The End is Near for Doctor as Data-Entry Clerk
Also: Minnesota takes action on psych boarding, Mass General Brigham residents unionize, Physicianeering, PE is expensive, & McKinsey on nursing.
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Imagine if every time a baseball pitcher threw a pitch, they had to return to the dugout to describe the pitch to a computer. Who would want to be a pitcher? Who would want to attend a baseball game?
The point: physician documentation is a massive waste. A classic 2013 paper - titled “4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED” - concluded that “Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care.” Emergency physicians have become data-entry clerks.
Not surprisingly, physicians despise data entry. Bureaucratic tasks and EMR inefficiency are top reasons for physician burnout. Physicians want to be at the bedside like pitchers want to be on the mound.
The updated 2023 CMS documentation guidelines were supposed to free emergency clinicians from charting burdens. The key change per ACEPNow: “Since 1992, a visit level was based on a combination of history, physical exam, and medical decision-making elements. Beginning in 2023, the emergency department E/M services will be based only on medical decision-making.”
The new regs, though well-intentioned, do not appear to be significantly decreasing documentation time. A recent JAMA paper studied the effects of the 2021 changes to primary care charting, which parallel the 2023 EM guidelines. The new guidelines led to an average 19-second per chart decrease. 19 seconds.
Enter AI. ChatGPT, the large language model chatbot from OpenAI, has transformed how people interact with computers. Can AI relieve physician documentation burdens more effectively than government regulatory efforts did?
First, the limitations. AI is not ready to diagnose your patient. ChatGPT isn’t great at telling fact from fiction, leading to hallucinations and confabulations. The LLM is also not designed to be a medical diagnostician, so it doesn’t ask the right questions. In a Fast Company article titled “I’m an ER doctor: Here’s what I found when I asked ChatGPT to diagnose my patients”, Dr. Josh Tamayo-Sarver wrote: “For roughly half of my patients, ChatGPT suggested six possible diagnoses; the “right” diagnosis—or at least the diagnosis that I believed to be right after complete evaluation and testing—was among the six that ChatGPT suggested. Not bad. Then again, a 50% success rate in the context of an emergency room is also not good.”
What if instead of asking AI to be a diagnostician, we asked it simply to be a scribe? The steps would be:
Listen to physician-patient encounters;
Record the history and physical exam;
Organize the information in a way that fits into billing and medical communication structures;
Enter appropriate text into the electronic medical record.
Such an AI-based system would be replacing the $30/hr 19-year-old pre-med student scribe with an app. Creating a scribe equivalent is much simpler than engineering a doctor-level AI diagnostician. The companies racing to automate your history & physical exam documentation:
Microsoft-Nuance
Nuance, the maker of Dragon Dictation, was purchased by Microsoft in 2021. The company has released Dragon Ambient eXperience (DAX). DAX is being beta-tested at several health systems - including at Cooper University Healthcare in NJ - with plans to expand later in 2023.
Per Nuance, “DAX can do much more than a virtual or personal scribe. Among its many capabilities, the solution can:
Capture multi‑party conversations ambiently using a mobile app;
Distinguish between “small talk” and clinically relevant dialogue;
Create comprehensive and compliant clinical documentation;
Integrate with electronic health records to streamline workflows;
Scale to a healthcare organization’s needs.”
Nuance DAX also has the advantage of being led by an emergency physician, Dr. Jared Pelo.
Augmedix
Augmedix has announced that it is piloting its ambient documentation system at two HCA emergency departments - along with a $12m investment from the largest hospital chain in the US. “Augmedix will collaborate with HCA Healthcare to advance the development of AI-powered ambient documentation products for acute care clinicians, helping to streamline hospital workflows. These cutting-edge products instantly convert natural clinician-patient conversations into medical notes that physicians and nurses can review and finalize before they are seamlessly transferred in real-time to the Electronic Health Record (EHR). The transformation of this vital but often time-consuming task can improve the ease of documentation and provide nurses and physicians more time to spend with patients.”
Check out Augmedix’s investor slide deck here.
Ambience
Ambience’s AutoScribe has an impressive set of backers, including OpenAI (creator of ChatGPT, Kleiner Perkins, Optum Ventures, and Andreesen-Horowitz.
Abridge
Founded by Dr. Shiv Rao, a UPMC cardiologist, Abridge is interested not only in ambient transcription but also in improving clinician-patient communication. Abridge recently announced a partnership with the University of Kansas.
EM Practice
The Minnesota College of Emergency Physicians is taking action on the scourge of boarding psychiatric patients in emergency departments.
From the Wall Street Journal: “Burned Out, Doctors Turn to Temp Work”. Per the article, the number of locum tenens doctors in the US has increased by 90% since 2015.
AAEM asked a federal court to allow their corporate practice of medicine lawsuit against Envision to proceed despite Envision’s bankruptcy.
House of Medicine
CMS launched a new value-based primary care pilot program in eight states.
Mass General Brigham residents have unionized, joining the Committee of Interns and Residents (CIR-SEIU).
A study in the journal Pediatrics showed that NICUs staffed by Envision and Pediatrix (large physician management companies) were “associated with large increases in prices and total spending for NICU services, but not with changes in length of stay or adverse clinical outcomes.”
Texas A&M and Houston Methodist graduated its first class of “physicianeers”. The program combines medical school training with an engineering degree.
Hospitals & Health Systems
Per a Health Affairs analysis, hospital profits and cash reserves significantly increased between 2012 and 2019, while their delivery of charity care did not. The article concludes: “With operating profits for nonprofit hospitals growing, the share of community health benefits they provide should also be growing to justify their favorable tax treatment.”
Reflections from the former Kaiser CEO on the Kaiser-Geisinger merger’s impact.
Hospital finances are improving, per the Kaufman Hall National Hospital Flash Report.
Nursing & Allied Health
McKinsey’s in-depth analysis of nursing workforce challenges.
The Dispo
Dr. Glaucomflecken’s new video: “The residents have unionized”.
EMR is a major factor in why I retired. I spent 4 hours at home per shift reviewing charts for accuracy, as best as I could remember it. We had scribes which were not always accurate.
19 seconds?
Reminds of the time our hospital spent nearly a year trying to streamline the ORs after identifying turn-around times between cases as the biggest problem. At the conclusion they had a big luncheon and announced that they had shaved 11 minutes off the average turn-around.
Unfortunately, they never addressed the surgeons who weren't available when the patient arrived in the OR or the ones who consistently took at least three hours to do a lap chole.