Are Medical Scribes For You?

picjumbo.com_HNCK3323 (2)

A role gaining popularity in the ever growing electronic healthcare industry is the medical scribe.  Scribes perform the data entry in the EHR so that the doctor can focus on the patient. They’re clerical in nature, don’t communicate directly with patients, and don’t perform clinical procedures or administer medications.  We’ll examine the pros and cons of using medical scribes in today’s dynamic healthcare field.

These positions are very competitive to obtain, which ensures that only strong candidates are selected.  They’re typically filled by pre-med students pursuing a career in healthcare, often during a gap year, as the idea of real provider-patient interactions appeals to many.  Observing providers as they diagnose and treat patients is an invaluable real-world learning opportunity that can’t be paralleled in a classroom.

 

PROS:

Refocus attention on the patient: Scribes manage the majority of the data entry for the physician, affording the provider the freedom to listen attentively and focus on the patient’s needs.  In one example, “An American Journal of Emergency Medicine study found that emergency physicians spent 43% of their time entering data into a computer, compared to only 28% of their time spent talking to patients

Real-time documentation: While the physician examines the patient, a scribe can enter all relevant findings in real-time.  The result is more comprehensive and accurate documentation with fewer incomplete notes for the physician to circle back to at the end of the day.

Reduced Visit Durations: By minimizing the physician-computer interaction during the actual patient encounter, the time required to document a patient visit is significantly shortened.  This leads to decreased patient wait times and ultimately, increased patient and physician satisfaction.

Increased Revenues: Along those lines, practices stand to see potential long-term revenue improvement on two fronts:

  1. They can schedule a higher volume of daily appointments since patient visits are shortened, while maintaining high levels of accuracy and face-to-face interactions
  2. From a billing aspect, claims submissions should be more efficient since the documentation is completed in a quicker and more accurate fashion. This is especially important with the ICD-10 cutover less than 2 months out, but also very beneficial for incentivized programs.

Provide adaptability for incentive programs: Practices and physicians are constantly challenged with new regulations, and it is imperative that proper documentation accompanies each visit.  Scribes can alleviate some of the stresses by expediting the documentation process for initiatives such as Meaningful Use or PCMH, and capturing the added details required by the move to ICD-10.

 

CONS:

Provider Responsibility: Regardless of how a visit is documented, the provider is liable for their notes, and is required to review all scribed documents for accuracy before signing off.

Loss of alerts and decision support functions: Providers will not see the alerts and decision support prompts if they are not personally navigating through the EHR.

Initial Investment: Scribes may increase revenue over time, however the initial investment shouldn’t be overlooked.  The additional compensation is an obvious consideration to account for, but using scribes also requires a workflow overhaul which may disrupt daily throughput (as any workflow change might).

Learning Curves: Other costs to consider are the associated learning curves.  Scribes require training in multiple areas – the application, HIPAA, medical terminology, etc. – and the adjustment periods between the providers and scribes could hinder workflow efficiency.  Practices must factor all of this, including the high turnover rate of pre-med students heading off to medical school, in their evaluation process.

Big Data: The need for structured, reportable data is greater now than ever before as pay-for-performance initiatives that leverage EHR reports are taking off.  Moving forward, it’s not only important that a patient visit gets documented, it’s also important how it gets documented. As part of the initial onboarding, organizations must train their scribes to document in the appropriate fashion to ensure their providers get the full credit for each patient encounter

Patient Comfort Level: Patients may not be comfortable with other non-clinical personnel in the exam room, which could lead to them being less open about relevant healthcare information.  Sensitive or embarrassing conversations necessary for accurate diagnosis and treatment may be omitted in certain scenarios.

 

There are definitely lots of discussion points when considering medical scribes. The cost/revenue analysis will differ at each practice. Patient and physician satisfaction are likely to improve, but at the cost of alert and decision support functions.

Our recommendation before even considering medical scribes is to assess your EHR and note module to ensure they are optimally configured for your providers’ use and for all requirements (e.g. ICD-10, Meaningful Use, P4P initiatives).  We are all familiar with the additional work required of providers to document and order within the EHR, but often these efforts can be greatly reduced by streamlining the EHR’s configuration, especially the note forms, for ease of use.  At the same time, an optimization can improve the documentation and data required for ICD-10, Meaningful Use, and other initiatives. Under pressure to first implement EHRs and then to conform to Meaningful Use, many organizations have not had the time to perform such an assessment. Once your EHR, especially the notes, is optimized, you may find that fewer providers actually require a scribe.  For additional information and an example of an assessment, you can check out Galen’s complimentary Assessment & Gap Analysis for ICD-10.

