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Scribes in Primary Care @ Beth Israel Deaconess Medical Center

Keywords: Scribes, EMR, Clinic Throughput

Brief Overview

Patient satisfaction, provider satisfaction, and patient throughput with use of scribes in primary care

Innovators

James Heckman, MD

Editor

Rebecca Hammond

Location

Healthcare Associates at Beth Israel Deaconess Medical Center

Organizational Context

  • BIDMC is an academic medical healthcare system with a broad payer mix including 10% Medicare, 10% Medicaid, 35% commercial at risk, 45% commercial non-risk. It serves a diverse population from Boston and the surrounding metro area as well as Cape Cod, Western Massachusetts, and New Hampshire. 
  • Healthcare Associates (HCA) is an adult, adolescent, and geriatric primary care center based at BIDMC that serves as the primary teaching site for internal medicine residency. The clinic is a Level 3 patient centered medical home that sees 40,000 patients annually in 100,000 visits, staffed by 65 faculty, 145 rotating medical house staff, 6 nurse practitioners.
  • HCA is BIDMC's hospital affiliated primary care clinic. It is part of a network of BIDMC-associated primary care clinics that span across the greater Boston area. Clinic operations are overseen by Marc Cohen, MD, the medical director of HCA, as well as Eileen Reynolds, the chief of the Division of General Internal Medicine and Primary Care at BIDMC.
  • HealthCare associates hired a new Director of Ambulatory Operations, Blair Bisher, MHA in the Spring of 2017. Blair was very supportive of this initiative and helped adjust staffing levels to support increased throughput in the clinic.

Population Served

  • HCA serves diverse adult, adolescent, and geriatric populations with a broad payer mix from Boston and the surrounding metro area and Cape Cod, Western Massachusetts, and New Hampshire.

Project Leadership

  • James Heckman MD

Funding

  • Dr. Heckman wrote a business proposal containing the projected overhead and cost of scribes (totaling $30,000) and estimated returns based on potential increases in patient throughput, which he presented to the Department of Medicine.
  • The Linde Family Fellowship in Primary Care Leadership provide 10% salary support for Dr. Heckman while the Division of General Internal Medicine provided 5% FTE.

Tech

  • Beth Israel Deaconess Medical Center and HCA use a proprietary, home-grown EMR

Training

  • A medical scribe company called ScribeAmerica sourced medical scribes and oversaw their training

Daily Workflow

  • Before the patient visit: Scribe pulls up relevant notes, test results etc. as requested by the paired physician.
  • During the patient visit: Scribe documents the entire encounter while the physician interacts with the patient. 
  • After the patient visit: The scribe finalizes notes and orders, and enters test results; the physician reviews, edits, and signs notes and orders.

Budget

  • $30,000 USD (including $6000 overhead)
    • The Department of Medicine covered the cost of the scribes. Dr. Heckman received a combined 15% FTE salary support from the Linde Family Foundation (10% FTE) and the Division of General Internal Medicine (5% FTE).

Current Status

  • The pilot ran from May 2017 through August 2017.
    • The original 4 clinicians in the intervention still have scribes today. A proposal to expand the program to the other physicians in the practice is currently in progress.

Outcomes

  • Provider experience
    • Measured using the AMA Steps Forward provider satisfaction survey: 5 questions after each clinic session
    • No significant difference between total provider experience scores between intervention and control during any of the pilot phase periods. (p-0.26)
    • There was a statistically significant difference for “feeling that work for the encounter would be completed during the visit” (p=0.04)
  • Patient experience
    • Measured using the AMA Steps Forward patient satisfaction survey: 4 questions after each visit
    • No significant difference between provider experience scores between intervention and control during any of the pilot phase periods.
  • Throughput
    • Expressed in work Relative Value Units (wRVUs) per hour, calculated for each patient visit based on number and complexity of patients seen, as well as patients seen per hour.
    • Scribe providers saw approx. 0.5 more patients per hour and generated 0.4 additional wRVU per hour compared with those not working with scribes. (P<0.001 in both instances)
  • Financial
    • Medical scribes effectively increase provider capacity without adversely affecting clinician or patient experience.
    • Increased patient throughput generated $46,000 in extra revenue; this translated to net revenue of $16,000 after subtracting the $30,000 cost of the pilot (approximately 50% ROI). 

Future Outcomes

  • A business plan to continue and extend the use of scribes to other physicians in the clinic is in the works. One of requirements for this expansion plan is the involvement of house staff (residents).
  • Future outcomes will include how to incorporate scribe use into resident workflow, and what the resultant effects are on productivity as well as education of these residents.

Benefits

  • Higher patient throughput without negatively affecting provider or patient experience.
  • Physicians were able to focus more on the patients instead of using their time to perform the algorithmic note-writing and order-entry work.
  • The physicians involved in the pilot were able to utilize the medical scribes to offload some of the non-physician work - for example, normally medical assistants write patients’ vitals on paper prior to inputting them into the computer system. Scribes were able to save the medical assistants some time by performing these last steps

Challenges

  • Higher patient throughput in the final weeks for the physicians using scribes meant higher staffing needs - medical assistants, lab staff, etc. Great partnerships with the clinic managers ensured they were always adequately staffed on the days the scribes were used.

Questions Used to Assess Provider/Patient Satisfaction

​Thinking about today's clinic session, how much do you agree or disagree with the following statements (1 Strongly disagree, 2 disagree, 3 neutral, 4 agree, 5 strongly agree):

  1. I was able to provide the patient care I needed without feeling rushed.
  2. I left the exam room feeling satisfied with the encounter.
  3. I left the exam room feeling that majority of the work for the encounter would be completed by the end of the visit.
  4. I was able to give my patients my full attention.
  5. Overall I was able to stay on schedule for this session.

 

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