Ashish Atreja, MD

The Centers for Medicare & Medicaid Services (CMS) has defined six National Quality Strategic priorities that will form the foundation of Medicare performance measures used to populate value-based reimbursement programs. These programs will directly influence our reimbursement in the years to come as we move away from fee-for-service payment. One of the Priority Strategies is person- and caregiver-centered experience and outcomes. Measuring patient experience is not easy, yet many gastroenterologists will be confronted with survey results collected by their practices, hospitals, and hospital systems. Dr. Rizk and his colleagues help us understand the framework, implementation, and implications of the major patient experience surveys used today. Many of us have used results from such surveys to identify gaps of care that can be improved in ways that impact our patient care.

John I. Allen, M.D., MBA, AGAF, Special Section Editor

Until recently, prioritizing patient experience was still a relatively novel idea. The general assumption was that because patients come to the hospital out of necessity rather than choice, health care providers could ignore customer service. Operating models typically focused on two improvement measures: positive clinical outcomes and cost containment. The major advances of the health care industry – cutting-edge treatments, technologically sophisticated delivery methods, high-efficiency protocols—have often come at the expense of patient experience, making care delivery increasingly impersonal and mechanized.¹

By 2010, however, improving patient experience had become part of the mainstream health care agenda. In fact, a recent survey of health care executives found that 37% ranked "patient experience" as a top three priority, the second-most frequent answer just after cost reduction (40%).²

As health care transforms into a consumer-based model, there is increasing demand from health care institutions, insurance companies, and government to measure patient experience. Although a staple in many industries for years, this is a relatively new phenomenon in health care. The primary mode through which patient experience is assessed is with surveys, the most important being the government-mandated Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This article provides an introduction to the use of surveys as an instrument for measuring patient experience, details government-mandated and private surveys, and suggests tools that may be beneficial in both measuring and improving patient experience.

Surveys: A scientific instrument

When performed correctly, surveys replace assumptions with data and serve as a scientific instrument for social and behavioral sciences by collecting information in the form of a structured set of questions, with the intention of revealing trends and patterns over time. In addition, but less commonly, surveys can be used as a tool to identify specific service recovery opportunities.³

There are important considerations when a survey is designed. How participants are selected is just as important as the number of participants. Specifically, surveys can vary from including every member of a group to including a sample cohort, which may or may not be representative and bias free. Who is approached for a survey and who responds to it depends on multiple factors including cost, feasibility, proximity to the experience, availability, whether the respondent received the survey through referral, the engagement and participation of those being surveyed, and whether incentives are provided.³ The verbiage and design of a survey also can introduce bias. Respondents tend to choose the first option from a list and to answer as they think they should rather than being truthful. Good surveys randomly sample respondents so they are representative, are designed to minimize selection biases, and adjust for known variables that can confound results.³

Trend toward standardized national benchmarking surveys

There has been a shift away from using stand-alone survey instruments developed by private companies (such as Press-Ganey) for internal use by health care organizations to using national benchmark surveys developed by Federal agencies for public consumption. Three broad goals have shaped this trend. First, standardization of both the survey tool and implementation protocol allow valid comparisons to be made across hospitals locally, regionally, and nationally. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the first national standardized survey of patients’ perspectives of hospital care, has gone through rigorous development and testing by the Agency for Healthcare Research and Quality (AHRQ) including a public call for measures, literature review, cognitive interviews, consumer focus groups, stakeholder input, a 3-state pilot test, extensive psychometric analyses, consumer testing, numerous small-scale field tests, and input by the general public.⁴ Second, data collected from the national surveys are reported publicly to increase transparency of the quality of hospital care nationally. Third, performance on these surveys is tied to reimbursement and value-based payments to create new incentives for health care organizations to improve quality of care. Gastroenterologists need to be aware of these national standardized surveys (inpatient HCAHPS and outpatient Clinician and Group [CG]–CAHPS) because these will have direct implications for many aspects of care that will be provided in the future.

Hospital Consumer Assessment of Health Care Providers and Systems

With bundled payments on the horizon and organizations being required to attain goal participation levels, gastroenterologists have a vested interest to understand HCAHPS (pronounced H-caps). Although most gastroenterologists do not have a primary inpatient gastroenterology service, but rather are consultants, a significant number of gastroenterologists do have such a service. In 2002, the Centers for Medicare and Medicaid Services (CMS), in partnership with the AHRQ, developed and tested what is now known as the Hospital CAHPS survey.⁴ In 2005, the HCAHPS survey was endorsed by the National Quality Forum and in December 2005 the Office of Management and Budget approved it for national implementation. CMS implemented the HCAHPS survey in 2006 and the first public reporting of HCAHPS results occurred in 2008. Hospitals were incentivized further to improve patient experience with the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment contained within the hospital value-based purchasing program, beginning with discharges in October 2012.

HCAHPS is a 27-item survey instrument (available in official English, Spanish, Chinese, Russian, and Vietnamese versions) that is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge via mail, telephone, mail with telephone follow-up evaluation, or voice recognition. Hospitals must achieve at least 300 completed surveys over four calendar quarters to be eligible for incentives. Ten HCAHPS measures (six summary measures, two individual items, and two global items) are reported publicly on the Hospital Compare website (www.hospitalcompare.hhs.gov). The six summary measures address how well nurses and doctors communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key information is provided at discharge. The two individual items ask information about the cleanliness and quietness of patients’ rooms, and the two global items report patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends.⁴

The Clinician and Group Consumer Assessment of Health Care Providers and Systems

The CG-CAHPS survey is a standardized tool, developed by the AHRQ, to measure patient perceptions of care provided by physicians in an office setting, and will be the survey that will impact gastroenterology practices the most. Similar to the CAHPS surveys for hospitals (HCAHPS) and home health agencies, it is anticipated that there will be national implementation of CG-CAHPS by CMS. CMS has included the CG-CAHPS survey as part of the required quality metrics within the Medicare Shared Savings Program, and it is anticipated that a CG-CAHPS instrument eventually will be required for full reimbursement for all medical practices, with results publicly reported at the Physician Compare website (http://www.medicare.gov/physiciancompare). Currently, participation is voluntary, although several states (Minnesota, Oregon, Vermont, and Maine) have mandated its use, and there is potential for group practices, including those with ambulatory surgical centers, participating in the Physician Quality Reporting System, to be required to participate in the near future (Figure 1). There are different versions of the survey including adult, child, visit specific, and 12-month visit versions. In addition, there are versions for accountable care organizations (with specialist questions built in) and patient-centered medical home. As of September 2012, there were 275 hospital and clinic clients participating in CG-CAHPS, although this is expected to grow. Many gastroenterology practices use surrogate outpatient surveys from a number of different vendors to assess outpatient experience, the most common being from Press-Ganey, which although similar, have distinct differences. The Press-Ganey survey is proprietary, is used mainly for internal use, and has no mandate for public reporting. Although both CG-CAHPS and Press-Ganey questionnaires have questions that focus on access, provider communication, provider rating, office staff, and recommendation of practice, Press-Ganey has additional questions regarding safety, cleanliness, and privacy. CG-CAHPS uses a four-point scale for the 12-month survey and a three-point scale for the visit survey, compared with Press-Ganey, which uses a five-point scale.

Potential limitations

Because patient experience survey scores increasingly are used to benchmark different institutions and provide reimbursement incentives, they also have received substantial criticism because of potential biases and pitfalls. To date, there are no convincing data that higher patient experience scores translate into better patient outcomes. In fact, there is a concern that catering solely to patient experience scores may be ill guided because it may implicitly encourage health care providers to honor requests for discretionary health care services. Such efforts may lead to overuse, higher costs, and worse outcomes. Some researchers argue that the surveys do not adequately take into account variables that can skew results against academic medical centers or hospitals in regions of the country that treat large numbers of patients with mental or other serious illnesses. Geographic, cultural, language, and ethnic differences can affect a patient's perspective about their medical or hospital experiences and it has been shown that none of the hospitals in the nation with 500 or more beds has scored in the 90th percentile for basic measures such as physician or nurse communication.²

In addition, patient motivation to fill out a survey can bias results because it may be those who had an extreme experience – either superb or terrible – who are more likely to respond to the survey.

How can gastroenterologists stay ahead of the curve?

Despite the limitations in patient experience surveys mentioned earlier, they are likely here to stay and directly will impact physician compensation and hospital reimbursement for care.⁵

Although CG-CAHPS is not yet mandated for outpatient clinics and ambulatory surgical centers, gastroenterologists in community and academia should begin taking the steps outlined later to improve their practices before the results become publicly reportable. There is a paucity of well-designed studies that show improvement in HCAHPS after an intervention. The literature is anecdotal and individualized. Hence, it is more important for gastroenterologists to focus on culture, infrastructure, and processes to identify their specific opportunities than it is to adopt specific recommendations.

First, shift your thinking from resenting these surveys to embracing them as an opportunity to improve every aspect of care we provide as a health care team. This would entail making patient experience a priority for all staff and granting them the authority to positively impact the customer experience.

