Overview

  • A 6-month pilot of medical scribes as documentation partners in primary care

Organization Name

South Huntington Advanced Primary Care Associates

Organization Type
  • Academic Hospital
  • Academic Medical Center
  • Community outpatient clinic
  • Integrated healthcare system/network
Local/Organizational Context

  • BWH Advanced Primary Care Associates – South Huntington (BWH South Huntington) is an outpatient primary care clinic affiliated with Brigham and Women’s Hospital.
  • Along with Massachusetts General Hospital, BWH is a founding member of Partners Healthcare, which includes community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health-related entities.
  • BWH South Huntington is part of the BWH Primary Care Center of Excellence which includes 16 outpatient primary care clinics.
  • In June 2016 when the intervention was conceived, BWH had just implemented a new EMR system (Epic) that its physicians perceived as adding to their out-of-ofce workload, which exacerbated feelings of burnout as the physicians continued to buy into BWH efforts to spearhead population health management efforts as it engaged in Accountable Care Organization contracts.
  • BWH physicians reported internally that they spent 2-4 hours on work outside the ofce for every 4 hour clinic session.
  • BWH South Huntington hired medical scribes to serve as documentation partners to primary care physicians during ofce visits so that the physicians could focus more on the patient when in the exam room and to decrease the physician’s out-of-visit time spent on documentation.
  • This article refers to the original 6 month pilot at BWH South Huntington from June to December 2016 which has now been expanded.

Patient Population Served and Payor Information

  • Due to its association with a tertiary/quaternary referral center, BWH South Huntington treats patients of every payor and medical complexity imaginable.
  • Many patients skew towards having higher medical complexity and many patients travel from out-of-state to get primary care at BWH South Huntington in order to coordinate with their specialist physicians at BWH.

Leadership

  • The pilot was spearheaded by the author as a representative of BWH Center for Primary Care Excellence Administration and the BWH South Huntington Medical Director
  • Approval for the pilot was obtained from the Division of Primary Care within the BWH Department of Medicine
  • Approval was also needed for update to existing BWH contract with ScribeAmerica (medical scribe vendor company) to reflect the new work

Funding

  • Leadership successfully applied for a back-stop grant from the BWH Department of Medicine to support hiring of 2 FTE medical scribes for a period of 6 months

Research + Planning

  • Vendor
    • Leadership surveyed a number of medical scribe vendor companies that BWH had used in other departments and who were interested in the pilot and selected ScribeAmerica
    • Leadership signed a contract with ScribeAmerica in compliance with the BWH vendor policy
  • Recruitment
    • Leadership solicited volunteers among BWH South Huntington primary care physicians for the pilot 
    • Volunteering physicians were also asked to add two additional visits per half-day clinic session to their schedules in order to generate patient care revenue to support the goal of making the pilot budget-neutral
  • Scheduling
    • A group of 4-5 primary care physicians’ schedules were paired with 1 FTE medical scribe
    • As most primary care physicians in the practice are scheduled for 2-4 half-day clinic sessions per week, the volunteering physicians’ schedules had to be grouped in concordant ways in order to fully utilize the 2 FTEs of medical scribes’ worth of hours
    • Volunteering physicians also had to be grouped together to work with language-concordant scribes – for example, a physician who delivered care in Spanish had to be matched with a Spanish-speaking medical scribe 2 FTE hours’ worth of primary care physician clinic sessions in which the medical scribes could be used was identified & scheduled
  • Information Technology
    • Leadership worked with the BWH Information Technology Department to oversee proper credentialing, access, and EMR (Epic) access for the scribes
    • This process took four months from start to finish

Training

  • Medical Scribes
    • ScribeAmerica oversaw training of the medical scribes in three phases:
    • Phase 1: General training for medical scribes, including how to use BWH’s Epic system
    • Phase 2: New medical scribes shadowed a more experienced medical scribe in the outpatient primary care setting
    • Phase 3: New medical scribe would conduct their own work under close monitoring of a scribe coordinator
  • Physicians
    • Physicians conducted 1-2 half-day clinic sessions with a medical scribe supervisor assigned to BWH South Huntington so that the supervisor could learn each physician’s unique workow preferences and patterns 
    • Physicians worked individually with new medical scribes during clinic sessions on learning to communicate findings effectively and efficiently i.e. “The physical exam was normal if I didn’t say anything.”

