Patient Assessments and Online Ratings of Quality Care
Patient Assessments and Online Ratings of Quality Care
Internet-based physician evaluation is a rapidly growing phenomenon that shows little sign of slowing—much less disappearing. Patients will continue to praise and criticize their physicians, as well as seek new providers on the Internet. This is a natural extension of how consumers find and react to products and services in today's digital world. In the past, doctors have been wary of, and even sought to discredit, these online resources. However, the sheer number of PEWs, their success in the courts, and their apparent profitability makes them unlikely to pass away. The time has come for physicians to face, and even embrace, PEWs. Doctors who are unafraid to learn about and use these resources are most likely to benefit from them, whereas those who ignore their online reputations are at the greatest risk.
The full potential of PEWs remains to be reached, and there are two notable reasons for this. First, many sites claim to profile 90% or more practicing physicians in the United States, but only a small fraction of listed physicians have even a single patient review—much less several. Second, physicians with reviews tend to be located in urban sections of the country with great variance of review coverage in rural areas. However, as more physicians are scored online, patient confidence is likely to grow in the use of these websites. With this confidence, PEWs will generate more traffic, more doctors will be rated, and the cycle will continue. In this way PEWs will likely push beyond their current geographic limitations with near-complete coverage of the country as the most probable outcome. One can foresee a future in which the Internet overcomes traditional word-of-mouth and physician-referral methods of finding new caregivers. The timetable is uncertain, but this eventuality may be more a question of "when" than "if". This review aims to provide clinicians with a better understanding of PEWs, their users, and what doctors and other health professionals can do to make improvements to their practices and their online reputations.
Physicians should be aware of the values emphasized by online rating services. Other than a physician's overall score, the feature for which he or she is most likely to be critiqued online is punctuality, followed closely by perceived quality of office or nursing staff (see Table 6). This does not mean that these are the elements of greatest concern to patients. These are only the values by which patients are most likely to be asked to score their physicians online. It is particularly interesting to note that some of the items by which physicians are most frequently critiqued are not in fact direct commentaries about the physicians themselves. Doctors are regularly graded on "external features," such as the quality of their office staff, the cleanliness of their offices, and their costs/billing.
Demographics of PEW users This study gives insight into the profile of the typical PEW user. The demographics of http://healthgrades.com/—which receives more unique visitors in a typical month than all other dedicated PEWs combined—is shown in Figure 7. Most visitors to dedicated PEWs (and by conjecture most online evaluators of physician performance) are female. They are between the ages of 45 and 65 years. They usually have children, and have at least some college education—but have not attended a post-graduate school. A number of items should be considered. First is the apparent phenomenon that women are more likely than men to use PEWs. Do women trust online reviews more than their male counterparts, or are women generally more engaged in their healthcare than men? If women are more likely than men to rate their physicians online (which remains to be scientifically affirmed), should physicians be more concerned about the impact of dissatisfied female patients on their online reputations than the impact of displeased male patients? It is beyond the scope of this review to answer these questions.
Furthermore, one would likely surmise that younger patients, who presumably are the most Internet savvy, would be more likely to use PEWs than the middle-aged, but this does not appear to be the case. Maybe younger patients simply opt to attend their designated student health clinics, or perhaps they visit the doctor less frequently than adults. Do pediatricians then have less to gain from PEWs than physicians of older patients? Before embracing this conclusion one should remember that most users of PEWs also have children.
Patients with the least or most education alike are less likely to take advantage of dedicated PEWs than those with a college degree or with some college experience. Conceivably, those without any college exposure could either be unaware of PEWs or have insufficient access to their services. Furthermore, it is possible that those with graduate school degrees have stronger personal contacts with physicians—or friends of physicians—and are therefore better able to identify providers of interest without the use of the Internet.
There are notable exceptions to these demographics among certain of the smaller dedicated PEWs. http://zocdoc.com/, e.g., is very popular among patients aged 18–34 years compared with those of older generations, and at http://docspot.com/ the differences between those with college and graduate school training is less pronounced than at http://healthgrades.com/. It appears that different PEWs appeal to different groups of users.