Second, identify resources that help conduct surveys efficiently and effectively. Most academic medical centers and community hospitals have set up interdisciplinary quality-improvement teams that can be a good starting point to learn about ongoing patient experience initiatives. The widespread use of tablet computers and patient experience survey applications have made it easier to conduct patient surveys for internal use at the point-of-care, often at a fraction of the cost of mailed paper surveys.⁶

Third, stay proactive by regularly reviewing survey information and identifying areas of poor experience in your practice. This can be accomplished by identifying within-practice variation (comparing members of the same practice), between-practice variation (comparing one’s practice with other similar practices), evaluating time trends (comparing current scores with your past scores), or comparison with national benchmarks. It is important to remember that direct physician care is not the only place to examine when trying to improve patient experience scores. As patient care transitions to team-based models, every member of the team is central to providing an optimal patient experience. In fact, some of the common issues that adversely affect patient experience relate to attitude of the front desk staff, the cleanliness in the office, or timely access to care. Hence, it is important to work as a team – staff and physicians – to design solutions to the specific patient experience issues.^1,2,3

Conclusions

A value-based purchasing initiative is now required under the Patient Protection and Affordable Care Act as part of the 2010 national health care reform legislation. Patient experience surveys, despite limitations, serve an important role in patient-centered care and value-based purchasing. Hospital-based HCAHPS currently is mandated by the CMS, and clinic-based CG-CAHPS will soon follow suit and provide data for the publicly reported Physician Compare website. A proactive approach to patient surveys that uses a team-based approach and health information technology will help gastroenterologists stay ahead in the changing landscape of health care delivery.

References

1. Raman, A., Tucker, A. The Cleveland Clinic: improving the patient experience. Harvard Business Review. September 12, 2011.

2. Merlino, J. Speaking from experience. When doctors improve communication, patients become better partners. Mod. Healthc. 2012;42:30.

3. Malone, L.E. Surveys: tracking opinion. National Science Foundation. Available at: http://www.nsf.gov/news/special_reports/ survey/index.jsp. Accessed: June 10, 2013.

4. Center for Medicare & Medicaid Services. HCAHPS fact sheet (CAHPS hospital survey). Available at: http://www.hcahpsonline.org/ files/August%202013%20HCAHPS%20Fact%20Sheet2.pdf. Accessed: June 10, 2013.

5. Allen, J.I. The road ahead. Clin. Gastroenterol. Hepatol. 2012;10:692-6.

6. Atreja, A., Rizk, M. Capturing patient reported outcomes and quality of life in routine clinical practice: ready for prime time? Minerva Gastroenterol. Dietol. 2012;58:19-24.

Dr. Rizk is quality improvement officer, Digestive Disease Institute, and clinical assistant professor, Cleveland Clinic Lerner College of Medicine; Dr. Atreja is chief technology innovation and engagement officer, medicine, and assistant professor and director of Sinai AppLab, gastroenterology, Icahn School of Medicine at Mount Sinai, New York; and Dr. Merlino is chief experience officer, Cleveland Clinic. Dr. Rizk and Dr. Atreja disclosed that they are investors in Innowaiting.com (Dawazu, LLC). The remaining author discloses no conflicts. Dr. Atreja is supported by a Crohn’s and Colitis Foundation of America Career Development Grant.

The Centers for Medicare & Medicaid Services (CMS) has defined six National Quality Strategic priorities that will form the foundation of Medicare performance measures used to populate value-based reimbursement programs. These programs will directly influence our reimbursement in the years to come as we move away from fee-for-service payment. One of the Priority Strategies is person- and caregiver-centered experience and outcomes. Measuring patient experience is not easy, yet many gastroenterologists will be confronted with survey results collected by their practices, hospitals, and hospital systems. Dr. Rizk and his colleagues help us understand the framework, implementation, and implications of the major patient experience surveys used today. Many of us have used results from such surveys to identify gaps of care that can be improved in ways that impact our patient care.

John I. Allen, M.D., MBA, AGAF, Special Section Editor

Until recently, prioritizing patient experience was still a relatively novel idea. The general assumption was that because patients come to the hospital out of necessity rather than choice, health care providers could ignore customer service. Operating models typically focused on two improvement measures: positive clinical outcomes and cost containment. The major advances of the health care industry – cutting-edge treatments, technologically sophisticated delivery methods, high-efficiency protocols—have often come at the expense of patient experience, making care delivery increasingly impersonal and mechanized.¹

By 2010, however, improving patient experience had become part of the mainstream health care agenda. In fact, a recent survey of health care executives found that 37% ranked "patient experience" as a top three priority, the second-most frequent answer just after cost reduction (40%).²

As health care transforms into a consumer-based model, there is increasing demand from health care institutions, insurance companies, and government to measure patient experience. Although a staple in many industries for years, this is a relatively new phenomenon in health care. The primary mode through which patient experience is assessed is with surveys, the most important being the government-mandated Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This article provides an introduction to the use of surveys as an instrument for measuring patient experience, details government-mandated and private surveys, and suggests tools that may be beneficial in both measuring and improving patient experience.

Surveys: A scientific instrument

When performed correctly, surveys replace assumptions with data and serve as a scientific instrument for social and behavioral sciences by collecting information in the form of a structured set of questions, with the intention of revealing trends and patterns over time. In addition, but less commonly, surveys can be used as a tool to identify specific service recovery opportunities.³

There are important considerations when a survey is designed. How participants are selected is just as important as the number of participants. Specifically, surveys can vary from including every member of a group to including a sample cohort, which may or may not be representative and bias free. Who is approached for a survey and who responds to it depends on multiple factors including cost, feasibility, proximity to the experience, availability, whether the respondent received the survey through referral, the engagement and participation of those being surveyed, and whether incentives are provided.³ The verbiage and design of a survey also can introduce bias. Respondents tend to choose the first option from a list and to answer as they think they should rather than being truthful. Good surveys randomly sample respondents so they are representative, are designed to minimize selection biases, and adjust for known variables that can confound results.³

Trend toward standardized national benchmarking surveys

There has been a shift away from using stand-alone survey instruments developed by private companies (such as Press-Ganey) for internal use by health care organizations to using national benchmark surveys developed by Federal agencies for public consumption. Three broad goals have shaped this trend. First, standardization of both the survey tool and implementation protocol allow valid comparisons to be made across hospitals locally, regionally, and nationally. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the first national standardized survey of patients’ perspectives of hospital care, has gone through rigorous development and testing by the Agency for Healthcare Research and Quality (AHRQ) including a public call for measures, literature review, cognitive interviews, consumer focus groups, stakeholder input, a 3-state pilot test, extensive psychometric analyses, consumer testing, numerous small-scale field tests, and input by the general public.⁴ Second, data collected from the national surveys are reported publicly to increase transparency of the quality of hospital care nationally. Third, performance on these surveys is tied to reimbursement and value-based payments to create new incentives for health care organizations to improve quality of care. Gastroenterologists need to be aware of these national standardized surveys (inpatient HCAHPS and outpatient Clinician and Group [CG]–CAHPS) because these will have direct implications for many aspects of care that will be provided in the future.

Hospital Consumer Assessment of Health Care Providers and Systems

With bundled payments on the horizon and organizations being required to attain goal participation levels, gastroenterologists have a vested interest to understand HCAHPS (pronounced H-caps). Although most gastroenterologists do not have a primary inpatient gastroenterology service, but rather are consultants, a significant number of gastroenterologists do have such a service. In 2002, the Centers for Medicare and Medicaid Services (CMS), in partnership with the AHRQ, developed and tested what is now known as the Hospital CAHPS survey.⁴ In 2005, the HCAHPS survey was endorsed by the National Quality Forum and in December 2005 the Office of Management and Budget approved it for national implementation. CMS implemented the HCAHPS survey in 2006 and the first public reporting of HCAHPS results occurred in 2008. Hospitals were incentivized further to improve patient experience with the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment contained within the hospital value-based purchasing program, beginning with discharges in October 2012.

HCAHPS is a 27-item survey instrument (available in official English, Spanish, Chinese, Russian, and Vietnamese versions) that is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge via mail, telephone, mail with telephone follow-up evaluation, or voice recognition. Hospitals must achieve at least 300 completed surveys over four calendar quarters to be eligible for incentives. Ten HCAHPS measures (six summary measures, two individual items, and two global items) are reported publicly on the Hospital Compare website (www.hospitalcompare.hhs.gov). The six summary measures address how well nurses and doctors communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key information is provided at discharge. The two individual items ask information about the cleanliness and quietness of patients’ rooms, and the two global items report patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends.⁴

The Clinician and Group Consumer Assessment of Health Care Providers and Systems

The CG-CAHPS survey is a standardized tool, developed by the AHRQ, to measure patient perceptions of care provided by physicians in an office setting, and will be the survey that will impact gastroenterology practices the most. Similar to the CAHPS surveys for hospitals (HCAHPS) and home health agencies, it is anticipated that there will be national implementation of CG-CAHPS by CMS. CMS has included the CG-CAHPS survey as part of the required quality metrics within the Medicare Shared Savings Program, and it is anticipated that a CG-CAHPS instrument eventually will be required for full reimbursement for all medical practices, with results publicly reported at the Physician Compare website (http://www.medicare.gov/physiciancompare). Currently, participation is voluntary, although several states (Minnesota, Oregon, Vermont, and Maine) have mandated its use, and there is potential for group practices, including those with ambulatory surgical centers, participating in the Physician Quality Reporting System, to be required to participate in the near future (Figure 1). There are different versions of the survey including adult, child, visit specific, and 12-month visit versions. In addition, there are versions for accountable care organizations (with specialist questions built in) and patient-centered medical home. As of September 2012, there were 275 hospital and clinic clients participating in CG-CAHPS, although this is expected to grow. Many gastroenterology practices use surrogate outpatient surveys from a number of different vendors to assess outpatient experience, the most common being from Press-Ganey, which although similar, have distinct differences. The Press-Ganey survey is proprietary, is used mainly for internal use, and has no mandate for public reporting. Although both CG-CAHPS and Press-Ganey questionnaires have questions that focus on access, provider communication, provider rating, office staff, and recommendation of practice, Press-Ganey has additional questions regarding safety, cleanliness, and privacy. CG-CAHPS uses a four-point scale for the 12-month survey and a three-point scale for the visit survey, compared with Press-Ganey, which uses a five-point scale.

