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EMR Inbox: the growing burden of uncompensated electronic paperwork

Posted by Dan Mazanec, MD on Mar 24, 2016 10:53:02 AM

 

Reviewing test results and responding to patient phone messages has always been a part of medical practice.  However, a recent study suggests that the ease of creating notifications in the era of  Electronic Medical Records has dramatically increased the time physicians spend dealing with this "electronic paperwork." Researchers at the Houston VA hospital reviewed the electronic logs of all EMR notifications to physicians in 3 large practices over a 6 month period.  Notifications were categorized as related to test results or not.  Primary care physicians received an average of almost 77 messages in their inboxes daily, only 20% related to test results! 

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Errors in electronic prescriptions in the EMR

Posted by Dan Mazanec, MD on Mar 16, 2016 10:10:27 AM

Common, Costly, and Concerning for Patient Outcomes


A new study published this week reports a dangerously high frequency of errors in electronic prescriptions.  The review of 26,341 e-prescriptions found two-thirds contained inappropriate content of which almost 20% contained conflicting patient instructions in the free-text notes to the pharmacist. Not surprisingly, these free-texts cause confusion at the receiving pharmacy with significant workflow disruption, requiring one or more calls to the prescribing office to clarify the order.  Beyond creating more work for the pharmacist and delaying the dispensing of the medication, the greater risk is that prescription errors can lead to an actual medication error of potential harm to the patient.  The authors cite an example from the study in which a free text for the anticonvulsant Dilantin ordered twice the dose in the structured fields of the e-prescription.  If not clarified by the pharmacy, these errors could result in harmful under or overdosage of the drug prescribed.

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Medical Decision Support in the EMR

Posted by Dan Mazanec, MD on Mar 9, 2016 9:42:22 AM

Physician engagement is key

Our primary objective at Dorsata is to develop and build technology which assists clinicians in delivering optimal patient-centered care. An important part of this process is the integration of clinical decision support (CDS) into the workflow. CDS is based on symptom or disease specific pathways built from the best available medical evidence. Published clinical practice guidelines for common medical problems abound but evidence they actually influence clinical decisions in daily practice is poor. Time-pressured practitioners need real-time access to a decision support system, ideally during the patient visit itself.

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The doctor - EMR - patient relationship

Posted by Dan Mazanec, MD on Mar 3, 2016 9:12:00 AM

What really is the EMR's impact on physician-patient communication?

patient_vs_emr.jpg

There’s a third party in the most doctor’s office exam rooms now – the computer housing the electronic medical record (EMR). A new study by Ratanawonga, et al published in this month’s JAMA internal Medicine (JAMA Intern Med 176 (1) 125-127, 2016) raises serious questions about the impact of the EMR on physician-patient communication. The authors recorded videos of 71 office visits to 39 different clinicians in practices commonly dealing with patients of low health literacy. High computer users (less eye contact) were compared with low users in domains of patient satisfaction and communication style. Patients of high computer users were less likely to rate their care as excellent. Communication style was altered by higher computer use with a tendency to "less authentic engagement” with the patient and more “negative rapport building.” 

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The Toyota Model in Healthcare Delivery

Posted by Dan Mazanec, MD on Feb 29, 2016 9:00:00 AM

“One Piece Flow”

 Can adopting the principles used in building a Toyota Camry really improve the outpatient practice of medicine?   “One piece flow” (also known as “single piece flow” or “continuous flow”) defines a manufacturing process in which all of the work on a single product (the Camry) is completed before moving onto the next unit. This contrasts with a “batching” model in which some portion of the work is done on multiple units (batch) before moving onto the next step in the process. The batch analogy in medical practice is seeing 30 patients daily but not finishing the work on any until later, i.e. not completing the notes until the evening or next day.   Pioneered by Toyota, adoption of one piece flow manufacturing in the auto industry has reduced cost of production and increased efficiency. How would such a model apply to clinical practice?

