Measuring Patient Experience 2.0 – A conversation with Phil Marshall, MD

Phil “Dr. Phil” Marshall is on his way to becoming a national expert in patient experience in his new role as Senior Vice President Clinical Products for Press Ganey Associates, Inc. He came to the #epicenter last week and we talked about the future of measuring how well patients are feeling in their use of health care.

Phil actually wrote a blog post about it which you can read here, and I asked him some follow-up questions in our discussion. Although I am a huge fan of a great patient experience, I am far from an expert in the measurement of it; I know that it gets very technical ….

What Phil talked to me about is the idea that we don’t really know, in a measurable way, how well patients do/feel when we treat them in the medical system. There are several surveys out there that patietnts get, typically after they receive care, that ask about their satisfaction, the care experience/environment, but not necessarily if they felt better after the health system worked with them. We also don’t typically do a comparison – we don’t ask  how a patient feels before therapy and if they got better after working with us. Finally, we don’t assess the patient’s “expectation,” of therapy, which would shape their perception of if they truly feel better or not.

In other words – a medical practice today can’t really look at its medical records (electronic or not) and tell if it made people feel better, better to achieve their life goals through optimal health, met their expectations for the time and effort they spent in their health care experience. In the end that’s why someone would access the health care system anyway – less because they want to lower their blood pressure, more because they want to stay healthy as long as possible with minimal interference from their health care regime.

The way medical practices sometimes find out if they are doing well for their patients is if they come back. Sometimes when things didn’t work, they don’t come back, and an avenue to learn and do better is lost.

I think Phil alludes to this in his blog post, which is the question – “are we afraid to ask because we’ll be shocked by the results?”

I pondered a few things with him-

  • If you asked a patient before treatment “what are your expectations” and you had access to their answer, maybe it would change what treatment you provide or if you provide treatment at all. So beyond a measure of success, it might be an intervention point for greater success in the long term.
  • In asking about “expectations” – I would ask in a holistic way, framing health and health care as a means not an end. So instead of asking, “What are your expectations for your treatment?” I would ask, “What’s something important to you that you can’t do that you hope to do after this treatment is over?” (again, not an expert on the question asking, just an example) Wouldn’t it sound great for a doctor to day, “95% of my patients are back to enjoying running” instead of “95% of my patients’ knees don’t hurt”.
  • The asking itself should be easy – I gave the example of a hotel that I’ve checked out of that has a card of many questions and at the top “please take 30 seconds to tell us what you think.” Not the best time to ask when rushing to travel, and not clear how the results of the 20 questions are better than the results of 2-3 in this situation. Better would be, “Please text your satisfaction with this visit on a scale of 1 to 5 to the following place.” One question is about right for this hotel situation. I don’t know what it is for the situation Phil’s clients see in their work, just a word about prioritizing what’s important and letting the patients know that something is important because it’s one of only a few items.

Thanks to Phil for the thought provoke and for being interested in the question, “Did we help you feel better?” I’m hoping it’s possible that we can know the answer to this for every patient and make a positive difference for them when it matters, to them.




Dr. Ted,

Thanks for the invigorating discussion! It is always fun to envision with you a better and more patient-centric health care experience – and my guess is that asking patients how they feel, and if their expectations were met, would give us information as valuable as any that we might gather from even the most complete EHR system. And think about this: one of the biggest complaints about measuring health care performance – "But my patients are sicker" – would no longer be an issue because you'd be measured NOT on if your patients had any complications, but on their outcomes compared to baseline and whether their expectations of outcomes were met (and perhaps we'd set more realistic expectations). Fascinating.

One area where patients are being asked if "they feel better" is in mental health services. Some clinics and therapists have implemented a "client directed outcome informed care model" with impressive results – regardless of the type of therapy used. One of the key factors is the "alliance" between the patient and soul

Dr. L. Gordon Moore also is doing some interesting work building on his work with the Ideal Primary Care Practice – "Quality of relationship predicts probability of meeting preventive care guidelines as well as achieving improved process indicators in chronic disease management" and the research shows that good "collaborative care" results in better outcomes.

You often only need to ask people 3 quick questions.

1) Access:- Did you have access to care when and how they need it

2) Relationship: good communication & understanding – Did you understand what to do if…

Coordination: “I know who is in charge if…”

One area that still needs work is the current tool that the NCQA’s uses to measure a patient centered medical home – where only 3% of their scoring system comes from the patient voice.

Phil and Sherry,

Thanks for filling out what is known and the possibilities for measuring patient experience. I didn't know about the behavioral health approach. Seems promising as a practice to look at.

Michael Millenson also just sent me this article which may be of interest:

Fried TR, Tinetti ME, Iannone L. Primary Care Clinicians' Experiences With Treatment Decision Making for Older Persons With Multiple Conditions. [Internet]. Archives of internal medicine. 2010 ;archinternmed.2010.318.

In it, you get the sense that physicians want this data, too. They probably don't want to say, "my patients are sicker" either. Consistent with the theme that everyone wants to perform well for their patients and no one gets up in the morning hoping to deliver poor health care.

See what you think,


Ted Eytan, MD