Potential limitations

Because patient experience survey scores increasingly are used to benchmark different institutions and provide reimbursement incentives, they also have received substantial criticism because of potential biases and pitfalls. To date, there are no convincing data that higher patient experience scores translate into better patient outcomes. In fact, there is a concern that catering solely to patient experience scores may be ill guided because it may implicitly encourage health care providers to honor requests for discretionary health care services. Such efforts may lead to overuse, higher costs, and worse outcomes. Some researchers argue that the surveys do not adequately take into account variables that can skew results against academic medical centers or hospitals in regions of the country that treat large numbers of patients with mental or other serious illnesses. Geographic, cultural, language, and ethnic differences can affect a patient's perspective about their medical or hospital experiences and it has been shown that none of the hospitals in the nation with 500 or more beds has scored in the 90th percentile for basic measures such as physician or nurse communication.²

In addition, patient motivation to fill out a survey can bias results because it may be those who had an extreme experience – either superb or terrible – who are more likely to respond to the survey.

How can gastroenterologists stay ahead of the curve?

Despite the limitations in patient experience surveys mentioned earlier, they are likely here to stay and directly will impact physician compensation and hospital reimbursement for care.⁵

Although CG-CAHPS is not yet mandated for outpatient clinics and ambulatory surgical centers, gastroenterologists in community and academia should begin taking the steps outlined later to improve their practices before the results become publicly reportable. There is a paucity of well-designed studies that show improvement in HCAHPS after an intervention. The literature is anecdotal and individualized. Hence, it is more important for gastroenterologists to focus on culture, infrastructure, and processes to identify their specific opportunities than it is to adopt specific recommendations.

First, shift your thinking from resenting these surveys to embracing them as an opportunity to improve every aspect of care we provide as a health care team. This would entail making patient experience a priority for all staff and granting them the authority to positively impact the customer experience.

Second, identify resources that help conduct surveys efficiently and effectively. Most academic medical centers and community hospitals have set up interdisciplinary quality-improvement teams that can be a good starting point to learn about ongoing patient experience initiatives. The widespread use of tablet computers and patient experience survey applications have made it easier to conduct patient surveys for internal use at the point-of-care, often at a fraction of the cost of mailed paper surveys.⁶

Third, stay proactive by regularly reviewing survey information and identifying areas of poor experience in your practice. This can be accomplished by identifying within-practice variation (comparing members of the same practice), between-practice variation (comparing one’s practice with other similar practices), evaluating time trends (comparing current scores with your past scores), or comparison with national benchmarks. It is important to remember that direct physician care is not the only place to examine when trying to improve patient experience scores. As patient care transitions to team-based models, every member of the team is central to providing an optimal patient experience. In fact, some of the common issues that adversely affect patient experience relate to attitude of the front desk staff, the cleanliness in the office, or timely access to care. Hence, it is important to work as a team – staff and physicians – to design solutions to the specific patient experience issues.^1,2,3

Conclusions

A value-based purchasing initiative is now required under the Patient Protection and Affordable Care Act as part of the 2010 national health care reform legislation. Patient experience surveys, despite limitations, serve an important role in patient-centered care and value-based purchasing. Hospital-based HCAHPS currently is mandated by the CMS, and clinic-based CG-CAHPS will soon follow suit and provide data for the publicly reported Physician Compare website. A proactive approach to patient surveys that uses a team-based approach and health information technology will help gastroenterologists stay ahead in the changing landscape of health care delivery.

References

1. Raman, A., Tucker, A. The Cleveland Clinic: improving the patient experience. Harvard Business Review. September 12, 2011.

2. Merlino, J. Speaking from experience. When doctors improve communication, patients become better partners. Mod. Healthc. 2012;42:30.

3. Malone, L.E. Surveys: tracking opinion. National Science Foundation. Available at: http://www.nsf.gov/news/special_reports/ survey/index.jsp. Accessed: June 10, 2013.

4. Center for Medicare & Medicaid Services. HCAHPS fact sheet (CAHPS hospital survey). Available at: http://www.hcahpsonline.org/ files/August%202013%20HCAHPS%20Fact%20Sheet2.pdf. Accessed: June 10, 2013.

5. Allen, J.I. The road ahead. Clin. Gastroenterol. Hepatol. 2012;10:692-6.

6. Atreja, A., Rizk, M. Capturing patient reported outcomes and quality of life in routine clinical practice: ready for prime time? Minerva Gastroenterol. Dietol. 2012;58:19-24.

Dr. Rizk is quality improvement officer, Digestive Disease Institute, and clinical assistant professor, Cleveland Clinic Lerner College of Medicine; Dr. Atreja is chief technology innovation and engagement officer, medicine, and assistant professor and director of Sinai AppLab, gastroenterology, Icahn School of Medicine at Mount Sinai, New York; and Dr. Merlino is chief experience officer, Cleveland Clinic. Dr. Rizk and Dr. Atreja disclosed that they are investors in Innowaiting.com (Dawazu, LLC). The remaining author discloses no conflicts. Dr. Atreja is supported by a Crohn’s and Colitis Foundation of America Career Development Grant.

The Centers for Medicare & Medicaid Services (CMS) has defined six National Quality Strategic priorities that will form the foundation of Medicare performance measures used to populate value-based reimbursement programs. These programs will directly influence our reimbursement in the years to come as we move away from fee-for-service payment. One of the Priority Strategies is person- and caregiver-centered experience and outcomes. Measuring patient experience is not easy, yet many gastroenterologists will be confronted with survey results collected by their practices, hospitals, and hospital systems. Dr. Rizk and his colleagues help us understand the framework, implementation, and implications of the major patient experience surveys used today. Many of us have used results from such surveys to identify gaps of care that can be improved in ways that impact our patient care.

John I. Allen, M.D., MBA, AGAF, Special Section Editor

Until recently, prioritizing patient experience was still a relatively novel idea. The general assumption was that because patients come to the hospital out of necessity rather than choice, health care providers could ignore customer service. Operating models typically focused on two improvement measures: positive clinical outcomes and cost containment. The major advances of the health care industry – cutting-edge treatments, technologically sophisticated delivery methods, high-efficiency protocols—have often come at the expense of patient experience, making care delivery increasingly impersonal and mechanized.¹

By 2010, however, improving patient experience had become part of the mainstream health care agenda. In fact, a recent survey of health care executives found that 37% ranked "patient experience" as a top three priority, the second-most frequent answer just after cost reduction (40%).²

As health care transforms into a consumer-based model, there is increasing demand from health care institutions, insurance companies, and government to measure patient experience. Although a staple in many industries for years, this is a relatively new phenomenon in health care. The primary mode through which patient experience is assessed is with surveys, the most important being the government-mandated Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This article provides an introduction to the use of surveys as an instrument for measuring patient experience, details government-mandated and private surveys, and suggests tools that may be beneficial in both measuring and improving patient experience.

Surveys: A scientific instrument

When performed correctly, surveys replace assumptions with data and serve as a scientific instrument for social and behavioral sciences by collecting information in the form of a structured set of questions, with the intention of revealing trends and patterns over time. In addition, but less commonly, surveys can be used as a tool to identify specific service recovery opportunities.³

There are important considerations when a survey is designed. How participants are selected is just as important as the number of participants. Specifically, surveys can vary from including every member of a group to including a sample cohort, which may or may not be representative and bias free. Who is approached for a survey and who responds to it depends on multiple factors including cost, feasibility, proximity to the experience, availability, whether the respondent received the survey through referral, the engagement and participation of those being surveyed, and whether incentives are provided.³ The verbiage and design of a survey also can introduce bias. Respondents tend to choose the first option from a list and to answer as they think they should rather than being truthful. Good surveys randomly sample respondents so they are representative, are designed to minimize selection biases, and adjust for known variables that can confound results.³

Trend toward standardized national benchmarking surveys

There has been a shift away from using stand-alone survey instruments developed by private companies (such as Press-Ganey) for internal use by health care organizations to using national benchmark surveys developed by Federal agencies for public consumption. Three broad goals have shaped this trend. First, standardization of both the survey tool and implementation protocol allow valid comparisons to be made across hospitals locally, regionally, and nationally. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the first national standardized survey of patients’ perspectives of hospital care, has gone through rigorous development and testing by the Agency for Healthcare Research and Quality (AHRQ) including a public call for measures, literature review, cognitive interviews, consumer focus groups, stakeholder input, a 3-state pilot test, extensive psychometric analyses, consumer testing, numerous small-scale field tests, and input by the general public.⁴ Second, data collected from the national surveys are reported publicly to increase transparency of the quality of hospital care nationally. Third, performance on these surveys is tied to reimbursement and value-based payments to create new incentives for health care organizations to improve quality of care. Gastroenterologists need to be aware of these national standardized surveys (inpatient HCAHPS and outpatient Clinician and Group [CG]–CAHPS) because these will have direct implications for many aspects of care that will be provided in the future.