Tech Involved
  • Electronic medical record
  • Epic
Team Members Involved
  • Administrative Assistant
  • Medical Scribe
  • Physicians
  • Scribe Coordinator
  • Scribe Supervisor
Workflow Steps

  • The BWH South Huntington Practice Coordinator sends a weekly schedule to ScribeAmerica with details about the volunteering primary care physicians’ scheduled sessions for the week
  • ScribeAmerica coordinates staffing of medical scribes according to this schedule
  • The schedule attempts to optimize matching of scribes and physicians so that the same medical scribe works with the same primary care physicians week after week
  • Fifteen to five minutes before each clinic session, the medical scribe meets the primary care physician in the clinic workroom
  • The medical scribe begins preparing the visit note in Epic
  • The primary care physician and medical scribe enter the exam room and begin the appointment The medical scribes bring a laptop with them into the exam room and utilizes a rolling laptop stand The physician uses their usual desktop computer station in the exam room

Budget
  • $25K to $50K
Budget Details

  • The pilot was funded through a successful back-stop grant of $50,000 but became budget-neutral within 6 months as each volunteering physician added two additional patient appointment slots to their weekly schedule
  • ScribeAmerica charges the clinic on a hourly basis of $18-26/hour
  • 2 rolling laptop stands were purchased

Where We Are

  • The intervention is currently ongoing and has been expanded as of April 2017.
  • The intervention has now spread to six BWH outpatient primary care clinics and may soon spread to a seventh as of April 2017.

Outcomes

  • Productivity
    • Physicians self-reported that the time they spent on documentation after a clinic session decreased between 20 minutes and 1.5 hours
    • Productivity metrics including work RVUs/FTEs, patient visits/FTE, and panel size were tracked
      • Work RVUs/FTE increased during this period (2.5 wRVU per session)
        • Panel size did not change
  • Physician Satisfaction
    • The team surveyed the volunteering physicians with a questionnaire using a Likert scale to survey physician satisfaction, which increased over this period.

Benefits

  • Increased patient satisfaction with the patient experience was the greatest benefit of this intervention. Patients enjoyed having the attention of their doctor during the visit and they didn’t mind the additional person in the room
  • Patients felt “their doctors were no longer talking to the computer and talking to them again.”
  • The intervention increased patient access as providers made more patient appointment slots available, although this metric was not specifically studied.

Unique Challenges

  • It takes each medical scribe six to twelve weeks of working with the same provider to reach full efficiency and efficacy

Personnel Challenges

  • There is a high turnover rate among medical scribe personnel who often turn over after 12-18 months of employment

Metrics

The following is CareZooming’s original analysis on how implementing an intervention such as the one described here will assist your practice / organization in improving performance on HEDIS, MIPS, and PCMH quality measures. 

HEDIS Quality Measures

The evidence base shows statistically significant improvement in HEDIS Family Medicine measures commonly measured in outpatient adult primary care. In their original study, Platt et. al. found, “Documentation of 4 quality measures improved with the use of scribes, demonstrating statistical significance: fall risk assessment (odds ratio [OR] = 5.5; P = .02), follow-up tobacco screen (OR = 6.4; P = .01), follow-up body mass index plan (OR = 6.2; P < .01), and follow-up blood pressure plan (OR = 39.6; P < .01).”

Here are those 4 HEDIS quality measures:

MIPS Improvement Activities

However, implementing the use of medical scribes could reasonably help one’s practice qualify for the MIPS Improvement Activities as listed below:

MIPS Quality Measures – Electronic clinical quality measures

In addition, as the primary benefit of medical scribes is to improve clinician documentation in a timely fashion, most commonly in an electronic health record, the use of medical scribes could be expected to assist one’s practice in improving performance on any measure that relies on what MIPS defines as an “eCQM”, which is “a clinical quality measure that is expressed and formatted to use data from electronic health records (EHRs) and/or health information technology in systems to measure healthcare quality, specifically data captured in structured form during the process of patient care.” (Centers for Medicaid and Medicare Services)

You can find the individual eCQM measures listed here:

  • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
  • Anti-Depressant Medication Management
  • Appropriate Testing for Children with Pharyngitis
  • Appropriate Treatment for Children with Upper Respiratory Infection (URI)
  • Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
  • Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
  • Breast Cancer Screening
  • Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
  • Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
  • Cervical Cancer Screening
  • Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
  • Childhood Immunization Status
  • Children Who Have Dental Decay or Cavities
  • Chlamydia Screening for Women
  • Closing the Referral Loop: Receipt of Specialist Report
  • Colorectal Cancer Screening
  • Controlling High Blood Pressure
  • Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)
  • Dementia: Cognitive Assessment
  • Depression Remission at Twelve Months
  • Depression Utilization of the PHQ-9 Tool
  • Diabetes: Eye Exam
  • Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
  • Diabetes: Medical Attention for Nephropathy
  • Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
  • Documentation of Current Medications in the Medical Record
  • Falls: Screening for Future Fall Risk
  • Follow-Up Care for Children Prescribed ADHD Medication (ADD)
  • Functional Status Assessment for Total Hip Replacement
  • Functional Status Assessment for Total Knee Replacement
  • Functional Status Assessments for Congestive Heart Failure
  • Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • HIV Screening
  • HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
  • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
  • Maternal Depression Screening
  • Oncology: Medical and Radiation – Pain Intensity Quantified
  • Pneumococcal Vaccination Status for Older Adults
  • Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
  • Preventive Care and Screening: Influenza Immunization
  • Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  • Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  • Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
  • Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
  • Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
  • Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  • Use of High-Risk Medications in the Elderly
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

Toolkit

WHAT YOU WILL NEED:

  • TECHNOLOGY
    • Electronic Medical Record Software
    • Laptops
    • Laptop Stands
  • PEOPLE
    • DIRECTLY INVOLVED IN IMPLEMENTATION
      • Administrative Assistant / Scheduling Coordinator
      • Medical Scribe 
      • Physicians / Clinicians
    • CRUCIAL FOR BUY-IN
      • Physicians / Clinicians
      • Medical / Nursing Director
      • (If applicable) Scribe Coordinator / Scribe Supervisor 

WHAT TO DO:

  • Determine whether your practice would like to hire, train, and staff their own medical scribes or work with medical scribes staffed by a local, regional, or national medical scribe vendor such as ScribeAmerica
  • (If applicable) Determine how your practice will off-set increased costs associated with hiring medical scribes, either by adding additional visits per physician per clinic session or by asking physicians to pay out of pocket for the benefit of using a medical scribe
  • Work with your local IT department early on in planning your intervention to ensure proper credentialing, access, and functionality for medical scribes
  • Train medical scribes 
    • Provide medical scribes with EMR-specific training
    • If this is an option, provide direct shadowing opportunities for new medical scribes to shadow more experienced medical scribes or a scribe coordinator / scribe supervisor in the target care setting
  • Train physicians/clinicians on utilizing certain standardized language to indicate their preferences for scribe output, i.e. “The physical exam was normal if I didn’t say anything.”
  • Each week, have your practice coordinator or administrative manage send the participating physicians’ session schedules to the entity (whether you are working with a scribe vendor company or an internal administrator) 
  • Assign specific medical scribes to specific visits or sessions and prioritize longitudinal relationships between medical scribes and the physicians with which they work
    • Remember: It takes each medical scribe six to twelve weeks of working with the same provider to reach full efficiency and efficacy
  • Fifteen minutes before the clinic session, have the medical scribe meet with the physician with whom they will work in their office or shared office space to discuss certain aspects of their upcoming session and to allow time for the medical scribe to prepare the visit notes in the electronic medical record or medical record as applicable
  • At the start of each patient visit, have the medical scribe and physician enter the exam room together
    • Have the medical scribe use an office-provided laptop, perhaps on a rolling stand, to ensure that the computer in the room is available for the physician to use
  • After each patient visit, allot 5 minutes for physician and medical scribe to review the generated EMR note together

Related CareZooming Innovators

James Heckman, MD
Assistant Medical Director & Director of Team Based Initiatives, Healthcare Associates, Beth Israel Deaconess Medical Center Boston
Expertise: Scribes in Primary Care @ Beth Israel Deaconess Medical Center

Stuart Pollack MD
Medical Director, South Huntington Primary Care Associates
Region 1 Medical Director, Brigham Primary Care Center of Excellence
Expertise: Diabetes Management via Team-Based Approach with Pharmacist & Dietitian Support @ Brigham & Women’s Hospital – South Huntington, Behavioral Health Integration in Primary Care @ Brigham & Women’s Hospital – South Huntington, Scribes in Primary Care @ Brigham & Women’s Hospital – South Huntington

Erika Pabo MD MBA
Chief Health Officer, Humana Edge
Expertise: Scribes in Primary Care @ Brigham & Women’s Hospital – South Huntington

Cost Analysis

Below is CareZooming’s cost estimates for replicating this intervention for 1-year, staffed at a rate to support 1 clinician FTE. These cost estimates are conservative and based on retail prices publicly available. Click here to be brought to a customizable Excel spreadsheet calculator where you can adjust these estimates to fit your practice’s needs.

Innovators
  • Erika Pabo MD MBA
Location

Boston, MA

Talk to the Innovators