Download Utilizing Scribes for Improved Quality, Productivity, and

2/3/2016
Provider Retention Strategy
Utilizing Scribes –Taking the “Doc” out of Documentation
Patricia Sand, MD
Elaine Porter, MD
Michaela Mangas BS, ACMSS
Charles Kitzman, MMI
Shasta Community Health Center, Redding CA
▪ Vital Signs/
▪ History of the Scribe Program
▪ Lessons Learned
▪ Guardrails
▪ Training/Onboarding/Team Building
▪ Provider Perspectives
▪ Q/A
▪ 35 FT Provider FQHC 5 locations ▪ Live on since May 2007
▪ 138,000 encounters annually ▪ Multiple services
▪ Primary Care/Residency 2‐2‐2*
▪ NP/PA Fellowship*
▪ Pediatrics
▪ Primary Care Neuropsychiatry
▪ Dental
▪ Homeless Van
▪ Various Specialties – Rheumatology, Podiatry, Neurology, Endocrinology etc.
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Motivations
▪ Extend shelf‐lives of our veteran Provider staff (Retention)
▪ Improve the Quality of our Documentation
▪ Mitigate workers comp claims/repeated computer use
▪ Let our Clinicians feel like Clinicians again (Satisfaction)
*Making money was/is NOT a goal of the program
In the beginning…
3rd party Evaluator
5 scribes for the pilot
Bachelors Degrees required
Early adoption was met with Resistance
Opinion leaders influenced others over time
Today all providers utilize scribes
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐Onset
▪ College educated ‐ Bachelor
▪ Interested in Medical Arts – Nursing, PA, NP
▪ Type 45+ minute
▪ 1 year commitment
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐After Training Program Development
 Some College
 Scribe as Career Mindset
Scribe Profile
 Type 45+ minute
 Expanded team role
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Scribe Profile
Scribe Profile
Career Path Vs Educational Model ▪ Longer Tenure/Less Turnover
▪ Running Start
▪ More Training from Provider Required
▪ Higher Turnover
▪ More oversight necessary
▪ Easier on Providers – Short term
▪ More compartmentalization
▪ Faster Training/Onboarding
▪ Training‐based
▪ More crossover/flexibility
▪ People based
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Risks and Assumptions
Gender issues may interfere with care
Co‐dependency Territoriality CPOE (Meaningful Use) numbers could be impacted adversely
Learning/Training process might negatively impact access
▪ Medications off limits. No Abstracting, No Editing, No Ordering
▪ No injectable medications
▪ Pediatric Scribes are allowed to get Immunizations ordered
▪ Can order Labs, Diagnostics, Referrals, CLIA Tests
▪ Provider must create the chart note, not the scribe
▪ Role has expanded significantly over time to include:
▪ Data Gathering – Report Abstraction ‐ Pre‐Visit Planning ‐ Answer Portal Traffic ‐ Clinical Guidelines
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Q: Why can’t we just go back to the 1950’s where Doctors were Gods and no one ever questioned them?
A: Because the CIO said so.
Better communication with patients
Time‐
Consuming Data Entry
Information Overload
MU <> Clinical Practice
Template based notes degrade quality of note
I don’t feel like a provider anymore
Lower skilled work is demoralizing
Burnout*
The Ugly
Improves Some aspects of Care
The Bad
Access to Data
The Good
EHR – The Good the Bad and the Ugly
*an overwhelming majority of providers surveyed would not go back to paper.
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*Each ‘X’ is a clinician
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Increased Access*
Costs (onboarding – ongoing)
Better Data Capture
Turnover
Better Notes
Co‐dependence Another Set of Eyes on Quality
Patient Adoption/Sensitivity
Easier Trainees (ICD‐10/Changes)
Territoriality
Provider/Patient Satisfaction
Better Behavior
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Before
After
Financial Considerations
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Basics
Scribe pay range (13.00 – 18.80) @ SCHC is not as low as ER’s not as high as some.
Average tenure of Scribe is 1.8 years
Certification by American College of Medical Scribe Specialists ($370 to start $170 Annual Dues)
www.theacmss.org for more information. Primary Care is a focus of certification
This is primarily for the Meaningful Use CPOE measures though other reasons may apply.
Impact
The Scribes are a straight up cost for SCHC. No evidence of sustainability in the program in and of itself.
Budget 18 Pt/Day without a scribe 20 Pt/Day if you have a scribe. Clinical Average remains at 18.
Benefits exist elsewhere and are worth consideration
Ex. Retention, Recruitment, Work/Life Balance, Quality Improvement, Communication
Some teams are more fluid than others. Can see 20+ ‐ helps to subsidize others/onboarding etc.
Backfilling Operations
▪ Other Revenue Streams are vital for us to continue to use Scribes.