Hospital Consumer Assessment of Health Care Providers and Systems

With bundled payments on the horizon and organizations being required to attain goal participation levels, gastroenterologists have a vested interest to understand HCAHPS (pronounced H-caps). Although most gastroenterologists do not have a primary inpatient gastroenterology service, but rather are consultants, a significant number of gastroenterologists do have such a service. In 2002, the Centers for Medicare and Medicaid Services (CMS), in partnership with the AHRQ, developed and tested what is now known as the Hospital CAHPS survey.⁴ In 2005, the HCAHPS survey was endorsed by the National Quality Forum and in December 2005 the Office of Management and Budget approved it for national implementation. CMS implemented the HCAHPS survey in 2006 and the first public reporting of HCAHPS results occurred in 2008. Hospitals were incentivized further to improve patient experience with the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment contained within the hospital value-based purchasing program, beginning with discharges in October 2012.

HCAHPS is a 27-item survey instrument (available in official English, Spanish, Chinese, Russian, and Vietnamese versions) that is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge via mail, telephone, mail with telephone follow-up evaluation, or voice recognition. Hospitals must achieve at least 300 completed surveys over four calendar quarters to be eligible for incentives. Ten HCAHPS measures (six summary measures, two individual items, and two global items) are reported publicly on the Hospital Compare website (www.hospitalcompare.hhs.gov). The six summary measures address how well nurses and doctors communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key information is provided at discharge. The two individual items ask information about the cleanliness and quietness of patients’ rooms, and the two global items report patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends.⁴

The Clinician and Group Consumer Assessment of Health Care Providers and Systems

The CG-CAHPS survey is a standardized tool, developed by the AHRQ, to measure patient perceptions of care provided by physicians in an office setting, and will be the survey that will impact gastroenterology practices the most. Similar to the CAHPS surveys for hospitals (HCAHPS) and home health agencies, it is anticipated that there will be national implementation of CG-CAHPS by CMS. CMS has included the CG-CAHPS survey as part of the required quality metrics within the Medicare Shared Savings Program, and it is anticipated that a CG-CAHPS instrument eventually will be required for full reimbursement for all medical practices, with results publicly reported at the Physician Compare website (http://www.medicare.gov/physiciancompare). Currently, participation is voluntary, although several states (Minnesota, Oregon, Vermont, and Maine) have mandated its use, and there is potential for group practices, including those with ambulatory surgical centers, participating in the Physician Quality Reporting System, to be required to participate in the near future (Figure 1). There are different versions of the survey including adult, child, visit specific, and 12-month visit versions. In addition, there are versions for accountable care organizations (with specialist questions built in) and patient-centered medical home. As of September 2012, there were 275 hospital and clinic clients participating in CG-CAHPS, although this is expected to grow. Many gastroenterology practices use surrogate outpatient surveys from a number of different vendors to assess outpatient experience, the most common being from Press-Ganey, which although similar, have distinct differences. The Press-Ganey survey is proprietary, is used mainly for internal use, and has no mandate for public reporting. Although both CG-CAHPS and Press-Ganey questionnaires have questions that focus on access, provider communication, provider rating, office staff, and recommendation of practice, Press-Ganey has additional questions regarding safety, cleanliness, and privacy. CG-CAHPS uses a four-point scale for the 12-month survey and a three-point scale for the visit survey, compared with Press-Ganey, which uses a five-point scale.

Potential limitations

Because patient experience survey scores increasingly are used to benchmark different institutions and provide reimbursement incentives, they also have received substantial criticism because of potential biases and pitfalls. To date, there are no convincing data that higher patient experience scores translate into better patient outcomes. In fact, there is a concern that catering solely to patient experience scores may be ill guided because it may implicitly encourage health care providers to honor requests for discretionary health care services. Such efforts may lead to overuse, higher costs, and worse outcomes. Some researchers argue that the surveys do not adequately take into account variables that can skew results against academic medical centers or hospitals in regions of the country that treat large numbers of patients with mental or other serious illnesses. Geographic, cultural, language, and ethnic differences can affect a patient's perspective about their medical or hospital experiences and it has been shown that none of the hospitals in the nation with 500 or more beds has scored in the 90th percentile for basic measures such as physician or nurse communication.²

In addition, patient motivation to fill out a survey can bias results because it may be those who had an extreme experience – either superb or terrible – who are more likely to respond to the survey.

How can gastroenterologists stay ahead of the curve?

Despite the limitations in patient experience surveys mentioned earlier, they are likely here to stay and directly will impact physician compensation and hospital reimbursement for care.⁵

Although CG-CAHPS is not yet mandated for outpatient clinics and ambulatory surgical centers, gastroenterologists in community and academia should begin taking the steps outlined later to improve their practices before the results become publicly reportable. There is a paucity of well-designed studies that show improvement in HCAHPS after an intervention. The literature is anecdotal and individualized. Hence, it is more important for gastroenterologists to focus on culture, infrastructure, and processes to identify their specific opportunities than it is to adopt specific recommendations.

First, shift your thinking from resenting these surveys to embracing them as an opportunity to improve every aspect of care we provide as a health care team. This would entail making patient experience a priority for all staff and granting them the authority to positively impact the customer experience.

Second, identify resources that help conduct surveys efficiently and effectively. Most academic medical centers and community hospitals have set up interdisciplinary quality-improvement teams that can be a good starting point to learn about ongoing patient experience initiatives. The widespread use of tablet computers and patient experience survey applications have made it easier to conduct patient surveys for internal use at the point-of-care, often at a fraction of the cost of mailed paper surveys.⁶

Third, stay proactive by regularly reviewing survey information and identifying areas of poor experience in your practice. This can be accomplished by identifying within-practice variation (comparing members of the same practice), between-practice variation (comparing one’s practice with other similar practices), evaluating time trends (comparing current scores with your past scores), or comparison with national benchmarks. It is important to remember that direct physician care is not the only place to examine when trying to improve patient experience scores. As patient care transitions to team-based models, every member of the team is central to providing an optimal patient experience. In fact, some of the common issues that adversely affect patient experience relate to attitude of the front desk staff, the cleanliness in the office, or timely access to care. Hence, it is important to work as a team – staff and physicians – to design solutions to the specific patient experience issues.^1,2,3

Conclusions

A value-based purchasing initiative is now required under the Patient Protection and Affordable Care Act as part of the 2010 national health care reform legislation. Patient experience surveys, despite limitations, serve an important role in patient-centered care and value-based purchasing. Hospital-based HCAHPS currently is mandated by the CMS, and clinic-based CG-CAHPS will soon follow suit and provide data for the publicly reported Physician Compare website. A proactive approach to patient surveys that uses a team-based approach and health information technology will help gastroenterologists stay ahead in the changing landscape of health care delivery.

References

1. Raman, A., Tucker, A. The Cleveland Clinic: improving the patient experience. Harvard Business Review. September 12, 2011.

2. Merlino, J. Speaking from experience. When doctors improve communication, patients become better partners. Mod. Healthc. 2012;42:30.

3. Malone, L.E. Surveys: tracking opinion. National Science Foundation. Available at: http://www.nsf.gov/news/special_reports/ survey/index.jsp. Accessed: June 10, 2013.

4. Center for Medicare & Medicaid Services. HCAHPS fact sheet (CAHPS hospital survey). Available at: http://www.hcahpsonline.org/ files/August%202013%20HCAHPS%20Fact%20Sheet2.pdf. Accessed: June 10, 2013.

5. Allen, J.I. The road ahead. Clin. Gastroenterol. Hepatol. 2012;10:692-6.

6. Atreja, A., Rizk, M. Capturing patient reported outcomes and quality of life in routine clinical practice: ready for prime time? Minerva Gastroenterol. Dietol. 2012;58:19-24.

Dr. Rizk is quality improvement officer, Digestive Disease Institute, and clinical assistant professor, Cleveland Clinic Lerner College of Medicine; Dr. Atreja is chief technology innovation and engagement officer, medicine, and assistant professor and director of Sinai AppLab, gastroenterology, Icahn School of Medicine at Mount Sinai, New York; and Dr. Merlino is chief experience officer, Cleveland Clinic. Dr. Rizk and Dr. Atreja disclosed that they are investors in Innowaiting.com (Dawazu, LLC). The remaining author discloses no conflicts. Dr. Atreja is supported by a Crohn’s and Colitis Foundation of America Career Development Grant.

