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-office 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 office for every 4 hour clinic session.
• BWH South Huntington hired medical scribes to serve as documentation partners to primary care physicians during office 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 workflow 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

• 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

• 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