Overview

Creating a medical scribe program at an academic public hospital with dedicated scribes for each specialty area.

Organization Name

Hennepin County Medical Center

Organization Type
  • Academic Hospital
  • Academic Medical Center
  • Integrated healthcare system/network
  • Public Health System
  • Safety net hospital
Local/Organizational Context

  • HCMC is a Level 1 trauma center and safety-net academic public hospital serving Minneapolis and greater Hennepin County
  • Since 2014, the scribe program has been led by two co-directors, Marc Martel and Brian Imdieke.
  • Positions that were created as the program expanded include the medical scribe supervisor position and the scribe coordinator position.

Patient Population Served and Payor Information

  • Hennepin County Medical Center serves the citizens of Hennepin County, in particular, providing care for low-income, uninsured and vulnerable populations.
  • Medicaid and Medicare contribute to a combined 75% of the hospital’s revenue (45% and 30% respectively).

Leadership

  • The program is part of the Office of Provider Services and is overseen by the chief of provider services and chief medical officer.
  • The scribe program co-directors consist of an NP and MD. The NP co-director oversees the training/personnel/scheduling of scribing staff, while the MD co-director is in charge of IT, documentation, provider training, innovation, and risk adjustment/population health.
  • Besides the medical scribes, other members of the scribe program team include the scribe supervisor, the scribe coordinator, and the scribe trainer.
  • Scribe trainers are more experienced scribes who train new medical scribes in a specific clinical area.
  • The scribe coordinators are individuals who are present in clinics to help with day-to-day management of scribes and to help with EHR and workflow issues.
  • The scribe supervisor trains and prepares the scribe coordinators, scribe trainers, and medical scribes. The supervisor also works with the scribe coordinators to review scribe performance.

Funding

  • Scribes’ salaries are currently paid for by the hospital and individual departments.

Research + Planning

  • In 2007, the emergency medicine and psychiatry department separately began to employ scribes.
  • In 2009, the psychiatry department’s scribe program expanded to include some pediatric providers, with a total of 5 scribes supporting both departments’ providers. By 2010, the emergency department employed twelve scribes.
  • In 2014, scribes were first piloted in a primary care clinic.
  • In 2015, the program expanded to include more primary care clinics, ophthalmology, and hematology/oncology.
  • By 2016, a formal institution-wide medical scribe program was established, and scribes were introduced to the urology and orthopedics departments. As of 2017, about 50 scribes are employed by HCMC.

Tools or Products Developed

  • The program worked with documentation and coding specialists from each department to develop standard documentation templates, with modifications for unique needs of each specialty.
  • Key individuals involved in developing these templates included HCMC’s chief health information officer and Epic analysts.

Training

  • The organization implemented scribe-tiered training. The scribe supervisor trains coordinators about HR/documentation issues, EHR protocols, and assessment of scribes. Scribe trainers receive training with the supervisor and coordinators prior to every hiring cycle on assessing new scribes’ progress. Scribes go through 6 eight-hour training sessions with scribe trainers and are assessed at 4 and 8 weeks after training concludes. Scribes are trained in specialty-specific terminology as well as documentation.
  • The organization also implemented mandatory provider training for providers receiving medical scribe support. The curriculum included strategies on working with scribes and discussing the risk adjustment model, problem-list management, and problem-oriented charting.
  • With each expansion of the scribe program, a detailed analysis of the relevant clinic was performed. The program worked with clinical leadership but also observed clinical dynamics to identify ‘functional leaders’ in the clinic to prepare a welcoming environment for new scribes. The program also assessed the needs of the clinic to make equipment and workspace adjustments.
  • To accommodate legal issues surrounding documentation, a profile for medical scribes was created in HCMC’s EHR system. Other restrictions were set in place for EHR entry by scribes – scribes are not permitted to enter or pend orders, and notes must be authenticated by the provider before an encounter is ‘closed.’

Tech Involved
  • Desktop computer
  • Epic
Team Members Involved
  • Administrator
  • Medical Scribe
  • NPs
  • PAs
  • Physicians
  • Scribe Coordinator
  • Scribe Supervisor
Workflow Steps

  • Clinic staff and the scribe program team perform a clinical assessment and prepare the clinic (8-12 weeks). This time allows staff to understand planned changes, make necessary workspace changes, adjust to new documentation styles, and hire and train scribes. Providers also attend a 60-minute training session.
  • Scribe supervisor and scribe coordinator observe clinicians using new documentation templates (2-3 weeks). Departmental physician champion and scribe program directors are involved in feedback and modifications to templates.
  • Supervisor and coordinator then train scribe trainers in the new clinic. Scribes can be fully integrated within an additional 6-10 weeks, with 2-3 additional scribes being added every 2 to 4 weeks in larger rollouts.

Budget
Budget Details

  • Currently 50% of scribes’ salaries is paid for by the institution, with the other 50% being covered by individual departments.
  • The budget also includes new and replacement hardware costs for computers and mobile workstations.

Where We Are

The intervention is currently ongoing.

  • HCMC currently employs about 50 scribes for approximately 1-3 trainers per clinical area. Each scribe works about 32-36 hours per week, with some buffer time for extended encounters, which allows for a 1.1 to 1.2 scribe-to-provider session ratio.

Outcomes

  • Process Outcomes
    • HCMC has not seen an overall net revenue gain, though patient throughput has improved with the medical scribe program.
    • Primary care clinics that had medical scribes had an increase in documentation on complex hierarchical conditional categories conditions.
  • Clinician or Patient Satisfaction
    • Based on a survey of outpatient providers, the program has significantly improved certain provider wellness measures – this includes increased provider satisfaction with their role in clinic, increased providers’ ability to provide high-quality care, increased providers’ ability to listen to patients, and decreased time spent on the EMR at home.
    • No significant increase in patient satisfaction was observed. However, most patients accepted having scribes present during encounters.

Benefits

  • There is more consistent and more accurate documentation of clinic visit and patient history.
  • There is more accurate coding and billing for visits.
  • Having scribes has decreased documentation burden for providers, increased providers’ time with patients, decreased providers’ time with the EHR at home, and improved job satisfaction. Providers also anecdotally describe a ‘revitalization’ of their careers with decreased documentation burden.
  • The organization’s “homegrown” program allows for internal management and measurement of scribe program and training that meets organizational standards.
  • The organization is able to maintain cost-effective hiring, retention, and scheduling of scribes.
  • The use of scribes in the ED, especially via the use of scribes in a triage treatment plan, has led to increased revenue generation by decreasing the ED elopement rate and increasing patient volume. In other clinics, having a scribe can allow physicians to see additional patients – scribes are frequently revenue positive in subspecialty clinics and cost neutral in primary care.
  • Providers feel they are able to better take care of patients by giving them their full attention.

Unique Challenges

  • Providers were concerned about inexperienced scribes who were early on in their employment. Scribes also sometimes struggled with certain parts of the patient record, such as nuances of the history of presenting illness and assessment and plan sections.
  • The most significant challenge in implementing the program is cost, including covering administrative, equipment, and salary costs.
  • Some providers wanted to maintain personal documentation style and preferences, which can be more difficult when using a scribe.

Innovators
  • Marc Martel MD
Editors
  • Jacqueline You, BA
Location

Minneapolis, MN

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