Defining Peer Review
Peer review is used in many industries and in scholarly publishing to decide whether an individual´s experience, background, professional behavior and credentials provide sufficient qualifications to engage in an activity. The individuals conducting the review are the person´s peers, who have similar experience, backgrounds and credentials in the industry or field of study. They review the individual´s qualifications and work product and judge whether that individual is suitable for the task. This type of review is a “credentialing peer review.”
Credentialing peer reviews have been used for years in academia and science to review a candidate´s qualifications and publications. Other professions, such as accounting and finance also use credentialing reviews. Likewise, hospitals and medical practices perform them before hiring doctors. At AllMed, we conduct credentialing reviews to determine whether a doctor has the right to practice a particular specialty or procedure before bringing that physician specialist into our review panel.
But there are multiple meanings of peer review in health care. Peer review can mean an “independent medical review,” where doctors, who are not associated with the case in question, provide claims decisions for health insurance payers, workers compensation insurance payers and disability insurance payers. This kind of peer review uses independent, unbiased doctors to look at medical cases of other doctors in order to make an objective third-party decision about the doctors´ actions, and in some cases, the accountability of those actions.
In another broader meaning, the term focuses on improving the delivery of services to patients in hospitals by also examining the actions of doctors. In this case, physician peer reviewers evaluate the results of sentinel events in a hospital for quality assurance purposes. They investigate bad outcomes to determine if there was a misdiagnosis, maltreatment or any systematic problems leading to that event. These peer reviews can lead to corrective actions that can include hospital process changes or even sanctions against doctors.
Unfortunately in the healthcare business everybody uses their own vocabulary to talk about the same thing. So today the terms peer review, independent medical review, hospital peer review and medical peer review are used interchangeably.
At AllMed the term “peer review” is a synonym for “independent medical review” or “hospital peer review.” For both, the peer review activity uses board-certified and actively practicing doctors who are not a party to the particular treatment or case in review. These doctors examine cases to provide medically based and unbiased determinations about the root cause of the patient treatment problem. Was it medically necessary? If there was a sentinel event, what was the reason for it and why?