Most reviews are, in fact, positive Conventional wisdom would suggest that dissatisfied patients are more likely to review doctors than patients who are very happy with their care. This concern has been disproved numerous times. A 2010 study by Lagu et al. found that 88% of online physician reviews are positive. Similarly, the questionnaire used in this study was sent to all PEWs that provided sufficient contact information. Site administrators were asked to report the number of their reviews that are positive, neutral, or negative. The self-reported figures from responding websites ranged from 69–75% positive, 4–22% neutral, and 9–21% negative.
Addressing negative reviews The abundance of positive reviews cannot negate the impact of negative ones. Negative reviews can have long-lasting ramifications and many physicians are unaware that these damning critiques are hiding in plain sight. The social media world may be viewed as a "wild wild west" environment where most websites are not held accountable. Furthermore, there is a perceived validity of consumer rants, as most comments on the Internet are offered without physician rebuttals. For the medical community, it is important to acknowledge negative reviews. Patients who are dissatisfied with their physician turn to the Internet for information more frequently than others and are likely to continue spreading criticism across multiple healthcare providers.
With encouragement from the medical community it is possible that PEWs will change and become more "doctor friendly." For example, standardizing and validating reviews through reporting assessments may improve trust. Next, enabling physicians to respond to critics online is a feature that, if implemented more broadly by PEWs, would likely encourage greater physician enthusiasm for these websites. Websites like http://yourcity.md/ have taken the lead on this concept, and their example is one that other PEWs should consider following.
In the future, gastroenterologists may be interested in exploring formal partnerships between professional gastroenterological societies and PEWs. Currently, no such liaisons exists, but the connection between The American Board of Dermatology and the website, http://drscore.com/, is an interesting model that could be followed and added upon by other professional organizations. Such collaboration might make available to patients specific indicators of physician experience and skill in addition to the subjective reports of patient satisfaction that are now available. This added information could also assist providers who are technically excellent but who have received poor reviews in still attracting new patients. It remains to be determined whether or not patients would be interested in or benefit from access to such data.
Some physicians have improved their reputations by prompting their favorite patients to write glowing reviews. However, physicians must never yield to the temptation to "fight back" against negative reviews by reviewing themselves online or by commissioning third parties to generate reviews on their behalves. Doing so is patently unethical and debases the medical professional as a whole. Furthermore, as PEWs continue to expand, there will likely be legal actions taken against physicians who fabricate their own reviews.
Using PEWs to improve one's online reputation Physicians who are doubtful that patients are studying them online may want to consider conducting an initial test by searching for their own profiles on the website: http://ucomparehealthcare.com/. There, physicians can learn free-of-charge how many times they have been compared against their competitors in the region. The physician featured in Figure 8 has been compared over 275 times (red oval) with only a single, uninspiring review to provide contrast from his colleagues.
(Enlarge Image)
Figure 8.
Screen shot from ucomparehealthcare.com taken in December 2012. This physician has been compared with other gastroenterologists in his area over 275 times (red oval). He has only a single (and poor) review by which he has been compared against his colleagues.
Most physicians' profiles have already been created by website administrators—who draw much of their information from government databases. However, some PEWs do not add profiles unless asked to do so (by the physician or sometimes by a patient). Physicians interested in harnessing the potential of PEWs will want to consider claiming or creating their profiles on the many websites that offer this service free-of-charge. Almost every one of the 35 websites studied enable physicians to create, or claim and then modify their profiles for free. Notable exceptions include: http://angieslist.com/, http://checkbook.org/, http://drscore.com/, http://iconnectmedic.com/, and http://merchantcircle.com/. It is possible that even these sites offer a free profile to physicians, but none could be found in this study.
There are many ways by which a free profile can be enhanced. To begin, information listed on PEWs is often missing or incorrect. Next, physicians can usually attach a photograph to their free profiles. Studies of human eye movements over an Internet page have demonstrated that people spend more time looking at a picture in the top-left corner of a given profile than anywhere else on the screen. A profile with no picture is presumably less likely to attract as much attention as the alternative. One additional point to consider is that many PEWs are venturing into the realm of smart phone applications. It is recommended that photos be of good quality, but sufficiently small to be quickly uploaded on a portable 3G- or 4G-capable device. A report by the web acceleration company, http://strangeloop.com/, states that the average mobile device user only waits 5 s for a page to load before moving on to another website—or in this case—to a competitor's profile.
