Two primarily leveraged models have resulted in increased provider and patient satisfaction.
A while ago, I read an article from the American Medical Association (AMA) by Sara Berg titled “With Two New Patients a Day, Medical Scribes are Profitable in One Year.” Compounding being totally overburdened caring for COVID patients, physicians are experiencing burnout related to spending excessive time managing the medical record instead of addressing patients’ medical care.
Following the references from the article, I read additional pieces and took Continuing Medical Education- (CME)-associated modules regarding scribing, team documentation, and eliminating inefficiencies derived from the electronic health record (EHR). Here’s what I gleaned:
- The number of additional patients per day to recoup the cost of the scribe varied according to specialty and whether the patients were new or established. It was found, across all specialties, that the addition of two new or three returning visits per day resulted in profitability.
- There are two basic models:
- The clerical documentation assistant (CDA) model, where there is one dedicated CDA per physician who accompanies the provider into each patient encounter. Their sole purpose is to assist with record-keeping. This characterizes the traditional scribe model, and the scribe is anchored to the provider.
- The advanced team-based care model, where there is a set of nurses or medical assistants who perform both clinical support functions and the clinical documentation. They perform pre-visit duties like taking preliminary histories, setting up orders for health maintenance tasks, and reviewing medications, then they return with the provider and scribe during the visit. They provide the patient with a post-visit med list, visit summary, and patient discharge counseling. This model anchors the assistant to the patient, freeing up the provider to travel to the next room, patient, and medical assistant.
- Whichever model is utilized, there is significant increase in provider and patient satisfaction.
In the AMA STEPSforward module from 2014 (https://edhub.ama-assn.org/steps-forward/module/2702598), they detail the process to effectively design and implement team documentation. To develop a program, you need to determine who will participate in whichever model is selected, start with a pilot of motivated personnel, and use it on a limited basis initially, designing and planning the workflow within your system, and conducting weekly touch-bases to assess, review, and tweak the system.
Another click of an embedded link led me to an article from February 2020 regarding a program implemented by Hawaii Pacific Health called “Getting Rid of Stupid Stuff.” The concept of this initiative is to identify and eliminate EHR inefficiencies. More details were forthcoming in the original New England Journal of Medicine (NEJM) article by Dr. Melinda Ashton, and in another STEPSforward module (https://edhub.ama-assn.org/steps-forward/module/2758834).
Employees (including healthcare providers) were enlisted to identify interactions with the documentation experience they perceived as being poorly designed, unnecessary, inefficient, or “just plain stupid.” The justified suggestions fell into three broad categories:
- Never meant to occur and should be eliminated promptly (10 percent);
- Needed, but could be more efficient (75 percent); and
- Required, but not understood (e.g., those tools existed already, but the user was unaware of them; 15 percent).
Actions included elimination of fields or tasks that were “never meant to occur,” adaptation of templates, reduction in number of clicks required, removal of gratuitous alerts, and education of providers regarding capabilities already built into the EHR. Think about when you get a new phone or computer – how much functionality can you pick up on your initial orientation? It is little wonder that periodic review of the abilities of your system can improve efficiency.
The healthcare system was surprised at the amount of time (and money) saved. Decreases in documentation burden increase job satisfaction and productivity.
Let me add a couple of my own suggestions. Providers should confer with their partners or colleagues and compare tips and tricks. The first day of my physician advisor orientation, I saved a seasoned clinical documentation integrity specialist 20 minutes a day by instructing her on the trend function in our EHR. Up until then, she would open a lab, review, and close it, open the same lab study from the previous day, close it, and repeat. Another tip is to import and utilize colleagues’ acronym expansions or macros. Pick the youngest, most computer-savvy colleague you have!
The best people to improve efficiency are the ones who use the system and benefit from being efficient. They may not be the ones to design improvements, but when opportunity is identified, it should be determined if there is a way to make the desired change a reality. Anything that can be done to improve the functioning of our medical staff will collectively improve our lives and the care of our patients.