Whatever decision you ultimately make, we always encourage our clients to define metrics and implement a pilot group before proceeding.  Determine what is important to your organization.  Maybe the focus is increased revenue, provider productivity, staff and patient satisfaction, accurate and timely documentation, or a combination of the above.  Either way, goals need to be established and measured to be able to track success.  Piloting a program on a small scale prior to enterprise-wide implementation could prove very insightful.  Changes in a practice are always difficult, so it’s important to research and obtain the necessary information ahead of any decision making.  For more information on medical scribes, EHR assessment & optimization, or Galen’s implementation methodology, feel free to contact us.

 

References:

http://www.ajemjournal.com/article/S0735-6757(13)00405-1/abstract

http://www.fortherecordmag.com/archives/0115p10.shtml

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049807.hcsp?dDocName=bok1_049807

 

Optimization: Is it all about the timing?

TimeIsEverything

You know that saying, “Timing is everything?” With the torrent of change that has hit healthcare, it seems as if the timing has not felt right for many organizations to attempt optimization. Why optimize if we cannot predict and factor in the next change? Optimization can come in 31 flavors!, our first blog in this series, introduced the methodology to manage the diversity of an optimization project by breaking it down into incremental, achievable goals. In this second article of the series, let’s discuss a real scenario.

St. Charles Medical Group, located in the Pacific Northwest, collaborated with Galen Healthcare Solutions to define its optimization approach. This organization’s business strategy aligned with the current industry trend of acquiring smaller practices, which meant its long-term success depended upon a well-documented, metric-driven, and, more importantly, repeatable processes that met the needs of both existing and newly on-boarded practices. St. Charles’ initial goal prior to beginning its optimization project was much like many other clients we’ve worked with through the years. As had quickly grown from 30 providers to more than 180+ providers with 19 specialties, the focus was solely on-boarding and adoption, not necessarily optimization.

During the initial engagement, our team lead laid out a plan based on Galen’s methodology and highlighted the importance of having baseline benchmarks and clearly-defined metrics that could be used at any time to gauge the optimization project’s success. The joint St Charles-Galen optimization project team began to brainstorm a plan, and, as is often the case, objectives for optimization differed depending on the audience. Obvious goals ranged from achieving quality improvement, to increasing efficiency and productivity of providers, to improving patient safety and compliance. However, there was one universal priority that everyone agreed to work toward: improving the provider experience.

One challenge to address is how to measure success. Provider satisfaction surveys are often too subjective, and if concerns are not acknowledged in a timely and meaningful way, they can have the opposite impact. With this and the fact that much of the EHR is driven by time- and date-stamped tasking, it was decided that analyzing visit numbers, tasks counts, and times to completion for certain tasks would produce a solid baseline. Analysis of several different types of tasks offered a definitive way to gauge overall operational efficiency. Investigating on a more granular level allowed for the identification and resolution of workflow issues.

By design, this well-rounded project plan aligned leadership, providers, and staff toward common goals. Both senior leadership and the provider end user base acknowledged that the time it took a provider to document a patient visit was impacting satisfaction. They mutually agreed that times to complete tasks and sign notes could serve as a direct correlation to benchmark goals and measure the overall efficacy of the project. Additionally, this fed into quality outcomes and patient safety goals, considering that prescription renewals and reviewing pending results also fell into trackable task types. They could monitor diminishing completion times for these tasks, which translated to patients getting their medications refilled on time without missing doses, as well as receiving quick, as needed changes in treatment plans based on lab results. This was a quick win for all involved and could be easily tracked on dashboards for progress throughout the project’s duration.

Task Optimization

Actual baseline metrics and outcome of task completion time pre- and post-optimization.

The time it took a provider to sign a note was an inventive way to evaluate the reduction in time it took a provider to document a visit. The complaint from providers was that they were charting way past clinic hours to close out their patient visit documentation. The Galen team developed a query to identify the percentage completed by the end of patient hours (6 PM) versus the percentage completed in the evening on the providers’ off-hours (10 PM). Looking at these numbers on a monthly basis at both the practice and the individual level showed trending patterns of who was struggling and who was succeeding. This data helped the HIT staff discover the best practice workflows that could be adopted across the organization. An added bonus was the allowance of more efficient, cohesive support with a consistent workflow approach. Sharing the statistics monthly buoyed the spirit of collaboration around a topic providers were passionate about, and it set the tone for provider participation in other optimization exercises. Ultimately, they were able to increase the percentage of notes completed during office hours, which improved provider satisfaction. At the same time, daily documentation completion was a positive impact for revenue purposes.

