What could be wrong with receiving a 5-star rating from a patient? Nothing is the obvious response, but what if that rating included actual patient comments posted on the doctor's public profile page that might contain clues to the identify of the patient?

That's when things get complicated as a large academic medical center in Southern California found out. Customer ratings are a boon to industries from airlines to food trucks, so it is not surprising that the University of California's San Diego Medical Center, which has 500 physicians at its two hospitals, decided to reach out to its outpatients with a survey seeking reviews. And although many healthcare systems offer such survey results for internal use only, UCSD decided it would make the comments public.

The Uh-Oh Moment
But 2 weeks ago, UCSD halted its rollout of patients' comments -- positive and negative -- about its doctors when it realized the surveys' disclosure letters didn't inform the patients that their comments would be posted on its website. Once made public, there was a chance that individual reviews could hold clues to the reviewer's identity.

"We were ramped up to go live," said Thomas Savides, MD, chief patient experience officer for the UCSD system.

The plan was halted when a member of the organization's patient experience improvement team received a electronic version of the survey after his own visit to a doctor and noticed "there was no disclaimer to the patients that the information (they wrote) might be put on the internet," Savides said.

"We decided that's not fair to patients ... So we've had to re-set the clock," he said.

UCSD now is looking at a launch 3 to 6 months from now, which should give it time to distribute patient experience surveys with appropriate disclosure language.

Failure to postpone the program would be "not quite a HIPAA (Health Insurance Portability and Accountability Act) violation, but it could be," Savides said.

That realization prompted UCSD to take down a demonstration of the program, which was limited to comments about Savides' own patients on his official UCSD profile page.



How It Works
UCSD uses an outside vendor, Press Ganey, to distribute the surveys electronically, but health systems need to supply disclosure information -- a step that was initially overlooked by UCSD.

Press Ganey one of about 40 vendors approved by the Centers for Medicare and Medicaid Services to provide patient surveys, and is the current industry leader.

In an email, Savides explained that "my understanding is that each healthcare organization writes their own cover letters for their Press-Ganey administered surveys. In our case, when we noticed that our letter did not inform our patients that we might use their anonymous comments online, we did not feel comfortable" with posting patients' comments.

National Movement
Across the country, at least two dozen big name hospital systems and medical groups have started posting physician star ratings along with comments patients write after their outpatient visits.

In 2012 the University of Utah Hospitals and Clinics was the first to test the patient rating waters followed by Piedmont Healthcare in Atlanta in 2013; Wake Forest Baptist in Winston-Salem, North Carolina, in 2014; and Stanford Medicine in Palo Alto, Cleveland Clinic, Geisinger Health System in Pennsylvania and Northwell Health in New York in 2015. Officials say this transparency has made public critical reviews of their physicians routine, which helped improve patients' experience as well as doctors' bedside manner.

The surveys ask patients to score doctors on a five-star scale based on five to 10 questions, such as whether the doctor listened, was courteous and respectful, and spent enough time. The responses are aggregated into a star score, which if too low, prompts interventions aimed at improving patient scores.

The experience survey star ratings and comment postings are not designed to measure quality of care -- whether the patient got the right diagnosis or treatment -- only the experience of care, and only that provided in an outpatient setting.

Organization to organization, however, the criteria for inclusion is highly variable. Some allow comments and star ratings for the entire patient experience, including wait times for appointments, time on the phone on hold, courtesy of office staff, and even ease of parking.

Others include only what happened between the patient and the doctor in the exam room. Some allow comments and ratings for nurse practitioners, midwives, and physician assistants while others limit responses just for physicians.
While most comments are overwhelmingly positive, some are brutal even when overall scores are not awful.

For example, at the University of Utah Hospitals and Clinics, A. Wayne Meikle, MD received a low 3.8 stars and this: "I have little confidence in this doctor. He almost gave me a prescription based on the lab results of the wrong date. I had to point that out to him." Or Don Coleman, MD, who received 4.4: "HORRIBLE PATIENT CARE ... I felt like I was just a burden to them and a quick paycheck."

One patient said Mudita Bhatia, MD, of the Cleveland Clinic, who received 4.1 stars, "held a mocking tone when I told her I was feeling anxious." Another patient wouldn't "trust [Bhatia] w/any complex question/concern."

Any Review Helps
By allowing these reviews, organizations risk tarnishing the reputations of some of their doctors. But by having a higher number of reviews for each physician, doctors get higher ranking in a Google search, above listings from Healthgrades.com, Vitals.com, ZocDoc.com, Yelp.com, and other online physician rating companies. According to a 2014 paper published in JAMA, one in four people surveyed in 2012 said they picked a primary care physician based on such commercial ratings.

The organizations also can be sure that the comments come only from real patients with real experiences, not competitors or angry family members, or the doctors themselves. The process also puts pressure on physicians to adopt friendlier behaviors, and alerts them to issues in their practices about which they may not be aware.

And, most organizations only post reviews or star ratings for providers who have at least 30 reviews, so a few single negative remarks about one doctor will almost always be overshadowed by positive comments from other patients.

Savides wasn't sure if the lack of disclosure might be an issue for other organizations now using Press Ganey's online tool.
But Thomas Miller, MD, chief medical officer for the University of Utah Hospitals and Clinics, said he's not worried. "This is a non-issue" because all personal remarks are scrubbed, he said.

"We've been doing this almost 4 years and patients know they can find the comments online. We've never had anybody complain about it." He added that although he doesn't have "a lot of background" on the UCSD discovery, "I think this is just physicians pushing back. It's an excuse not to do this."

Ira Nash, MD, executive director of the 2,500-physician Northwell Health Physician Partners, (formerly affiliated with North Shore-Long Island Jewish Health System), seemed more concerned. When he heard about the privacy issue, he said, "I checked. We do not explicitly state that comments may end up on our physicians' web profiles, but we will revisit this issue."

At Wake Forest Baptist Health in Winston-Salem, North Carolina, Russell Howerton, MD, Chief Medical Officer and vice president of clinical operations, said his organization deals with the privacy issue by reviewing each comment and not sharing online those "if it is deemed identifiable." Howerton said he's unaware of any feedback from patients about their comments being posted.