Reimagining the Humble but Mighty Pen: Quality Measurement and Naturalistic Decision Making

Much of the health system’s avoidable spending may be driven by doctors’ decision making. Past studies demonstrated potentially consequential and costly inconsistencies between the actual decisions that clinicians make in daily practice and optimal evidence-based decisions. This commentary examines the “best practices regimen” through the lens of the quality measurement movement.  Although quality measures have proliferated via public reporting and pay-for-performance programs, evidence for their impact on quality of care is scant; the cost of care has continued to rise; and the environment for clinical decisions may not have improved. Naturalistic decision making offers a compelling alternative conceptual frame for quality measurement. An alternative quality measurement system could build on insights from naturalistic decision making to optimize doctors’ and patients’ joint decisions, improve patients’ health outcomes, and perhaps slow the growth of health care spending in the future.