Letter to the editor--Regarding ‘Academic medicine: A bubble about to burst?’

TO THE EDITOR:

It was with great interest that I read the article on the impending consequences of our academic medicine bubble [“Academic medicine: A bubble about to burst?” February 2014]. The idea that clinical practice is effectively subsidizing the academic and research arms of medicine is poignant indeed.

This circumstance argues for improved ROI for the clinical enterprise, if only to give the other arms of academic medicine time to reinvent themselves. Fortunately, there is “low-hanging” fruit in making our physicians more productive, and opportunities lie hidden in how we “document” our care as physicians.

For whatever reasons, electronic physician documentation tools have not focused on physician productivity to date. However, there are technologies available now, which are capable of doubling physician productivity quickly, and cost effectively. Some of these are available from existing EHR vendors, while others are increasingly available from third party vendors, and easily integrated into existing EHR’s.

We have been testing ways to achieve this at our shop in Tampa. As CMIO at USF Health, and as a practicing full time urogynecologist and fellowship director, I see that the burden of reliable, compliant clinical documentation is a dramatic drain on the efficiency of our docs, and a drain on the quality of care that we provide. As an example, for every minute spent in direct clinical care, our docs spend another minute in documentation, itself disconnected from the act of generating a bill for the service rendered. This represents a 50% hit to efficiency, with no guarantee of billing compliance, and no embedded way to verify or guarantee quality of care.

Fortunately, there are sound, cost effective opportunities to improve our efficiency, quality of care, patient engagement, and billing compliance using existing or easily repurposed technologies, which can allow our docs to deliver high quality care to more patients, at comfortable levels of exertion. We have demonstrated that this can be done in small pilots, which I believe to be scalable to the enterprise level.

The goal here is not to go on an EHR replacement binge-I use 4 different EMRs in my daily clinical practice, and they all fail to adequately address physician productivity and outcomes improvement. Instead, the focus needs to be on physician and patient user interfaces that lead to productivity gains, and back-end analytics to lead us to better outcomes.

Innovators currently offer add-ons like these, seamlessly integrated into existing EMR systems. I know that this is a solvable problem because I seen a similar problem solved in my prior industry, electronics and computers, another place where extremely bright, highly trained, skilled practitioners were being overwhelmed by the burdens of increasing volume and complexity, in the face of falling profit margins. Over a period of 6 years, my colleagues and I engineered a design automation system for multiplying our electronic circuit design capability by over 10-fold, while incorporating “correct by construction” functionality that eliminated the need for design rule checking. This system dramatically increased our design throughput, reducing time to market for our products.

A similar improvement in clinical efficiency, through put, and demonstrated quality of care (outcomes) can also potentially reduce our costs of care, leading to improved, sustainable revenues for our clinical enterprise.

Lennox Hoyte, MD, MSEECS

Chief Medical Information Officer, USF HEALTH

Tampa, Florida

NEXT: DR. LOCKWOOD'S REPLY >>

IN REPLY:

Thank you so much for sharing your thoughts on how to “deflate” the academic medicine bubble. I believe that the widespread introduction of electronic health records has, to date, added far more cost than benefit but I also share your long term vision of its potential. However, to realize that potential fundamental re-thinking of both medical and nursing charting is needed. We need to abandon the concept that the EHR is simply an electronic version of the paper record.

Charting should be done largely “by exception” wherein only pertinent positives are charted after initial H&P’s with additional data (labs, vital signs, hemodynamic monitoring, imaging) automatically populating tables. We also need to make sound economic decisions around the use of scribes. It may make sense for busy surgeons to employ scribes, however, it is unlikely that they will be cost effective working for internists, neurologists, or family medicine practitioners. Again, thanks for sharing your insights.

Charles J. Lockwood, MD, MHCM

Editor in Chief, Contemporary OB/GYN