The Centers for Medicare & Medicaid Services (CMS) has defined six National Quality Strategic priorities that will form the foundation of Medicare performance measures used to populate value-based reimbursement programs. These programs will directly influence our reimbursement in the years to come as we move away from fee-for-service payment. One of the Priority Strategies is person- and caregiver-centered experience and outcomes. Measuring patient experience is not easy, yet many gastroenterologists will be confronted with survey results collected by their practices, hospitals, and hospital systems. Dr. Rizk and his colleagues help us understand the framework, implementation, and implications of the major patient experience surveys used today. Many of us have used results from such surveys to identify gaps of care that can be improved in ways that impact our patient care.

John I. Allen, M.D., MBA, AGAF, Special Section Editor

Until recently, prioritizing patient experience was still a relatively novel idea. The general assumption was that because patients come to the hospital out of necessity rather than choice, health care providers could ignore customer service. Operating models typically focused on two improvement measures: positive clinical outcomes and cost containment. The major advances of the health care industry – cutting-edge treatments, technologically sophisticated delivery methods, high-efficiency protocols—have often come at the expense of patient experience, making care delivery increasingly impersonal and mechanized.¹

By 2010, however, improving patient experience had become part of the mainstream health care agenda. In fact, a recent survey of health care executives found that 37% ranked "patient experience" as a top three priority, the second-most frequent answer just after cost reduction (40%).²

As health care transforms into a consumer-based model, there is increasing demand from health care institutions, insurance companies, and government to measure patient experience. Although a staple in many industries for years, this is a relatively new phenomenon in health care. The primary mode through which patient experience is assessed is with surveys, the most important being the government-mandated Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This article provides an introduction to the use of surveys as an instrument for measuring patient experience, details government-mandated and private surveys, and suggests tools that may be beneficial in both measuring and improving patient experience.

Surveys: A scientific instrument

When performed correctly, surveys replace assumptions with data and serve as a scientific instrument for social and behavioral sciences by collecting information in the form of a structured set of questions, with the intention of revealing trends and patterns over time. In addition, but less commonly, surveys can be used as a tool to identify specific service recovery opportunities.³

There are important considerations when a survey is designed. How participants are selected is just as important as the number of participants. Specifically, surveys can vary from including every member of a group to including a sample cohort, which may or may not be representative and bias free. Who is approached for a survey and who responds to it depends on multiple factors including cost, feasibility, proximity to the experience, availability, whether the respondent received the survey through referral, the engagement and participation of those being surveyed, and whether incentives are provided.³ The verbiage and design of a survey also can introduce bias. Respondents tend to choose the first option from a list and to answer as they think they should rather than being truthful. Good surveys randomly sample respondents so they are representative, are designed to minimize selection biases, and adjust for known variables that can confound results.³

Trend toward standardized national benchmarking surveys

There has been a shift away from using stand-alone survey instruments developed by private companies (such as Press-Ganey) for internal use by health care organizations to using national benchmark surveys developed by Federal agencies for public consumption. Three broad goals have shaped this trend. First, standardization of both the survey tool and implementation protocol allow valid comparisons to be made across hospitals locally, regionally, and nationally. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the first national standardized survey of patients’ perspectives of hospital care, has gone through rigorous development and testing by the Agency for Healthcare Research and Quality (AHRQ) including a public call for measures, literature review, cognitive interviews, consumer focus groups, stakeholder input, a 3-state pilot test, extensive psychometric analyses, consumer testing, numerous small-scale field tests, and input by the general public.⁴ Second, data collected from the national surveys are reported publicly to increase transparency of the quality of hospital care nationally. Third, performance on these surveys is tied to reimbursement and value-based payments to create new incentives for health care organizations to improve quality of care. Gastroenterologists need to be aware of these national standardized surveys (inpatient HCAHPS and outpatient Clinician and Group [CG]–CAHPS) because these will have direct implications for many aspects of care that will be provided in the future.

Hospital Consumer Assessment of Health Care Providers and Systems

With bundled payments on the horizon and organizations being required to attain goal participation levels, gastroenterologists have a vested interest to understand HCAHPS (pronounced H-caps). Although most gastroenterologists do not have a primary inpatient gastroenterology service, but rather are consultants, a significant number of gastroenterologists do have such a service. In 2002, the Centers for Medicare and Medicaid Services (CMS), in partnership with the AHRQ, developed and tested what is now known as the Hospital CAHPS survey.⁴ In 2005, the HCAHPS survey was endorsed by the National Quality Forum and in December 2005 the Office of Management and Budget approved it for national implementation. CMS implemented the HCAHPS survey in 2006 and the first public reporting of HCAHPS results occurred in 2008. Hospitals were incentivized further to improve patient experience with the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment contained within the hospital value-based purchasing program, beginning with discharges in October 2012.

HCAHPS is a 27-item survey instrument (available in official English, Spanish, Chinese, Russian, and Vietnamese versions) that is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge via mail, telephone, mail with telephone follow-up evaluation, or voice recognition. Hospitals must achieve at least 300 completed surveys over four calendar quarters to be eligible for incentives. Ten HCAHPS measures (six summary measures, two individual items, and two global items) are reported publicly on the Hospital Compare website (www.hospitalcompare.hhs.gov). The six summary measures address how well nurses and doctors communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key information is provided at discharge. The two individual items ask information about the cleanliness and quietness of patients’ rooms, and the two global items report patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends.⁴

The Clinician and Group Consumer Assessment of Health Care Providers and Systems

The CG-CAHPS survey is a standardized tool, developed by the AHRQ, to measure patient perceptions of care provided by physicians in an office setting, and will be the survey that will impact gastroenterology practices the most. Similar to the CAHPS surveys for hospitals (HCAHPS) and home health agencies, it is anticipated that there will be national implementation of CG-CAHPS by CMS. CMS has included the CG-CAHPS survey as part of the required quality metrics within the Medicare Shared Savings Program, and it is anticipated that a CG-CAHPS instrument eventually will be required for full reimbursement for all medical practices, with results publicly reported at the Physician Compare website (http://www.medicare.gov/physiciancompare). Currently, participation is voluntary, although several states (Minnesota, Oregon, Vermont, and Maine) have mandated its use, and there is potential for group practices, including those with ambulatory surgical centers, participating in the Physician Quality Reporting System, to be required to participate in the near future (Figure 1). There are different versions of the survey including adult, child, visit specific, and 12-month visit versions. In addition, there are versions for accountable care organizations (with specialist questions built in) and patient-centered medical home. As of September 2012, there were 275 hospital and clinic clients participating in CG-CAHPS, although this is expected to grow. Many gastroenterology practices use surrogate outpatient surveys from a number of different vendors to assess outpatient experience, the most common being from Press-Ganey, which although similar, have distinct differences. The Press-Ganey survey is proprietary, is used mainly for internal use, and has no mandate for public reporting. Although both CG-CAHPS and Press-Ganey questionnaires have questions that focus on access, provider communication, provider rating, office staff, and recommendation of practice, Press-Ganey has additional questions regarding safety, cleanliness, and privacy. CG-CAHPS uses a four-point scale for the 12-month survey and a three-point scale for the visit survey, compared with Press-Ganey, which uses a five-point scale.

Potential limitations

Because patient experience survey scores increasingly are used to benchmark different institutions and provide reimbursement incentives, they also have received substantial criticism because of potential biases and pitfalls. To date, there are no convincing data that higher patient experience scores translate into better patient outcomes. In fact, there is a concern that catering solely to patient experience scores may be ill guided because it may implicitly encourage health care providers to honor requests for discretionary health care services. Such efforts may lead to overuse, higher costs, and worse outcomes. Some researchers argue that the surveys do not adequately take into account variables that can skew results against academic medical centers or hospitals in regions of the country that treat large numbers of patients with mental or other serious illnesses. Geographic, cultural, language, and ethnic differences can affect a patient's perspective about their medical or hospital experiences and it has been shown that none of the hospitals in the nation with 500 or more beds has scored in the 90th percentile for basic measures such as physician or nurse communication.²

In addition, patient motivation to fill out a survey can bias results because it may be those who had an extreme experience – either superb or terrible – who are more likely to respond to the survey.

How can gastroenterologists stay ahead of the curve?

Despite the limitations in patient experience surveys mentioned earlier, they are likely here to stay and directly will impact physician compensation and hospital reimbursement for care.⁵

Although CG-CAHPS is not yet mandated for outpatient clinics and ambulatory surgical centers, gastroenterologists in community and academia should begin taking the steps outlined later to improve their practices before the results become publicly reportable. There is a paucity of well-designed studies that show improvement in HCAHPS after an intervention. The literature is anecdotal and individualized. Hence, it is more important for gastroenterologists to focus on culture, infrastructure, and processes to identify their specific opportunities than it is to adopt specific recommendations.

First, shift your thinking from resenting these surveys to embracing them as an opportunity to improve every aspect of care we provide as a health care team. This would entail making patient experience a priority for all staff and granting them the authority to positively impact the customer experience.

