Medical peer review

Medical peer review is the process by which a committee of physicians investigates the medical care rendered in order to determine whether accepted standards of care have been met.

A Medical Peer Review is meant to provide independent medical opinions conducted by an objective group of physicians and relevant medical staff that quickly resolve complex problems that hospitals, physicians and insurance carriers face. They are often used to help solve systems problems endemic to healthcare institutions and thereby reduce legal liability associated with them. The review of chart notes and other medical reports are used to help render objective written opinions.

The term has been improperly used, however, as a synonym for performance appraisal. Several organizations have co-opted the term "peer review" as a guise for performance appraisals meant to be used as negotiating tools.

A medical peer review committee can act at the request of a patient, a physician, or an insurance carrier depending on the politics of the venue.

The medical peer review committee
This is a generalized term that has been used to refer not only to physician-based departmental peer review committees (which comprises physicians), but also to hospital-based performance-appraisal and systems-analysis committees that may be variably made up of nurses and administrators with or without the participation of physicians.

The objective of a medical peer review committee is to investigate the medical care rendered in order to determine whether accepted standards of care have been met. The professional or personal conduct of a physician or other healthcare professional may also be investigated.

In hospitals, however, only a peer review committee authorized by the physician medical staff is authorized to take action regarding a physician's medical privileges at that institution.

A committee convened by the hospital administration or other group within the hospital may make recommendations (that actions be taken) to the physician medical staff, however.

Legally, each state has a definition of "protected" peer review activities, and it varies from state to state. In California, for example, not only are physician medical staffs afforded protection as peer review committees, but so are health plans and disability insurance plans, local non-profit medical societies, and groups of more than 25 licentiates.

If a medical peer review committee finds that the physician has departed from accepted standards, it may recommend limiting or terminating the physician's privileges at that institution (be it physician medical staff, health plan, or medical society, etc.) Remedial measures including education may also be recommended and are often intended as remediation by state law (as in California).

Medical boards as peer review committees
State medical boards conduct peer review of licentiates. In states where the board is composed of physicians, this is true peer review.

In other states, however, the medical board is made up of attorneys and other non-physician members of society-at-large. (The state medical board may be a division of the Attorney General's office, for example.) Physicians are part of the board in primarily advisory capacities. Under this structure, the medical board asks for a medical peer review by a committee of physicians that may or may not be part of the panel of physicians serving as advisors to the board.

Other state boards are run primarily by physicians from that state. In these states, peer review committees may be made up of members of the board solely, or by a committee selected from a panel physicians not affiliated with the board.

Decisions regarding physician licensure are recommended by the medical peer review committee to the board, which reject or accept the committee's recommendations.

Impartiality
The importance of impartiality (i.e. independent adjudication acceptable to all parties) in the selection of a medical peer review committee, both at the institutional and state level, has been stressed by multiple organizations and medical societies. Conflicts of interest (such as professional competition through defamation) in peer review have been demonstrated (by jury trial and confirmed in appeal) through lawsuits.

Use of independent committees
Several companies emerged that offer to provide "independent, unbiased retrospective reviews" of the performance and/or quality of care of a physician (or other healthcare professional.)

These companies offer a committee of "peers" that may or may not be physicians, and ideally their use is agreed upon by the physician or healthcare professional under review. However, their "expert" status has not been determined on a widespread basis and it has been suggested that such companies may have a pre-existing bias. The criteria for expert status is one of major importance to the California Medical Association and other medical associations across the country.

In response to the Health Care Quality Improvement Act of 1987, ( HCQIA) (P.L. 99-660 ) Past Presidents and Executives of national medical associations and other health care organizations formed a non-profit corporation to provide independent assessment of the quality of medical care by eminent physicians and surgeons. The American Medical Foundation for Peer Review and Education ( AMF ) is now 20 years old and has provided good faith physician and medical staff peer review,specialty department assessment and entire hospital quality of care evaluation for over 2000 of the nations community and academic hospitals. www.medicalfoundation.org

Their division the Foundation for Advanced Medical Education (FAME) developed a template with a two million dollar grant and six specialty societies to help physicians learn how to use new procedures and devices in a more knowledgeable way.

Abuse
Controversy exists in the USA because peer review has been used as a competitive weapon to gain "market share" in turf wars among physicians, hospitals, HMOs, and other entities, a process known as sham peer review. The creation of the National Practitioner Data Bank under the 1986 HCQIA facilitates such abuse, essentially creating a 'third-rail' or a 'first-strike' mentality instead of a sober attempt to protect patients through professional medical integrity.

There is a shortage of physicians in the USA. The absence of due process in medical peer review may affect medical manpower in that country.

Some believe that the Health Care Quality Improvement Act's original intent and the creation of the associated "Data Bank" have gone a long way to protect patients by preventing physicians who have lost their privileges in one state from traveling to practice in hospitals in distant states.

However, for physicians who have not been disciplined and have merely been accused, a sanction and "Data Bank" reporting can occur anyway, whether or not the peer review process eventually finds fault with the accused physician's care or not. This major fault in the system makes its usefulness extremely limited in evaluating physicians who have not already had their licenses revoked and who have not actually undergone a true peer review process.

This provides additional opportunities for abuse.

External Sources

 * Improving Internal Medical Review, Allmed Healthcare Management, Portland, OR
 * How Does an Independent Review Organization (IRO) Define "Peer Review"?
 * Medical Peer Review Definition