Finalized 6PM

Example report of Pre- and Post-Optimization benchmarks for note signing completion.

According to a Medical Group Management Association (MGMA) survey from 2008, the average physician’s work RVUs (relative value units) is 18.4 per day, based on 20 visits per day. This could fluctuate depending on the specialty and practice, but using this reference as an example, an 18% improvement could mean seeing an additional 3-4 patients per day. With new healthcare payment models and value-based care programs focusing on quality outcomes versus volume of patients seen, this could equate to potential open appointments for same-day access and lead organizations into quality programs such as PCMH and ACOs that they haven’t enrolled in yet. Optimization activities can lead to increased revenue, but avoiding them may cause more financial loss than expected.A different but equally impactful reporting point revolved around verifying patient results. Streamlining the best practice workflow for provider efficiency was the first step, and, by studying the data, an organizational workflow was developed. Time-saving efficiencies for the providers were generated with the development of Order-Result Management Worklists and text templates for result notes. The second part of the optimization involved retraining users on how patient communication tasks were triaged. Originally, all result tasks were routed to the clinical staff. However, in the new scenario, Call Patient with Results tasks were automatically sent to the Nurse Team View, and Mail Result to Patient tasks were automatically assigned to the Front Desk Staff View. Redistributing tasks to more appropriate staff members resulted in quicker handling and allowed clinical staff to remain focused on clinical matters, ultimately having a positive impact on patient care.

As many are preparing for alternative payment models where quality, efficiency, and patient satisfaction are key elements, now is the perfect time to conduct the optimization conversation. Assessing how your organization will transform with healthcare payment reform not only forces you to evaluate your EHR for optimal configuration, but it also helps ensure that your highly trained staff aren’t stuck in menial data entry mode to meet quality programs. It also helps ensure that all staff are performing at the top of their skill set and licensed capabilities. We have highlighted two of the many examples of how Galen’s methodology and reporting tools can positively impact many different areas, such as revenue and efficiency, which ultimately translate to improved patient care.

References

http://www.aafp.org/fpm/2009/0900/p31.html

 

5 Challenges to Overcome En Route to a Successful HIE Migration

Transition

Recently, Galen’s technical consultants took part in a large state Health Information Exchange’s (HIE) migration from Axolotl HIE to the Orion HIE platform.

Often times, connecting a participant to an HIE means compromising between two sets of standards to find a maintainable medium.  Having a flexible, driven team of passionate consultants committed to the long-term success of a project can be the difference between a successful and an unsuccessful endeavor.  These are some of the challenges faced throughout the HIE migration that were overcome with our technical experience and dynamic solutions.

Normalizing Converted Data With Minimal Background Information

When migrating from one HIE vendor to another, it is imperative to backload historical data to perpetuate the data repository built up over years on the legacy system.

Decisions are often made in healthcare IT to overcome limitations of a system.  These choices can cause unforeseen downstream issues, especially when migrating to an HIE with a different set of specifications and standards.  In many situations, decisions made in the past aren’t well tracked and the reasoning for handling the data isn’t easily discernable.  Over long periods of time, these issues become magnified, especially when they involve multiple data sources.  As issues are discovered, adjustments are made to mappings and resolutions are developed on the fly, though the documentation around these decisions is sometimes inadequate and difficult to follow.

Galen’s team of interface analysts is uniquely equipped to identify patterns in data sets and develop solutions to overcome the transition to a new HIE.  With our extensive interface knowledge and experienced team of healthcare IT professionals, Galen can provide a deep understanding into how data is changing over time, discern the specific reasoning behind why decisions were made, and determine how best to move forward with the information and tools that are available.

Managing Reused Patient Identifiers

HIE systems require that patient identifiers (e.g. MRNs) be unique.  That is to say, each patient identifier that comes into an HIE from a particular facility should be distinct to a patient, and should never be reused on another patient.

There are instances where this isn’t the case in HIT, for example, reference labs will sometimes recycle patient identifiers used in previous years.  In order to retain the uniqueness, identifiers need to be intelligently manipulated.  Galen’s interface analysts have experience dealing with this situation and can help partners develop customized solutions to overcome this challenge.