Those who want to maximize their returns online may want to consider paying for "advanced" or "upgraded" profiles. Several websites, including http://findadoc.com/, http://healthgrades.com/, http://ucomparehealthcare.com/, and http://wellness.com/ offer these advanced options. An upgraded profile usually moves its physician to the top of that website's search results in addition to other benefits. http://wellness.com/ claims that featured physicians receive 5–10 times more referrals than those with traditional free profiles, in addition to enjoying higher places on search results of web-wide search engines, such as Google.
Notable websites The vast number of PEWs makes it difficult to know where to begin when managing one's online presentation. Most PEWs are very similar to each other, and deciding which website is of greatest importance can be difficult to accomplish. As we have studied each of these websites at length, a small number of PEWs have stood out to us as being the most noteworthy. We recognize that the designation of one website as being more notable than another is highly subjective. Nevertheless, we hope that this short list will be of benefit:
Discussion
Internet-based physician evaluation is a rapidly growing phenomenon that shows little sign of slowing—much less disappearing. Patients will continue to praise and criticize their physicians, as well as seek new providers on the Internet. This is a natural extension of how consumers find and react to products and services in today's digital world. In the past, doctors have been wary of, and even sought to discredit, these online resources. However, the sheer number of PEWs, their success in the courts, and their apparent profitability makes them unlikely to pass away. The time has come for physicians to face, and even embrace, PEWs. Doctors who are unafraid to learn about and use these resources are most likely to benefit from them, whereas those who ignore their online reputations are at the greatest risk.
The full potential of PEWs remains to be reached, and there are two notable reasons for this. First, many sites claim to profile 90% or more practicing physicians in the United States, but only a small fraction of listed physicians have even a single patient review—much less several. Second, physicians with reviews tend to be located in urban sections of the country with great variance of review coverage in rural areas. However, as more physicians are scored online, patient confidence is likely to grow in the use of these websites. With this confidence, PEWs will generate more traffic, more doctors will be rated, and the cycle will continue. In this way PEWs will likely push beyond their current geographic limitations with near-complete coverage of the country as the most probable outcome. One can foresee a future in which the Internet overcomes traditional word-of-mouth and physician-referral methods of finding new caregivers. The timetable is uncertain, but this eventuality may be more a question of "when" than "if". This review aims to provide clinicians with a better understanding of PEWs, their users, and what doctors and other health professionals can do to make improvements to their practices and their online reputations.
Most Important Elements of Physician Evaluations
Physicians should be aware of the values emphasized by online rating services. Other than a physician's overall score, the feature for which he or she is most likely to be critiqued online is punctuality, followed closely by perceived quality of office or nursing staff (see Table 6). This does not mean that these are the elements of greatest concern to patients. These are only the values by which patients are most likely to be asked to score their physicians online. It is particularly interesting to note that some of the items by which physicians are most frequently critiqued are not in fact direct commentaries about the physicians themselves. Doctors are regularly graded on "external features," such as the quality of their office staff, the cleanliness of their offices, and their costs/billing.
Demographics of PEW users This study gives insight into the profile of the typical PEW user. The demographics of http://healthgrades.com/—which receives more unique visitors in a typical month than all other dedicated PEWs combined—is shown in Figure 7. Most visitors to dedicated PEWs (and by conjecture most online evaluators of physician performance) are female. They are between the ages of 45 and 65 years. They usually have children, and have at least some college education—but have not attended a post-graduate school. A number of items should be considered. First is the apparent phenomenon that women are more likely than men to use PEWs. Do women trust online reviews more than their male counterparts, or are women generally more engaged in their healthcare than men? If women are more likely than men to rate their physicians online (which remains to be scientifically affirmed), should physicians be more concerned about the impact of dissatisfied female patients on their online reputations than the impact of displeased male patients? It is beyond the scope of this review to answer these questions.
Furthermore, one would likely surmise that younger patients, who presumably are the most Internet savvy, would be more likely to use PEWs than the middle-aged, but this does not appear to be the case. Maybe younger patients simply opt to attend their designated student health clinics, or perhaps they visit the doctor less frequently than adults. Do pediatricians then have less to gain from PEWs than physicians of older patients? Before embracing this conclusion one should remember that most users of PEWs also have children.
