Jennifer Childs-Roshak, MD, MBA
Much has been made of finding the joy in medicine of late as more patients seek care, fewer physicians are trained for primary care and electronic medical record (EMR) systems become more sophisticated. Primary care clinician burnout is at epic proportions. Population health is often hailed as one way to help manage healthcare costs, yet population health requires even more sophisticated EMRs and well-functioning primary care teams, not just more primary care providers. One of the most commonly cited stressors on primary care clinicians is the amount and level of documentation required. As noted in the 2013 Rand Corporation study, Factors Affecting Physician Professional Satisfaction and their Implications for Patient Care, Health Systems and Health Policy, “the majority of sources of dissatisfaction identified…insufficient time per patient, EHRs with poor usability, regulations that require physicians to spend time on tasks that do not require their training, high turnover rates among allied health professionals and support staff.” (pg109)
Medical scribes have been increasingly used in practices as a way to improve access, documentation, patient experience and clinician satisfaction. Even with a sophisticated and well integrated EMR, the time spent documenting has increased and the burden continues to fall on the clinicians. In my career, I have transitioned from paper charts to charts with forms and check lists, to early EMRs to a very sophisticated, well integrated EMR with lots of short cuts and “smart stuff”. While the quality of documentation has improved, the time spent documenting has not decreased. In fact, it has been a bit like the parable of the frog in the boiling water: incremental adds to the EMR on new required documentation over the years has been slowly burning out clinicians.
In 2014 as a practicing primary care physician and regional medical director, I posed the question: would using scribes in primary care be financially viable, practical and improve both the patient and the clinician’s experience.
The paper, “Scribes: Re-writing the story on patient and provider experience” published in Healthcare: The Journal of Delivery Science and Innovation, outlines our experience. After a literature search that revealed little published experience in primary care, we developed a robust business plan including a “make vs. buy” analysis for piloting scribes in primary care. The analysis for primary care was clearly in the red if we hired and trained ourselves, but in the black if we used a scribe company and paid hourly. Armed with this analysis, we developed a RFP, interviewed three scribe companies and selected one.
By November of 2014, we launched our scribe pilot and many of the operational details can be found in the accompanying article. Of note, our practice was not the “typical” fee for service, RVU oriented-primary care practice. The patients in our urban Internal Medicine practice, on the whole, tended to be at a lower socio-economic level, be more diverse and have higher no show rates. Clinicians in the practice are dedicated to serving this diverse population and are typically more concerned about the quality of care than productivity. Many also teach in local primary care residencies and training programs. It took anywhere from 1-2 weeks to 1-2 months for the clinicians to feel comfortable using a scribe. The scribe company worked closely with us to develop best practices for scribes within our practice, including customized training to document things like Medicare Wellness exams, ACO metrics and HEDIS screening guidelines.
Throughout the pilot phase, we planned to monitor a number of metrics as part of this “proof of concept” – how would we know this was working in primary care in a complex, capitated environment? We made the decision to be as concrete as possible on the analysis – instead of trying to factor in expense savings from better panel management allowed by more breathing room using a scribe, we focused on more “traditional” metrics such as productivity, access and schedule utilization. We tracked productivity (at first patients per hour then encounters per week), patient experience (Press Ganey scores for “Time Spent with Patient”, “Patient’s Confidence in Care Provider”,” Likelihood of Recommending Care Provider” and “Likelihood of Recommending the Practice”) and clinician burnout using the Maslach Burnout Inventory.
Our results from the pilot period showed improvement in all quantitative areas. More importantly, we saw some qualitative improvement in work-life balance, burnout and joy. In fact, when asked to reflect back on 2014 and some of the things that went well, having scribes was top of the list for the pilot group. A key learning was that having a scribe takes the secretarial level work off clinicians’ plates and allows them the time to think more about the medical decision making and to connect better with patients.
For many, the idea of adding a scribe is just an additional expense to the budget. If, like in our PCMH designed practice, there is already a robust support staff, it is hard to appreciate why one might choose a scribe in primary care over another medical assistant. Here are a couple things to consider: We are asking our clinicians to spend time typing, clicking and documenting. That is something that is best done in real time for all sorts of reasons: patient communication, reducing risk and improving quality of note and care. An excellent MA can help with inputting things before or after the visit, but not in the room. Unlike voice recognition or the latest EMR bells and whistles, a scribe anticipates the clinician’s requests, enters orders and is able to craft a note in real time so that the clinician can spend nearly 100% of the visit fully engaged with the pt. Even with a well-designed EMR, the clinician is distracted by documentation. Additionally, we know that “Likelihood to Recommend the Care Provider” and “Confidence in Care Provider” correlate highly with better compliance and better outcomes. Thinking out loud and engaging the patient in the clinical thought process is what one needs to do to best utilize a scribe and, as it turns out, it also increases patient understanding and engagement. The “Likelihood to Recommend the Practice” score is also directly influenced by the patient’s perception that “My care team worked well together”; most patients see the scribe as an important part of the team.
No matter what your practice looks like, everyone in primary care is struggling to balance increasing workloads, documentation requirements and cost of care against decreasing margins, primary care clinicians and joy in practice. Scribes are not for everyone or every practice, but they are a great tool for some. Our goal was to prove the concept in primary care given that the burden of documentation is heavier and the reimbursement for non-procedural visits is still lower in primary care. Good primary care is the cornerstone of both personal and community health as well as population management. Any way to help primary care clinicians focus on the care and the patient is good for everyone. Preserving and growing our primary care clinician workforce is critical to a sustainable future for healthcare.
Jen Childs-Roshak, MD, MBA is President and CEO of Planned Parenthood League of Massachusetts (PPLM). Prior to joining PPLM in November 2015, Dr. Childs-Roshak served as the Boston Regional Medical Director for Atrius Health, she also served as the Site Medical Director of the Kenmore practice.