▪ 340B Prescription Drug Program ▪ Partnership HealthPlan QIP Program
▪ Meaningful Use
▪ Other Grants
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Our Reality May Not Be Your Reality
▪ Clinician Turnover
▪ Managed Care – Costs Continue to Rise ▪ Referral Center, Patient Navigators, Patient Education etc
▪ Preparations for eventual Value Based reimbursement which isn’t here yet
▪ We continue because it’s a major satisfier and we’ve been able to pay for it so far. (5 Years)
Training and Team Building
Michaela Mangas, BS ACMSS – Provider EHR Trainer
What to look for when hiring a medical scribe:
Computer and Typing Skills:
• At least 45 WPM. The higher the better.
• Basic computer proficiency in Windows environment Spelling and Grammar:
• A spell check feature is very helpful (We use Spell‐ex).
Attention to Detail
Organization
Works well under stress and in a fast paced environment
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What To Look For In Hiring A Scribe (continued)
Good listening and communication skills
Confidence
Deal with mental health issues Good customer service Tech Savvy Interested in healthcare Some college‐ Note taking and condensing conversations Helpful but not required:
•Medical Terminology/Anatomy/Physiology courses, Medical Transcription background.
Onboarding
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SCHC medical scribes:
Train the Trainer
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Recruitment
Red Flags Keys To Clinical Team Efficiency Scribe Etiquette
Additional Tasks Scribing No‐Nos Monthly Meetings What have we learned? Scribe Etiquette
*Introduction from clinician before every visit. “Hi, John. Good to see you again, this is my scribe Tabitha, she will be documenting our visit today.” *Moderate interaction with patient when appropriate. Scribe Meetings
• How often?: Once per month for an hour. • What for?: Discuss quality measures, EHR updates, workflow efficiencies, debriefing, etc. • Who runs the meetings?: Lead Scribe and other clinical directors. 11
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VIII. What have we learned?
Familiarity is key Differences in Pediatric vs. Family Practice Scribing Establishing a “float” scribe for sick calls and specialists Scribe Guides very useful Interdepartmental Collaboration Territoriality Early On Lead Scribe to work with clinician prior to training ACMSS Importance of Review Process Provider Perspectives
Dr. Patricia Sand Dr. Elaine Porter
Provider Perspectives – Early Adoption
▪ Have had 2 scribes assigned over a 5 year period ▪ College Experience is helpful – Synthesizing conversation is important
▪ Younger scribes more in tune with vocab/social trends in teens = helpful
▪ Scribe can chaperone for exams – freeing up the nurse = better workflow
▪ Job Sharing ‐ are you available to help? Faxing, Running Specimen to lab, etc. ▪ Pre‐Visit Planning – (3rd Gardasil, BMI Plan etc)
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Helping the Team
▪ Ordering Labs
▪ Scribes have shown they know how to learn the Immunization Schedule. ▪ Communication With Patients – Work/School excuses, Service Animal letters.
▪ Create and maintain Template Saves and My Phrases for Providers
▪ Some scribes have been trained to take vitals and room patients. Increases Utility
▪ The presence of a Scribe can have a positive impact on patient behavior.
Work/Life Balance
▪ Huge impact on time actually in the Health Center – Rarely do charts from home.
▪ Able to do today’s work today. Provides more control over my practice.
▪ Scribes, like nurses, learn your habits and can help keep you moving.
▪ Scribes are easy to delegate time‐consuming small tasks to – Finding paperwork, Calling IT, loading paper in the printers, re‐stocking shelves, creating labels etc.
▪ Investing the time and energy into training your scribe pays dividends. ▪ Learn to let some things go. Meet them halfway.
Quality Considerations
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Provider Perspective ‐ Quality
▪ Later Adopter – Has highly Capable Scribe
▪ College Degree (English) Fast learner, Tech Savvy. Good Spelling/Grammar
▪ Uses Tech to increase her helpfulness – (Looking up Provider Names, CDC website, OTC info)
▪ For complicated Patients – She is trained to summarize the previous note for greater continuity in the Chart Note.
▪ Reviews PAR reports and Med Management Agreements. Pre‐
emptive approach
▪ Helps Manage Guidelines, Report anomalies, Finds Variances in Vitals (High BP, Ht jumps)
Additional Impact on Quality
▪ Trained her to fill out disability forms based in previous chart info – Saves time.
▪ Can help with procedures like pap smears when nurse is busy.
▪ Copy forms for the patient, fetch resources, provide patient education and safety information.
▪ Saves me 2‐3 hours a day – very noticeable when I have to work without a scribe.
▪ We handle Clinical Quality as a Team in my clinic, the scribe definitely plays a role.
▪ Scribes develop a much better understanding of the EHR platform, trains me as necessary.
Questions?
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