Interview with Dr. Jared Ament: A New Way to Tell an Old Story

June 22, 2010 at 1:22 pm 2 comments

Dr. Jared D. Ament recently completed clinical research fellowships at Harvard Medical School’s Massachusetts Eye and Ear Infirmary (MEEI) and at the University of Massachusetts Medical Center (UMass) in surgical outcomes. He has worked with Dr. Dohlman (MEEI) and Dr. Black (Brigham and Women’s Hospital) for 3 years now and with Dr. Richard Moser (UMass) for the last year. His MD is from the Medical School for International Health, a collaborative initiative between Ben-Gurion and Columbia Universities. His MPH is from the Harvard School of Public Health. He is adjunct faculty at Harvard Medical School’s department of Population Health and Epidemiology and has specific interests in cost-effectiveness research, international surgery, surgical outcomes, and medical education. He is currently a surgical resident at UMass.

How did you become interested in medicine?

I was a kid who was fascinated by the workings of the body. I was also very involved in martial arts and interested in the inherent mechanics and physiology. And then, as a teenager interested in culture and public health, I traveled extensively to non-industrialized countries, volunteering in all sorts of public health efforts. I guess I just found a niche where working with people from many cultures, coupled with my fascination for human physiology, struck a cord. The left side of the equation seemed to equal “medicine” on the right.

And how did you decide on being a surgeon, specifically?

Many people just know; for a select minority, however, it’s a struggle between the operating rooms of surgery and the diagnostics and offices of internal medicine (and its specialty fields). I always loved surgery and truly knew that the operating room was where I belonged. Yet, I struggled, as the detective work and thorough understanding of bodily functions was tantalizing. My conclusion, however, was that a good surgeon should, first and foremost, be very strong, clinically. They are, too, diagnosticians, physicians, empathic healers, that have dedicated significant time and training to perfecting a tactile skill in addition to, and very much in parallel with, their medical skills. I am still in training but truly enjoy both the clinic and operating room. I need both. I enjoy the time with my patients; the interaction; the teaching and learning that takes place (bi-directional); collaborating with colleagues (surgical and medical); and hold the operating room, the unconscious patient and the delicate work to be performed with the utmost of respect.

How did you first hear about mTuitive?

Dr. Richard Moser, Chair of UMass Neurosurgery, had heard of mTuitive and asked me to look into it. So I looked into it and, conceptually, it made a lot of sense.

What made you think OpNote was a worthwhile venture? What about electronic postoperative reporting and structured data made sense to you?

Conceptually, the idea of OpNote – being a structured/discrete, data set driven, operative report, that replaces the current process of dictation/transcription – just made a lot of sense to me. Initially, Dr. Moser encouraged my involvement due to my recent Master of Public Health degree from Harvard (specifically in their clinical effectiveness program). I was teaching medical students, working heavily on surgical outcomes research and cost-effectiveness.

Dr. Moser planted the seed by saying, “you want to be able to do great surgical outcomes research and yet the most important information that we collect, as surgeons, is in the operating room. In its current format, that information is simply not recordable in an efficient, contemporaneous manner; and when it is recorded, it takes an enormous team and significant resources to manually extract the data from transcribed dictations.” In the era of cost-effectiveness and a contracting economy, it is simply not feasible for most institutions to have an experienced team (or company) scour through and extract data operative reports. I pursued electronic postoperative reporting from the angle that there’s a wealth of knowledge being collected on a daily basis in operating rooms and, unless there were specific research protocols in place to collect that data, it was often lost to medical records in very eloquent, and sometimes verbose, prose. The notion of a “one-stop-shop” report where we could:

1. collect data which would satisfy medical-legal reporting requirements; and
2. could serve as an operative note in the patient’s record; but also
3. could be in a format that was easily exportable, searchable and could be readily manipulated for any number of outcome parameters and measures

was, and remains, very appealing to me. And, that is why we have put the full force of the neurosurgery department and UMass Memorial Health behind this endeavor – it just makes sense.