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Standardized Quality Metrics for Physicians

Posted by Dan Mazanec, MD on Feb 22, 2016 9:47:18 AM

Beyond Process Towards Patient-Centered Outcomes

The long-awaited paradigm shift from reimbursement for volume to value for medical services is accelerating.  This week, the Core Quality Measures Collaborative (CQMC) released seven sets of standardized clinical quality metrics for practitioners.  Significantly, the collaborative represents a broad coalition of stakeholders:

  • Center for Medicare and Medicaid Services (CMS)
  • Americas Health Insurance Plans (AHIP)
  • American Academy of Family Physicians
  • American College of Gynecology and Obstetrics
  • American College of Cardiology
  • American Academy of Orthopedic Surgeons
  • Consumer groups

In the past, physicians, payers, and certainly patients have defined quality using multiple different metrics resulting in burdensome and unnecessary complex reporting by providers.  There is now general acceptance that  so-called "meaningful use" of the EMR bears little relationship to the quality of care.  In addition, the focus has shifted from process measures of care to a search for clinically relevant metrics.

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The EMR and Physician Burnout

Posted by Dan Mazanec, MD on Feb 16, 2016 1:02:25 PM

Less face time with patients

Less free time

Less personal satisfaction with practice

“After we get the kids to bed, I spend 2 or 3 hours at night finishing my charts.” “I’ve become a glorified data entry clerk.” “Is this really meaningful use?” During the last several years, I’ve heard these phrases from many of my colleagues in clinical practice, almost irrespective of their specialty. Dissatisfaction with the current state of the electronic medical record (EMR) is now widely recognized as an important contributor to physician “burnout.”

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Penn Medicine launches "Penn Pathways" on Dorsata

Posted by David Fairbrothers on Feb 12, 2016 9:00:00 AM

Dorsata is pleased to announce that The Penn Medicine Center for Evidence-based Practice (CEP) launched the new “Penn Pathways” program yesterday on the Dorsata platform.  The “Penn Pathways” program has been developed by the Office of the Chief Medical Officer to foster the consistent practice of high value care across Penn Medicine.  There are already more than 30 clinical pathways for use by physicians and nurses on the site, including pathways for evaluating and managing patients with gastrointestinal bleeds, infections, delirium, hemoptysis, urinary catheters, and cardiac ischemia and arrhythmias.

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The Employer Push for High Value Health Care

Posted by Dan Mazanec, MD on Feb 9, 2016 4:18:54 PM

HCA, Verizon, and 18 other major companies form The Health Transformation Alliance 

The transition to a value-based payment system in health care is clearly accelerating. For years, we’ve been bombarded with the buzz words “value” and “outcomes” as the core drivers of a future “brave new world” in health care delivery which would someday supplant the traditional model based on fee-for-service. Exactly how and when this transition would occur has seemed uncertain and vague. With the announcement last week of the Health Transformation Alliance the road forward became a bit less murky. 20 prominent employers, including American Express, Caterpillar, Coca Cola, HCA, Macy’s, Shell Oil and Verizon, have decided to pool their data on the 4 million lives covered by their respective health plans. The aggregated data includes both cost and outcome of treatment. By linking outcome and cost (i.e. value) the Alliance hopes to identify providers and practices who deliver high value care for certain illnesses. By steering employees to these “best practices”, the companies hope to bend the health care cost curve and make employer funded health care sustainable. The undesirable alternative is increasing copays and deductibles or reducing employees eligible for healthcare by reducing work hours.

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The EMR as the Physician’s Partner

Posted by Dan Mazanec, MD on Feb 4, 2016 4:43:51 PM

Enhancing decision support, easing documentation, avoiding errors

It’s time the EMR became the physician’s colleague rather than merely a burden or even an enemy! There’s an additional “clinician” in many medical office visits now – the laptop or tablet housing the electronic medical record (EMR). Described by Austin Frakt as “Your new medical team: algorithms and physicians” (New York Times, 12/7/2015) the potential benefits of computers to enhance medical care are finally being realized. Though the value of the “human factor” – physician touch, judgement, empathy and personal bond with the patient cannot be understated, increasing adoption and utilization of computer technology is impacting at least three areas of medical practice:

  • Analysis of clinical data from large populations to identify previously unrecognized patterns useful in diagnosis and treatment
  • Review of the immense and ever-growing medical literature to identify critical studies for best practice recommendations
  • The EMR – offering evidence based decision support, enhanced documentation, avoidance of medical errors, and opportunity for ongoing quality improvement.
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“Who you see is what you get" - Variability in medical diagnosis and treatment

Posted by Dan Mazanec, MD on Feb 1, 2016 9:12:27 AM

Recently, the California Healthcare Foundation (2014) defined variation in care as “the spectrum of approaches used by a defined group of practitioners to address a specific medical condition.”   Variation in care may include differences among providers in utilization of diagnostic tests and procedures, medications, frequency of visits, length of hospital stay, surgery, utilization of complementary/integrative medicine and specialty referrals.  

