Feb 23rd 2017

Why I’m Writing: Removing the “Gumption Traps” for Clinicians

​My mission here is personal. Making it easier for clinicians to find the patient data they need to make sound medical decisions became a personal mission for me one day in 2004, and I've been on that path ever since. Back then I was (and still remain) a practicing radiologist. I had completed the curriculum of medical school, residency, fellowship and grueling exams to interpret medical images and perform invasive procedures. I'm also a geek: I love software and have written lots of it. I'm enthusiastic about both clinical practice and computing. But one Spring day in '04, I began to interpret an abdominal-pelvic CT scan and ran into what the author Robert Pirsig once called "a gumption trap"—a set of obstacles that detract from one's enthusiasm and ability to perform quality work.

I was tasked with reading the scan on a patient who had a long and complex history of cancer, marked by multiple treatments, successes and set-backs. However, the clinical information presented to me as the 'history'—the reason for performing the scan—was woefully limited: a typo-filled one-liner entered by a well-meaning but non-clinical administrative assistant. Further, the source of context and clinical narrative on the patient—the electronic health record—was organized by file date and by kind, but not by the clinical concepts I needed to query. I could easily look for all labs and notes submitted on a given day. But I couldn't ask the software, "has this patient ever had evidence of distal metastases?" To answer that question—which is what my clinical job required—I would have to manually trove through lots of notes and reports. This was an obstacle. And I was under the gun.

'Under the gun' here means the strain that most clinicians experience firsthand, every day they practice. Healthcare is demanding and expensive. The waiting room is almost always full and the tests and procedures we perform lead to bills rapidly totaling thousands of dollars. How well I performed as a physician had a direct impact on that expenditure and I personally felt an obligation to justify my own contribution to that expense. Clinicians of all stripes are expected to deliver meaningful contributions promptly, reliably, and above all, efficiently. In my case that day: read, interpret, dictate…then onto the next case.

In response to frustration, I dreamed for a moment. I thought, "there ought to be a widget that organizes the information the way a clinician needs to think about a case…". Silence. Being a geek, I imagined what such a software system might do and how it might be composed. The story of what happened after that day—growing a "google for the medical record", helping to found QPID Health, a company that brought this software to market, and then in the last year joining forces to address medical decision-making at scale with eviCore—will inform what I share with you in this forum.

But one thing has become clear: the problems associated with that day in 2004 remain pertinent to improving health care now. How healthcare data—records, guidelines, and assessment of appropriateness and risk—flow through the conversations taking place between patients and clinicians remains critically important for the delivery of high quality, appropriate, and efficient care. The software tools and services currently available must continue to adapt to the demands and workflow of current care delivery. We have made progress—at least more of the information is now electronic—but clinical medicine is still rife with gumption traps and there is much opportunity for us to innovate.

Recently, the AMA released a set of 21 points to improve one common aspect of clinical decision-making—prior authorization. From the standpoint of clinicians and patient advocates, there is much to consider in this document and much to embrace. Decrease hassle. Keep the external reviews timely and relevant. In a phrase, when a burdensome process isn't absolutely necessary, get out of the way. At the same time, much more in the way of useful tools and information could be offered to clinicians in the moment to contribute constructively to their conversation and activity. Actionable guideline information. Transparent economic and risk information for patients.

The road map of opportunity is big and wide and this story will be an exciting one. Much will again revolve around information: data gathered and insights delivered promptly and in a way that supports the experience of providers and patients. The goal remains the same: improving the efficiency and quality of the care delivered.

Author: Dr. Mike Zalis

Dr. Mike Zalis is a board-certified Radiologist with extensive experience and expertise in abdominal imaging, interventional radiology, computer science and clinical research. His deep knowledge of what clinicians need to practice most effectively and his ability to translate those needs into software solutions inform QPID’s development. He initiated and directed the QPID Informatics Group at MGH and is also an associate professor at Harvard Medical School. In addition to his work with QPID, Dr. Zalis continues to serve part-time with MGH Interventional Radiology. He holds a BA in Biophysics from the University of Pennsylvania and an MD from University of Virginia, and was a visiting scholar at Stanford University.​