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. 1
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 3 rd 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 Scribe Profile After Training Program Development Some College Scribe as Career Mindset Type 45+ minute Expanded team role 2
Scribe Profile Scribe Profile Career Path Vs Educational Model Longer Tenure/Less Turnover More Training from Provider Required More oversight necessary More compartmentalization Training based Running Start Higher Turnover Easier on Providers Short term Faster Training/Onboarding More crossover/flexibility People based 3
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 4
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. EHR The Good the Bad and the Ugly Access to Data Improves Some aspects of Care Better communication with patients The Good Time Consuming Data Entry Information Overload MU <> Clinical Practice Template based notes degrade quality of note The Bad I don t feel like a provider anymore Lower skilled work is demoralizing Burnout* The Ugly *an overwhelming majority of providers surveyed would not go back to paper. 5
16 *Each X is a clinician 16 17 17 Increased Access* Better Data Capture Better Notes Another Set of Eyes on Quality Easier Trainees (ICD 10/Changes) Provider/Patient Satisfaction Better Behavior Costs (onboarding ongoing) Turnover Co dependence Patient Adoption/Sensitivity Territoriality 6
Before After Financial Considerations 7
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 8
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 9
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 10
SCHC medical scribes: Train the Trainer I. Recruitment II. Red Flags III. Keys To Clinical Team Efficiency IV. Scribe Etiquette V. Additional Tasks VI. Scribing No Nos VII. Monthly Meetings VIII. 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
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 (3 rd Gardasil, BMI Plan etc) 12
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 13
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. Preemptive 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? 14