Recognition of remarkable variability in healthcare practice is not new. More than 30 years ago Wennberg at Dartmouth in a classic study demonstrated marked geographical variation in use of health care services for no apparent reason. From spine surgery to tonsillectomy, more than 10-fold variations in surgery rates were found in different regions of the U.S., even within the same state.

Variation extends to the outpatient arena as well. In a paper entitled, “Who you see is what you get”, published more than a decade ago, the authors surveyed physicians of different specialties – neurosurgery, family medicine, rheumatology, and neurology – about appropriate tests for clinical scenarios related to back symptoms. Recommendations for diagnostic testing were markedly divergent and determined primarily by the physician’s specialty. Neurosurgeons recommended more MR testing, neurologists performed more electromyography, and rheumatologists suggested more blood tests.

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Why I Joined Dorsata - Dan Mazanec, MD

Posted by Dan Mazanec, MD on Jan 28, 2016 2:17:46 PM

After 33 years as a practicing physician at Cleveland Clinic, retiring just 2 months ago, I’ve concluded that there are two critical areas which must be addressed in healthcare if we’re ever going to optimize the value of every patient encounter:

  • Improving the physician-patient EMR experience
  • Real “meaningful use” of the EMR

I chose to accept the position of Chief Medical Officer at Dorsata because I believe it’s the best place for me to help the healthcare industry achieve these goals.

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Introducing Dr. Dan Mazanec, MD

Posted by David Fairbrothers on Jan 26, 2016 9:07:35 AM

We're growing!

As we've been quietly building our platform, our team has relied solely on the input and feedback of the 1500+ clinicians that use our products day in and day out.  This was an incredibly valuable and insightful experience as we were able to make objective decisions about our product roadmap that were based on real user feedback and not our own experiences.  

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Dorsata raises $1.1m seed round for pathway-based workflow and documentation tools.

Posted by David Fairbrothers on Jan 21, 2016 9:31:49 AM

Today is an exciting day for the Dorsata team and for the 1500+ clinicians that use our software every day.  We are pleased to announce that we recently closed a $1.1m seed round, led by the incredible team at QED Investors with participation from other institutional, strategic, and individual investors such as 5 Cap Ventures1776, the Partnership Fund for NYC, and the co-founders of Sheridan Healthcare, a $2.5bn physician services company. These investors have all grasped the great potential that we have to improve quality, lower costs and drive clinician engagement through the expansion of our platform and the increased use of care pathways.   

Peter Hotz of 5 Cap Ventures and the former head of Walgreens' retail clinics business has joined our board.  I couldn't be happier with the team of investors, mentors, software developers, and clinicians that we have assembled.

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Welcome to Dorsata!

Posted by David Fairbrothers on Jan 21, 2016 9:28:46 AM

If you’re a first year medical resident today, you’ve grown up with iPhones, iPads, Google, Facebook, and Waze. But as soon as you walk onto a hospital floor for your first rounds, you’re still handed a clipboard, pen, pager, and pointed to an electronic medical records system that has more in common with a bank teller console from the 1980s than with Waze. With an assist from incentives and mandates from the Federal Government, hospitals have come a long way in terms of technology. Medical records are largely electronic and systems control most processes in a hospital. And yet this hasn’t yet made it easier for hard working doctors and nurses to deliver quality care.

This is why we built Dorsata. Our mission is to make it as easy for a care provider to navigate the optimal delivery of care as it is for you to get anywhere with Waze.

We are glad that you’ve found your way to our blog. After months of development, engineering, iteration, and tweaking, we are ready to introduce ourselves. To this end, I wanted to give you a good idea of what we stand for as a company that is working tirelessly to help doctors and nurses get back to what they got into healthcare in the first place to do - provide the highest quality, patient-centered care.

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