Second, identify resources that help conduct surveys efficiently and effectively. Most academic medical centers and community hospitals have set up interdisciplinary quality-improvement teams that can be a good starting point to learn about ongoing patient experience initiatives. The widespread use of tablet computers and patient experience survey applications have made it easier to conduct patient surveys for internal use at the point-of-care, often at a fraction of the cost of mailed paper surveys.⁶

Third, stay proactive by regularly reviewing survey information and identifying areas of poor experience in your practice. This can be accomplished by identifying within-practice variation (comparing members of the same practice), between-practice variation (comparing one’s practice with other similar practices), evaluating time trends (comparing current scores with your past scores), or comparison with national benchmarks. It is important to remember that direct physician care is not the only place to examine when trying to improve patient experience scores. As patient care transitions to team-based models, every member of the team is central to providing an optimal patient experience. In fact, some of the common issues that adversely affect patient experience relate to attitude of the front desk staff, the cleanliness in the office, or timely access to care. Hence, it is important to work as a team – staff and physicians – to design solutions to the specific patient experience issues.^1,2,3

Conclusions

A value-based purchasing initiative is now required under the Patient Protection and Affordable Care Act as part of the 2010 national health care reform legislation. Patient experience surveys, despite limitations, serve an important role in patient-centered care and value-based purchasing. Hospital-based HCAHPS currently is mandated by the CMS, and clinic-based CG-CAHPS will soon follow suit and provide data for the publicly reported Physician Compare website. A proactive approach to patient surveys that uses a team-based approach and health information technology will help gastroenterologists stay ahead in the changing landscape of health care delivery.

References

1. Raman, A., Tucker, A. The Cleveland Clinic: improving the patient experience. Harvard Business Review. September 12, 2011.

2. Merlino, J. Speaking from experience. When doctors improve communication, patients become better partners. Mod. Healthc. 2012;42:30.

3. Malone, L.E. Surveys: tracking opinion. National Science Foundation. Available at: http://www.nsf.gov/news/special_reports/ survey/index.jsp. Accessed: June 10, 2013.

4. Center for Medicare & Medicaid Services. HCAHPS fact sheet (CAHPS hospital survey). Available at: http://www.hcahpsonline.org/ files/August%202013%20HCAHPS%20Fact%20Sheet2.pdf. Accessed: June 10, 2013.

5. Allen, J.I. The road ahead. Clin. Gastroenterol. Hepatol. 2012;10:692-6.

6. Atreja, A., Rizk, M. Capturing patient reported outcomes and quality of life in routine clinical practice: ready for prime time? Minerva Gastroenterol. Dietol. 2012;58:19-24.

Dr. Rizk is quality improvement officer, Digestive Disease Institute, and clinical assistant professor, Cleveland Clinic Lerner College of Medicine; Dr. Atreja is chief technology innovation and engagement officer, medicine, and assistant professor and director of Sinai AppLab, gastroenterology, Icahn School of Medicine at Mount Sinai, New York; and Dr. Merlino is chief experience officer, Cleveland Clinic. Dr. Rizk and Dr. Atreja disclosed that they are investors in Innowaiting.com (Dawazu, LLC). The remaining author discloses no conflicts. Dr. Atreja is supported by a Crohn’s and Colitis Foundation of America Career Development Grant.

The Centers for Medicare & Medicaid Services (CMS) has defined six National Quality Strategic priorities that will form the foundation of Medicare performance measures used to populate value-based reimbursement programs. These programs will directly influence our reimbursement in the years to come as we move away from fee-for-service payment. One of the Priority Strategies is person- and caregiver-centered experience and outcomes. Measuring patient experience is not easy, yet many gastroenterologists will be confronted with survey results collected by their practices, hospitals, and hospital systems. Dr. Rizk and his colleagues help us understand the framework, implementation, and implications of the major patient experience surveys used today. Many of us have used results from such surveys to identify gaps of care that can be improved in ways that impact our patient care.

John I. Allen, M.D., MBA, AGAF, Special Section Editor

Until recently, prioritizing patient experience was still a relatively novel idea. The general assumption was that because patients come to the hospital out of necessity rather than choice, health care providers could ignore customer service. Operating models typically focused on two improvement measures: positive clinical outcomes and cost containment. The major advances of the health care industry – cutting-edge treatments, technologically sophisticated delivery methods, high-efficiency protocols—have often come at the expense of patient experience, making care delivery increasingly impersonal and mechanized.¹

By 2010, however, improving patient experience had become part of the mainstream health care agenda. In fact, a recent survey of health care executives found that 37% ranked "patient experience" as a top three priority, the second-most frequent answer just after cost reduction (40%).²

As health care transforms into a consumer-based model, there is increasing demand from health care institutions, insurance companies, and government to measure patient experience. Although a staple in many industries for years, this is a relatively new phenomenon in health care. The primary mode through which patient experience is assessed is with surveys, the most important being the government-mandated Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This article provides an introduction to the use of surveys as an instrument for measuring patient experience, details government-mandated and private surveys, and suggests tools that may be beneficial in both measuring and improving patient experience.

Surveys: A scientific instrument

When performed correctly, surveys replace assumptions with data and serve as a scientific instrument for social and behavioral sciences by collecting information in the form of a structured set of questions, with the intention of revealing trends and patterns over time. In addition, but less commonly, surveys can be used as a tool to identify specific service recovery opportunities.³

There are important considerations when a survey is designed. How participants are selected is just as important as the number of participants. Specifically, surveys can vary from including every member of a group to including a sample cohort, which may or may not be representative and bias free. Who is approached for a survey and who responds to it depends on multiple factors including cost, feasibility, proximity to the experience, availability, whether the respondent received the survey through referral, the engagement and participation of those being surveyed, and whether incentives are provided.³ The verbiage and design of a survey also can introduce bias. Respondents tend to choose the first option from a list and to answer as they think they should rather than being truthful. Good surveys randomly sample respondents so they are representative, are designed to minimize selection biases, and adjust for known variables that can confound results.³

Trend toward standardized national benchmarking surveys

There has been a shift away from using stand-alone survey instruments developed by private companies (such as Press-Ganey) for internal use by health care organizations to using national benchmark surveys developed by Federal agencies for public consumption. Three broad goals have shaped this trend. First, standardization of both the survey tool and implementation protocol allow valid comparisons to be made across hospitals locally, regionally, and nationally. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the first national standardized survey of patients’ perspectives of hospital care, has gone through rigorous development and testing by the Agency for Healthcare Research and Quality (AHRQ) including a public call for measures, literature review, cognitive interviews, consumer focus groups, stakeholder input, a 3-state pilot test, extensive psychometric analyses, consumer testing, numerous small-scale field tests, and input by the general public.⁴ Second, data collected from the national surveys are reported publicly to increase transparency of the quality of hospital care nationally. Third, performance on these surveys is tied to reimbursement and value-based payments to create new incentives for health care organizations to improve quality of care. Gastroenterologists need to be aware of these national standardized surveys (inpatient HCAHPS and outpatient Clinician and Group [CG]–CAHPS) because these will have direct implications for many aspects of care that will be provided in the future.

Hospital Consumer Assessment of Health Care Providers and Systems

With bundled payments on the horizon and organizations being required to attain goal participation levels, gastroenterologists have a vested interest to understand HCAHPS (pronounced H-caps). Although most gastroenterologists do not have a primary inpatient gastroenterology service, but rather are consultants, a significant number of gastroenterologists do have such a service. In 2002, the Centers for Medicare and Medicaid Services (CMS), in partnership with the AHRQ, developed and tested what is now known as the Hospital CAHPS survey.⁴ In 2005, the HCAHPS survey was endorsed by the National Quality Forum and in December 2005 the Office of Management and Budget approved it for national implementation. CMS implemented the HCAHPS survey in 2006 and the first public reporting of HCAHPS results occurred in 2008. Hospitals were incentivized further to improve patient experience with the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment contained within the hospital value-based purchasing program, beginning with discharges in October 2012.

HCAHPS is a 27-item survey instrument (available in official English, Spanish, Chinese, Russian, and Vietnamese versions) that is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge via mail, telephone, mail with telephone follow-up evaluation, or voice recognition. Hospitals must achieve at least 300 completed surveys over four calendar quarters to be eligible for incentives. Ten HCAHPS measures (six summary measures, two individual items, and two global items) are reported publicly on the Hospital Compare website (www.hospitalcompare.hhs.gov). The six summary measures address how well nurses and doctors communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key information is provided at discharge. The two individual items ask information about the cleanliness and quietness of patients’ rooms, and the two global items report patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends.⁴

The Clinician and Group Consumer Assessment of Health Care Providers and Systems

The CG-CAHPS survey is a standardized tool, developed by the AHRQ, to measure patient perceptions of care provided by physicians in an office setting, and will be the survey that will impact gastroenterology practices the most. Similar to the CAHPS surveys for hospitals (HCAHPS) and home health agencies, it is anticipated that there will be national implementation of CG-CAHPS by CMS. CMS has included the CG-CAHPS survey as part of the required quality metrics within the Medicare Shared Savings Program, and it is anticipated that a CG-CAHPS instrument eventually will be required for full reimbursement for all medical practices, with results publicly reported at the Physician Compare website (http://www.medicare.gov/physiciancompare). Currently, participation is voluntary, although several states (Minnesota, Oregon, Vermont, and Maine) have mandated its use, and there is potential for group practices, including those with ambulatory surgical centers, participating in the Physician Quality Reporting System, to be required to participate in the near future (Figure 1). There are different versions of the survey including adult, child, visit specific, and 12-month visit versions. In addition, there are versions for accountable care organizations (with specialist questions built in) and patient-centered medical home. As of September 2012, there were 275 hospital and clinic clients participating in CG-CAHPS, although this is expected to grow. Many gastroenterology practices use surrogate outpatient surveys from a number of different vendors to assess outpatient experience, the most common being from Press-Ganey, which although similar, have distinct differences. The Press-Ganey survey is proprietary, is used mainly for internal use, and has no mandate for public reporting. Although both CG-CAHPS and Press-Ganey questionnaires have questions that focus on access, provider communication, provider rating, office staff, and recommendation of practice, Press-Ganey has additional questions regarding safety, cleanliness, and privacy. CG-CAHPS uses a four-point scale for the 12-month survey and a three-point scale for the visit survey, compared with Press-Ganey, which uses a five-point scale.

