of peer review, subsequent lawsuits and money exchanged.  Physicians became afraid of participation in peer review, fearing reprisal against negative decisions.  This led to legislative changes known as HCQIA – Health Quality Improvement Act of 1986. This act was meant to provide a means of peer review, to help protect the public from incompetent physicians while protecting the physicians and hospitals involved in peer review processes.  Because of this law, all physicians engaged in peer review are protected from legal ramifications of a negative finding against a physician that could result in financial or professional loss for that physician.
 
You, as a peer reviewer for CIMRO, an independent review organization, are particularly protected against litigation.  An independent review organization is required to be certain their peer reviewers do not have any conflict of interest when reviewing individual cases.  This means you should not have any direct or indirect ties to the physician, patient, hospital or organization under review.  If you do have any connections to the entities, there is risk of the review being claimed as a sham review – a review whose decision is motivated by actions other than the quality of physician care. An independent review organization is more assured to provide an unbiased review than one that might occur between competing physicians’ groups who might gain or lose money based upon the review decision.  Independent review organizations have the added benefit of maintaining a large body of physicians from a wide range of specialties and subspecialties to provide hospital systems of all sizes with the necessary expertise to review care.
 
In the last 10 years peer review has moved towards wider appraisal than a singular physician’s actions, acknowledging that more patient harm is caused by systems that promote human error. Peer Review is now building upon the Institute of Medicine’s 1999 report, To Err is Human: Building a Safer Health System, findings that “faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them”, rather than reckless or malevolent actions. Building protocols and guidelines helps standardize care so that more physicians, advanced practice providers, nurses and technicians of all sorts follow best practices.  These guidelines and protocols have included immunization schedules, standardized diabetic teaching, stroke care, STEMI (ST elevation myocardial infarction) response, numerous aspects of OB care just to name a few.
 
Protocolizing care is easier with an EMR which can provide easy and quick access to ordersets that walk a medical professional through the steps that are considered best practice.  However, these are meant to guide, not replace decision making and can lead a person astray if applied incorrectly or are not based upon best practices. EMRs can help identify patients that might be appropriate for a certain orderset, such as sepsis or alcohol withdrawal.  A best practice alert (BPA) pop up will alert the physician to this possibility. However, if the patient does not truly have the alerted condition, the BPA can lead the physician astray, introducing anchor bias, and hence the system is contributing to the error.
 
When reviewing cases, it is important to ask what guidelines, protocols or ordersets the hospital or healthcare organization has that might pertain to the case being reviewed.  The entity requesting a review of care is looking not only at the particular provider’s behavior, but also wants to know what barriers in their system either promote or hinder care.
 
Please don’t hesitate to seek out this information when reviewing cases, as it might make a significant contribution to the patient’s care.  As an example, I was asked to review the emergency department care of a baby with bronchiolitis.  It was important for me to know if the hospital had a care guideline for this condition.  It turns out they did, and the physician did not follow the bronchiolitis guideline as laid out by the hospital. While the physician is not obligated to follow the guideline if there are reasons not to, in this case, it would have improved his care and led to correct use of interventions, perhaps preventing intubation.  The hospital may not think to provide this information, but it can be discovered by our staff when needed.  Please feel free to ask staff’s assistance for any additional information you need to complete a peer review.
 
Audra Thomas, MD
CIMRO Medical Director