Patients with the least or most education alike are less likely to take advantage of dedicated PEWs than those with a college degree or with some college experience. Conceivably, those without any college exposure could either be unaware of PEWs or have insufficient access to their services. Furthermore, it is possible that those with graduate school degrees have stronger personal contacts with physicians—or friends of physicians—and are therefore better able to identify providers of interest without the use of the Internet.
There are notable exceptions to these demographics among certain of the smaller dedicated PEWs. http://zocdoc.com/, e.g., is very popular among patients aged 18–34 years compared with those of older generations, and at http://docspot.com/ the differences between those with college and graduate school training is less pronounced than at http://healthgrades.com/. It appears that different PEWs appeal to different groups of users.
Most reviews are, in fact, positive Conventional wisdom would suggest that dissatisfied patients are more likely to review doctors than patients who are very happy with their care. This concern has been disproved numerous times. A 2010 study by Lagu et al. found that 88% of online physician reviews are positive. Similarly, the questionnaire used in this study was sent to all PEWs that provided sufficient contact information. Site administrators were asked to report the number of their reviews that are positive, neutral, or negative. The self-reported figures from responding websites ranged from 69–75% positive, 4–22% neutral, and 9–21% negative.
Addressing negative reviews The abundance of positive reviews cannot negate the impact of negative ones. Negative reviews can have long-lasting ramifications and many physicians are unaware that these damning critiques are hiding in plain sight. The social media world may be viewed as a "wild wild west" environment where most websites are not held accountable. Furthermore, there is a perceived validity of consumer rants, as most comments on the Internet are offered without physician rebuttals. For the medical community, it is important to acknowledge negative reviews. Patients who are dissatisfied with their physician turn to the Internet for information more frequently than others and are likely to continue spreading criticism across multiple healthcare providers.
With encouragement from the medical community it is possible that PEWs will change and become more "doctor friendly." For example, standardizing and validating reviews through reporting assessments may improve trust. Next, enabling physicians to respond to critics online is a feature that, if implemented more broadly by PEWs, would likely encourage greater physician enthusiasm for these websites. Websites like http://yourcity.md/ have taken the lead on this concept, and their example is one that other PEWs should consider following.
In the future, gastroenterologists may be interested in exploring formal partnerships between professional gastroenterological societies and PEWs. Currently, no such liaisons exists, but the connection between The American Board of Dermatology and the website, http://drscore.com/, is an interesting model that could be followed and added upon by other professional organizations. Such collaboration might make available to patients specific indicators of physician experience and skill in addition to the subjective reports of patient satisfaction that are now available. This added information could also assist providers who are technically excellent but who have received poor reviews in still attracting new patients. It remains to be determined whether or not patients would be interested in or benefit from access to such data.
Some physicians have improved their reputations by prompting their favorite patients to write glowing reviews. However, physicians must never yield to the temptation to "fight back" against negative reviews by reviewing themselves online or by commissioning third parties to generate reviews on their behalves. Doing so is patently unethical and debases the medical professional as a whole. Furthermore, as PEWs continue to expand, there will likely be legal actions taken against physicians who fabricate their own reviews.
Using PEWs to improve one's online reputation Physicians who are doubtful that patients are studying them online may want to consider conducting an initial test by searching for their own profiles on the website: http://ucomparehealthcare.com/. There, physicians can learn free-of-charge how many times they have been compared against their competitors in the region. The physician featured in Figure 8 has been compared over 275 times (red oval) with only a single, uninspiring review to provide contrast from his colleagues.
(Enlarge Image)
Figure 8.
Screen shot from ucomparehealthcare.com taken in December 2012. This physician has been compared with other gastroenterologists in his area over 275 times (red oval). He has only a single (and poor) review by which he has been compared against his colleagues.
Most physicians' profiles have already been created by website administrators—who draw much of their information from government databases. However, some PEWs do not add profiles unless asked to do so (by the physician or sometimes by a patient). Physicians interested in harnessing the potential of PEWs will want to consider claiming or creating their profiles on the many websites that offer this service free-of-charge. Almost every one of the 35 websites studied enable physicians to create, or claim and then modify their profiles for free. Notable exceptions include: http://angieslist.com/, http://checkbook.org/, http://drscore.com/, http://iconnectmedic.com/, and http://merchantcircle.com/. It is possible that even these sites offer a free profile to physicians, but none could be found in this study.