Potential limitations

Because patient experience survey scores increasingly are used to benchmark different institutions and provide reimbursement incentives, they also have received substantial criticism because of potential biases and pitfalls. To date, there are no convincing data that higher patient experience scores translate into better patient outcomes. In fact, there is a concern that catering solely to patient experience scores may be ill guided because it may implicitly encourage health care providers to honor requests for discretionary health care services. Such efforts may lead to overuse, higher costs, and worse outcomes. Some researchers argue that the surveys do not adequately take into account variables that can skew results against academic medical centers or hospitals in regions of the country that treat large numbers of patients with mental or other serious illnesses. Geographic, cultural, language, and ethnic differences can affect a patient's perspective about their medical or hospital experiences and it has been shown that none of the hospitals in the nation with 500 or more beds has scored in the 90th percentile for basic measures such as physician or nurse communication.²

In addition, patient motivation to fill out a survey can bias results because it may be those who had an extreme experience – either superb or terrible – who are more likely to respond to the survey.

How can gastroenterologists stay ahead of the curve?

Despite the limitations in patient experience surveys mentioned earlier, they are likely here to stay and directly will impact physician compensation and hospital reimbursement for care.⁵

Although CG-CAHPS is not yet mandated for outpatient clinics and ambulatory surgical centers, gastroenterologists in community and academia should begin taking the steps outlined later to improve their practices before the results become publicly reportable. There is a paucity of well-designed studies that show improvement in HCAHPS after an intervention. The literature is anecdotal and individualized. Hence, it is more important for gastroenterologists to focus on culture, infrastructure, and processes to identify their specific opportunities than it is to adopt specific recommendations.

First, shift your thinking from resenting these surveys to embracing them as an opportunity to improve every aspect of care we provide as a health care team. This would entail making patient experience a priority for all staff and granting them the authority to positively impact the customer experience.

Second, identify resources that help conduct surveys efficiently and effectively. Most academic medical centers and community hospitals have set up interdisciplinary quality-improvement teams that can be a good starting point to learn about ongoing patient experience initiatives. The widespread use of tablet computers and patient experience survey applications have made it easier to conduct patient surveys for internal use at the point-of-care, often at a fraction of the cost of mailed paper surveys.⁶

Third, stay proactive by regularly reviewing survey information and identifying areas of poor experience in your practice. This can be accomplished by identifying within-practice variation (comparing members of the same practice), between-practice variation (comparing one’s practice with other similar practices), evaluating time trends (comparing current scores with your past scores), or comparison with national benchmarks. It is important to remember that direct physician care is not the only place to examine when trying to improve patient experience scores. As patient care transitions to team-based models, every member of the team is central to providing an optimal patient experience. In fact, some of the common issues that adversely affect patient experience relate to attitude of the front desk staff, the cleanliness in the office, or timely access to care. Hence, it is important to work as a team – staff and physicians – to design solutions to the specific patient experience issues.^1,2,3

Conclusions

A value-based purchasing initiative is now required under the Patient Protection and Affordable Care Act as part of the 2010 national health care reform legislation. Patient experience surveys, despite limitations, serve an important role in patient-centered care and value-based purchasing. Hospital-based HCAHPS currently is mandated by the CMS, and clinic-based CG-CAHPS will soon follow suit and provide data for the publicly reported Physician Compare website. A proactive approach to patient surveys that uses a team-based approach and health information technology will help gastroenterologists stay ahead in the changing landscape of health care delivery.

References

1. Raman, A., Tucker, A. The Cleveland Clinic: improving the patient experience. Harvard Business Review. September 12, 2011.

2. Merlino, J. Speaking from experience. When doctors improve communication, patients become better partners. Mod. Healthc. 2012;42:30.

3. Malone, L.E. Surveys: tracking opinion. National Science Foundation. Available at: http://www.nsf.gov/news/special_reports/ survey/index.jsp. Accessed: June 10, 2013.

4. Center for Medicare & Medicaid Services. HCAHPS fact sheet (CAHPS hospital survey). Available at: http://www.hcahpsonline.org/ files/August%202013%20HCAHPS%20Fact%20Sheet2.pdf. Accessed: June 10, 2013.

5. Allen, J.I. The road ahead. Clin. Gastroenterol. Hepatol. 2012;10:692-6.

6. Atreja, A., Rizk, M. Capturing patient reported outcomes and quality of life in routine clinical practice: ready for prime time? Minerva Gastroenterol. Dietol. 2012;58:19-24.

Dr. Rizk is quality improvement officer, Digestive Disease Institute, and clinical assistant professor, Cleveland Clinic Lerner College of Medicine; Dr. Atreja is chief technology innovation and engagement officer, medicine, and assistant professor and director of Sinai AppLab, gastroenterology, Icahn School of Medicine at Mount Sinai, New York; and Dr. Merlino is chief experience officer, Cleveland Clinic. Dr. Rizk and Dr. Atreja disclosed that they are investors in Innowaiting.com (Dawazu, LLC). The remaining author discloses no conflicts. Dr. Atreja is supported by a Crohn’s and Colitis Foundation of America Career Development Grant.

The Centers for Medicare & Medicaid Services (CMS) has defined six National Quality Strategic priorities that will form the foundation of Medicare performance measures used to populate value-based reimbursement programs. These programs will directly influence our reimbursement in the years to come as we move away from fee-for-service payment. One of the Priority Strategies is person- and caregiver-centered experience and outcomes. Measuring patient experience is not easy, yet many gastroenterologists will be confronted with survey results collected by their practices, hospitals, and hospital systems. Dr. Rizk and his colleagues help us understand the framework, implementation, and implications of the major patient experience surveys used today. Many of us have used results from such surveys to identify gaps of care that can be improved in ways that impact our patient care.

John I. Allen, M.D., MBA, AGAF, Special Section Editor

Until recently, prioritizing patient experience was still a relatively novel idea. The general assumption was that because patients come to the hospital out of necessity rather than choice, health care providers could ignore customer service. Operating models typically focused on two improvement measures: positive clinical outcomes and cost containment. The major advances of the health care industry – cutting-edge treatments, technologically sophisticated delivery methods, high-efficiency protocols—have often come at the expense of patient experience, making care delivery increasingly impersonal and mechanized.¹

By 2010, however, improving patient experience had become part of the mainstream health care agenda. In fact, a recent survey of health care executives found that 37% ranked "patient experience" as a top three priority, the second-most frequent answer just after cost reduction (40%).²

As health care transforms into a consumer-based model, there is increasing demand from health care institutions, insurance companies, and government to measure patient experience. Although a staple in many industries for years, this is a relatively new phenomenon in health care. The primary mode through which patient experience is assessed is with surveys, the most important being the government-mandated Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This article provides an introduction to the use of surveys as an instrument for measuring patient experience, details government-mandated and private surveys, and suggests tools that may be beneficial in both measuring and improving patient experience.

Surveys: A scientific instrument

When performed correctly, surveys replace assumptions with data and serve as a scientific instrument for social and behavioral sciences by collecting information in the form of a structured set of questions, with the intention of revealing trends and patterns over time. In addition, but less commonly, surveys can be used as a tool to identify specific service recovery opportunities.³

There are important considerations when a survey is designed. How participants are selected is just as important as the number of participants. Specifically, surveys can vary from including every member of a group to including a sample cohort, which may or may not be representative and bias free. Who is approached for a survey and who responds to it depends on multiple factors including cost, feasibility, proximity to the experience, availability, whether the respondent received the survey through referral, the engagement and participation of those being surveyed, and whether incentives are provided.³ The verbiage and design of a survey also can introduce bias. Respondents tend to choose the first option from a list and to answer as they think they should rather than being truthful. Good surveys randomly sample respondents so they are representative, are designed to minimize selection biases, and adjust for known variables that can confound results.³

Trend toward standardized national benchmarking surveys

There has been a shift away from using stand-alone survey instruments developed by private companies (such as Press-Ganey) for internal use by health care organizations to using national benchmark surveys developed by Federal agencies for public consumption. Three broad goals have shaped this trend. First, standardization of both the survey tool and implementation protocol allow valid comparisons to be made across hospitals locally, regionally, and nationally. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the first national standardized survey of patients’ perspectives of hospital care, has gone through rigorous development and testing by the Agency for Healthcare Research and Quality (AHRQ) including a public call for measures, literature review, cognitive interviews, consumer focus groups, stakeholder input, a 3-state pilot test, extensive psychometric analyses, consumer testing, numerous small-scale field tests, and input by the general public.⁴ Second, data collected from the national surveys are reported publicly to increase transparency of the quality of hospital care nationally. Third, performance on these surveys is tied to reimbursement and value-based payments to create new incentives for health care organizations to improve quality of care. Gastroenterologists need to be aware of these national standardized surveys (inpatient HCAHPS and outpatient Clinician and Group [CG]–CAHPS) because these will have direct implications for many aspects of care that will be provided in the future.