The discussion about implementing some form of standardization of medical reporting has begun within a lot of medical communities. The question comes up about creating a universal standard for criteria of medical reports, what sections should be required and also creating a standard, “universal” language. What do you think about the standardization of medical reporting?

I think it will be met with resistance. Most physicians were brought up in an era where personalization and flexibility is very important to them – everyone has a different style. Nevertheless, we were all trained in a very standardized way. In my opinion, it is absolutely crucial that as we move forward in medicine we realize that evidence-based practices are imperative – and what that implies. Medicine has always been very much an art, but the inherent science is rapidly becoming uncovered. Standardization, to the extent that is safe, is a requirement to ensure and assure quality, patient safety, and Level 1 evidence-based reporting that could direct management.

Standardization is a painful process. It’s like taking an artist’s hand while s/he’s painting and restricting the brush strokes between two lines. But, if we knew for a fact that the lines, in this particular painting, will produce a superior picture, then we ought to heed the lines. Shouldn’t we? We’re not impressionists, and as surgeons, we likely shouldn’t have such creative freedoms. Medicine is still rooted in science and it is still practiced by human beings. Medical algorithms, for example, have been created and used for years because in this every expanding and challenging profession, we too can fail.

We do have decision-making freedom, however. And, I do not foresee this changing with the adoption of standardization. The art of surgery is to cut or not to cut, where to go/where not to go, to make last minute, mortal decisions. That aspect of surgery, the art, isn’t going anywhere. Neither the surgeon nor the patient would relinquish such freedoms to mathematical algorithms or robots – how could they? What happens if you – a variable not accounted for in the algorithm – have to go under the knife?

When it comes to reporting though, most would agree that some standardized lexicon, methodology and criteria are no longer some nice ideas floating somewhere in the stratosphere but are, instead, an absolute requirement in modern evidence-based surgery and medicine.

There’s been a big push recently in EHR development and a lot more visibility for electronic medical records. Some of that is due to federal funding and some of it is just the media extolling on a new “hot button” issue. What do you think about the rise of electronic medical records and the discussion going on about them now?

We’re in the beginning phases still (you know, the 20-year-long phase so common in medicine). It’s going to unequivocally become the norm. Look at a country like Canada, for example. EMR systems are simply required in many institutions and practices. I’ve seen, firsthand, family practice physicians mandated to switch to EMR systems for safety concerns originating from inspections that revealed illegible notation and patient records.

It is inevitable; we will all be on electronic medical record system. There are concerns regarding privacy, HIPAA, protected health information, etc., but I think most of these have been mitigated by advances in IT/IS, encryption, and awareness. Most of the literature coming out of Boston (Center for Connected Health) reports general patient acceptance and comfort with digital records. I think issues such as quality assurance, patient safety and continuity of care will outweigh the risks and apprehensions.

What do you think are the main recurring problems with the reporting system of dictation & transcription?

The current process of dictation and transcription is really personal. I know many surgeons love it. They want to articulate their case in a way that is understandable and complete for them. Five years after a surgery and a quick perusal over the note should allow for complete comprehension. In truth, that is a positive.

The problem is what happens with the dictated report. First, it’s transcribed, usually off site; usually the job is pretty good, sometimes there are mistakes; there’s a delay, they have to get back to you, you have to look over the final product and sign off on it. The note is then available to physicians in a format – depending on the system at a particular institution – that is viewable and printable. With respect to data extraction and outcomes reporting, there is nothing substantive to be accomplished. I don’t think dictation is a bad concept. It made a lot of sense because surgeons are great narrators: we’re trained to present and report cases in coherent, logical and eloquent ways.

However, based on new requirements (and desire) to measure and report outcomes, the workflow will be considerably more seamless – if not entirely seamless – when dealing with mTuitive’s OpNote compared to transcribed operative reports. The latter requires several more steps, more approval time, is processed and re-processed and exported into unusable formats. The propensity for error is always greater when more steps are involved. The ability to better serve our patients requires careful examination of how we’re currently doing. Operative reports in eloquent prose make this exceedingly difficult; operative reports with mTuitive, in my opinion, will facilitate this.


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