There are many ways by which a free profile can be enhanced. To begin, information listed on PEWs is often missing or incorrect. Next, physicians can usually attach a photograph to their free profiles. Studies of human eye movements over an Internet page have demonstrated that people spend more time looking at a picture in the top-left corner of a given profile than anywhere else on the screen. A profile with no picture is presumably less likely to attract as much attention as the alternative. One additional point to consider is that many PEWs are venturing into the realm of smart phone applications. It is recommended that photos be of good quality, but sufficiently small to be quickly uploaded on a portable 3G- or 4G-capable device. A report by the web acceleration company, http://strangeloop.com/, states that the average mobile device user only waits 5 s for a page to load before moving on to another website—or in this case—to a competitor's profile.
Those who want to maximize their returns online may want to consider paying for "advanced" or "upgraded" profiles. Several websites, including http://findadoc.com/, http://healthgrades.com/, http://ucomparehealthcare.com/, and http://wellness.com/ offer these advanced options. An upgraded profile usually moves its physician to the top of that website's search results in addition to other benefits. http://wellness.com/ claims that featured physicians receive 5–10 times more referrals than those with traditional free profiles, in addition to enjoying higher places on search results of web-wide search engines, such as Google.
Notable websites The vast number of PEWs makes it difficult to know where to begin when managing one's online presentation. Most PEWs are very similar to each other, and deciding which website is of greatest importance can be difficult to accomplish. As we have studied each of these websites at length, a small number of PEWs have stood out to us as being the most noteworthy. We recognize that the designation of one website as being more notable than another is highly subjective. Nevertheless, we hope that this short list will be of benefit:
http://angieslist.com/: a general information website that requires a paid membership to access and post reviews. Anonymous reviews can therefore be prevented. http://angieslist.com/ also notifies physicians when they have been reviewed.
http://docspot.com/: a rapidly growing dedicated PEW. Rather than manage its own reviews, http://docspot.com/ draws on existing reviews from over 15 other websites. http://docspot.com/ also employs the most robust filtering mechanisms for sorting search results that we have seen. Finally, http://docspot.com/ is one website that permits physicians to readily respond to online critics.
http://drscore.com/: provisionally approved by the American Board of Dermatologists as a tool for measuring patient satisfaction for recertification.
http://findadoc.com/: a dedicated PEW with consistently positive growth. "Colleague endorsements" and "featured doctor" options are available.
http://healthgrades.com/: the largest dedicated PEW. http://healthgrades.com/ is unique in that it only allows users to rate physicians with scaled reviews (using stars) without providing the option of free response—thus avoiding the posting of libelous comments about a provider. http://healthgrades.com/ also has some of the most detailed physician profiles and reviews among PEWs and allows physicians to respond to critics online.
http://local.yahoo.com/: a general information website with physician evaluation features. http://local.yahoo.com/ received more traffic than any of the other 35 websites studied with an average of over 17 million unique visitors per month from Oct 2011 to September 2012. It is unclear how much of this traffic was directed at their physician evaluation services.
http://ratemds.com/: the fifth most visited dedicated PEW. http://ratemds.com/ allows physicians to respond to negative reviews online.
http://ucomparehealthcare.com/: the third most visited dedicated PEW and the only PEW with a feature that enables users to compare multiple providers simultaneously.
http://vitals.com/: the second largest dedicated PEW and a website with consistently positive growth.
http://yourcity.md/: the most rapidly growing and, in our estimation, the most "doctor friendly" PEW studied. Doctors are given the option to respond publically to negative reviews or to send a private message through the website to unsatisfied patients. After this communication, the patient is given the opportunity to revise or replace the negative review. As per the site's user agreement, a negative claim about a physician that cannot be substantiated and which is not altered by the patient may prompt the site administrators to either remove the comment or reveal the name of the reviewer to the physician to pursue legal action. This course is rarely selected as most disagreements are resolved by anonymous correspondence through the website.
http://zocdoc.com/: the fourth most visited dedicated PEW. http://zocdoc.com/ enables patients to see a doctor's schedule online, book appointments, and print new patient forms to complete before arriving at the office.
