More recently, the debate has turned to release of information on the hospital-based activities of particular physicians—for example, death rates associated with specific surgical procedures. Here the principle of public disclosure also seems to have gained acceptance, again with caveats about the soundness of the analyses and results. Nevertheless, because of the much greater difficulty of ensuring the reliability and validity of such analyses, especially on the level of individual physicians, many observers remain concerned about the possible downside of releasing information on specific clinicians. This criticism is especially pertinent to the extent that this information is a relatively crude indicator of the quality of care in hospitals or of that rendered by individual physicians, especially surgeons.

In the future, attention can be expected to shift to outpatient care and involve the ambulatory, office-based services of health plans and physician groups in primary or specialty care and of individual physicians. In these cases the stance in favor of public disclosure may become more difficult to adopt fully, for three reasons: the problems alluded to above for hospital-based physicians become exponential for office-based physicians; the clear, easy-to-count outcomes, such as deaths, tend to be inappropriate for office-based care because they are so rare; and quality-of-life measures, such as those relating to functional outcomes and physical, social, and emotional well-being, are more significant but also more difficult to assess, aggregate, and report.

Other types of providers and clinicians also must be considered in this framework. These include pharmacies and individual pharmacists; home health agencies and the registered nurses and therapists they employ; and durable medical device companies, such as those that supply oxygen to oxygen-dependent patients and the respiratory therapists they employ. Stretching the public-disclosure debate to these and other parts of the health care delivery environment may seem farfetched; to the extent that their data will appear eventually in databases maintained by HDOs, however, the prospect that someone will want to obtain, analyze, and publicize such data is real. This may illustrate the point raised in Chapter 2 that simple creation of databases may lead to applications quite unanticipated by the original creators.

Finally, some experts foresee the day when HDOs might do analyses by employer or by commercial industry or sector with the aim of clarifying the causes and epidemiology of health-related problems. Cases in point might be the incidence of carpal tunnel syndrome in banks, accidents in the meatpacking or lumber industry, or various types of disorders in the chemical industry. Here the issue is one of informing the public or specific employers in an economic sector about possible threats to the health and well-being of residents of an area or employees in a particular commercial enterprise.