Hospital Consumer Assessment of Health Care Providers and Systems

With bundled payments on the horizon and organizations being required to attain goal participation levels, gastroenterologists have a vested interest to understand HCAHPS (pronounced H-caps). Although most gastroenterologists do not have a primary inpatient gastroenterology service, but rather are consultants, a significant number of gastroenterologists do have such a service. In 2002, the Centers for Medicare and Medicaid Services (CMS), in partnership with the AHRQ, developed and tested what is now known as the Hospital CAHPS survey.⁴ In 2005, the HCAHPS survey was endorsed by the National Quality Forum and in December 2005 the Office of Management and Budget approved it for national implementation. CMS implemented the HCAHPS survey in 2006 and the first public reporting of HCAHPS results occurred in 2008. Hospitals were incentivized further to improve patient experience with the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment contained within the hospital value-based purchasing program, beginning with discharges in October 2012.

HCAHPS is a 27-item survey instrument (available in official English, Spanish, Chinese, Russian, and Vietnamese versions) that is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge via mail, telephone, mail with telephone follow-up evaluation, or voice recognition. Hospitals must achieve at least 300 completed surveys over four calendar quarters to be eligible for incentives. Ten HCAHPS measures (six summary measures, two individual items, and two global items) are reported publicly on the Hospital Compare website (www.hospitalcompare.hhs.gov). The six summary measures address how well nurses and doctors communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key information is provided at discharge. The two individual items ask information about the cleanliness and quietness of patients’ rooms, and the two global items report patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends.⁴

The Clinician and Group Consumer Assessment of Health Care Providers and Systems

The CG-CAHPS survey is a standardized tool, developed by the AHRQ, to measure patient perceptions of care provided by physicians in an office setting, and will be the survey that will impact gastroenterology practices the most. Similar to the CAHPS surveys for hospitals (HCAHPS) and home health agencies, it is anticipated that there will be national implementation of CG-CAHPS by CMS. CMS has included the CG-CAHPS survey as part of the required quality metrics within the Medicare Shared Savings Program, and it is anticipated that a CG-CAHPS instrument eventually will be required for full reimbursement for all medical practices, with results publicly reported at the Physician Compare website (http://www.medicare.gov/physiciancompare). Currently, participation is voluntary, although several states (Minnesota, Oregon, Vermont, and Maine) have mandated its use, and there is potential for group practices, including those with ambulatory surgical centers, participating in the Physician Quality Reporting System, to be required to participate in the near future (Figure 1). There are different versions of the survey including adult, child, visit specific, and 12-month visit versions. In addition, there are versions for accountable care organizations (with specialist questions built in) and patient-centered medical home. As of September 2012, there were 275 hospital and clinic clients participating in CG-CAHPS, although this is expected to grow. Many gastroenterology practices use surrogate outpatient surveys from a number of different vendors to assess outpatient experience, the most common being from Press-Ganey, which although similar, have distinct differences. The Press-Ganey survey is proprietary, is used mainly for internal use, and has no mandate for public reporting. Although both CG-CAHPS and Press-Ganey questionnaires have questions that focus on access, provider communication, provider rating, office staff, and recommendation of practice, Press-Ganey has additional questions regarding safety, cleanliness, and privacy. CG-CAHPS uses a four-point scale for the 12-month survey and a three-point scale for the visit survey, compared with Press-Ganey, which uses a five-point scale.

Potential limitations

Because patient experience survey scores increasingly are used to benchmark different institutions and provide reimbursement incentives, they also have received substantial criticism because of potential biases and pitfalls. To date, there are no convincing data that higher patient experience scores translate into better patient outcomes. In fact, there is a concern that catering solely to patient experience scores may be ill guided because it may implicitly encourage health care providers to honor requests for discretionary health care services. Such efforts may lead to overuse, higher costs, and worse outcomes. Some researchers argue that the surveys do not adequately take into account variables that can skew results against academic medical centers or hospitals in regions of the country that treat large numbers of patients with mental or other serious illnesses. Geographic, cultural, language, and ethnic differences can affect a patient's perspective about their medical or hospital experiences and it has been shown that none of the hospitals in the nation with 500 or more beds has scored in the 90th percentile for basic measures such as physician or nurse communication.²

In addition, patient motivation to fill out a survey can bias results because it may be those who had an extreme experience – either superb or terrible – who are more likely to respond to the survey.

How can gastroenterologists stay ahead of the curve?

Despite the limitations in patient experience surveys mentioned earlier, they are likely here to stay and directly will impact physician compensation and hospital reimbursement for care.⁵

Although CG-CAHPS is not yet mandated for outpatient clinics and ambulatory surgical centers, gastroenterologists in community and academia should begin taking the steps outlined later to improve their practices before the results become publicly reportable. There is a paucity of well-designed studies that show improvement in HCAHPS after an intervention. The literature is anecdotal and individualized. Hence, it is more important for gastroenterologists to focus on culture, infrastructure, and processes to identify their specific opportunities than it is to adopt specific recommendations.

First, shift your thinking from resenting these surveys to embracing them as an opportunity to improve every aspect of care we provide as a health care team. This would entail making patient experience a priority for all staff and granting them the authority to positively impact the customer experience.

Second, identify resources that help conduct surveys efficiently and effectively. Most academic medical centers and community hospitals have set up interdisciplinary quality-improvement teams that can be a good starting point to learn about ongoing patient experience initiatives. The widespread use of tablet computers and patient experience survey applications have made it easier to conduct patient surveys for internal use at the point-of-care, often at a fraction of the cost of mailed paper surveys.⁶

Third, stay proactive by regularly reviewing survey information and identifying areas of poor experience in your practice. This can be accomplished by identifying within-practice variation (comparing members of the same practice), between-practice variation (comparing one’s practice with other similar practices), evaluating time trends (comparing current scores with your past scores), or comparison with national benchmarks. It is important to remember that direct physician care is not the only place to examine when trying to improve patient experience scores. As patient care transitions to team-based models, every member of the team is central to providing an optimal patient experience. In fact, some of the common issues that adversely affect patient experience relate to attitude of the front desk staff, the cleanliness in the office, or timely access to care. Hence, it is important to work as a team – staff and physicians – to design solutions to the specific patient experience issues.^1,2,3

Conclusions

A value-based purchasing initiative is now required under the Patient Protection and Affordable Care Act as part of the 2010 national health care reform legislation. Patient experience surveys, despite limitations, serve an important role in patient-centered care and value-based purchasing. Hospital-based HCAHPS currently is mandated by the CMS, and clinic-based CG-CAHPS will soon follow suit and provide data for the publicly reported Physician Compare website. A proactive approach to patient surveys that uses a team-based approach and health information technology will help gastroenterologists stay ahead in the changing landscape of health care delivery.

References

1. Raman, A., Tucker, A. The Cleveland Clinic: improving the patient experience. Harvard Business Review. September 12, 2011.

2. Merlino, J. Speaking from experience. When doctors improve communication, patients become better partners. Mod. Healthc. 2012;42:30.

3. Malone, L.E. Surveys: tracking opinion. National Science Foundation. Available at: http://www.nsf.gov/news/special_reports/ survey/index.jsp. Accessed: June 10, 2013.

4. Center for Medicare & Medicaid Services. HCAHPS fact sheet (CAHPS hospital survey). Available at: http://www.hcahpsonline.org/ files/August%202013%20HCAHPS%20Fact%20Sheet2.pdf. Accessed: June 10, 2013.

5. Allen, J.I. The road ahead. Clin. Gastroenterol. Hepatol. 2012;10:692-6.

6. Atreja, A., Rizk, M. Capturing patient reported outcomes and quality of life in routine clinical practice: ready for prime time? Minerva Gastroenterol. Dietol. 2012;58:19-24.

Dr. Rizk is quality improvement officer, Digestive Disease Institute, and clinical assistant professor, Cleveland Clinic Lerner College of Medicine; Dr. Atreja is chief technology innovation and engagement officer, medicine, and assistant professor and director of Sinai AppLab, gastroenterology, Icahn School of Medicine at Mount Sinai, New York; and Dr. Merlino is chief experience officer, Cleveland Clinic. Dr. Rizk and Dr. Atreja disclosed that they are investors in Innowaiting.com (Dawazu, LLC). The remaining author discloses no conflicts. Dr. Atreja is supported by a Crohn’s and Colitis Foundation of America Career Development Grant.