Managing Reused Message Control Identifiers

Some interface engines also require that each HL7 message have a unique message identifier in the MSH-10 field.  If an HL7 comes in with the same message ID as one that was previously processed by the system, the interface engine knows to reject that message (typically, this would be a repeat message).  Some participants do not or cannot send a unique MSH-10.  In these cases, Galen’s analysts have collaborated with partners to develop creative solutions to circumvent these limitations when converting data from legacy systems.

Managing Order Codes with Multiple Descriptions

Order codes should be unique to the order description they align with, although there are instances in the real world where this isn’t the case.  Sometimes, facilities send the same order code (OBR-4.1) with distinct order descriptions for results that are actually different.  Take a microbiology result for example: a facility might provide an order code of MICRO with an order description (OBR-4.2) of URINE CULTURE, but they might also send an order code of MICRO with an order description of BLOOD CULTURE.

In some HIE systems, the first description loaded with the order code of MICRO is the description that will always display in the patient portal whenever a subsequent result with the same code of MICRO is processed, regardless of the actual description code.  Let’s say a patient first has a URINE CULTURE resulted, then a few months later, that same patient has a BLOOD CULTURE resulted.  That BLOOD CULTURE result is going to display in the patient portal as a URINE CULTURE because the system has already been populated with:

Order Code Order Description
MICRO URINE CULTURE

Galen has developed a methodology for working through this issue.  Our analysts can help organizations create a customized strategy for appropriately handling order code and order description data to enable an HIE to correctly display order codes with multiple descriptions.

Properly Linking Microbiology Results to Susceptibilities

Microbiology results are especially tricky when dealing with any consuming system.  Depending on whether the result indicates a need for further testing, microbiology HL7 results contain either:

  • Just the initial microbiology result
  • Both the initial result and susceptibility follow up results

When a microbiology result does require a susceptibility follow up, it will typically have two OBR segments.  The first OBR segment will pertain to the original culture like a Blood Culture or a Urine Culture.  The second OBR segment will contain information regarding results for the associated susceptibility.

Many systems require that the child (susceptibility) report contain elements from the parent result, though participants don’t always send this information in the parent report appropriately.  Galen is adept at identifying the patterns with which a participant sends their microbiology results, and our consultants have extensive experience developing logic to appropriately process microbiology results into consuming systems.

Overall, there are many challenges that can arise when converting from one HIE to another.  Galen Healthcare Solutions’ experienced interface analysts and HIE specialists can work with you to ensure a successful and timely migration that best serves your patients and physicians.  For additional information, feel free to contact us!

Reducing Complexity in Healthcare IT: Part 2…Preparing to move forward

Navigating the healthcare IT landscape and its parallel progression to risk-based patient care models brings with it multiple modes of organizational preparation. Application portfolio management is one of the architecture methodologies that can be deployed to help streamline your organization to work most efficiently to achieve its business objectives.

Let’s examine some general themes to highlight in preparation for streamlining your organization’s portfolio landscape and optimizing its capabilities.

Business Objectives…

THIS IS NOT IT. This seems like a pretty basic concept but is important to always remember that the IT infrastructure’s main role in in portfolio management is enabling and supporting the capabilities needed to satisfy business objectives. This even presents itself as a paradigm shift for some leaders as healthcare organizations begin to emerge from the settling dust of increased MSO healthcare activity, a sprint to implement Meaningful Use measures, and preparing for ICD-10.

Roadmap…

Having a well-defined and concise IT roadmap that clearly supports the organization’s core business objectives is crucial to the vision and planned execution of the business. Knowing the decisions previously made vs. the future state of the business is important to understanding what key architectural considerations need to be continuously prioritized. A major portfolio overhaul might not be as effective if it happens to cause misalignment from the overall vision.

Governance…

It’s certainly not assumed or conveniently implied that the core driver contributing to the makeup of terribly complex IT infrastructures is lack of governance. There are many time-sensitive functions such as the need for mergers, acquisitions, and general integration efforts that remain aggressive over an extended period of time.

An Architecture Review Board (ARB) is an example a key governance structure through which significant infrastructure decisions are presented, discussed, and prioritized.

Communication…

During the process of ramping up and structuring a portfolio management based initiative it will be clear that widespread, timely, and interdepartmental communication is a key driver to success. Both the systemic accuracy of project data and the amount of time required to gather and standardize the data for analysis and consumption are dependent on this being in place.

Data Gathering…

The data gathering process for this type of initiative can also be a learning process for the entire organization. It should also be acknowledged and accepted that this rarely happens in one fell swoop, after all, potentially years of layered integration creep can tend to erode certain elements of organizational communication in those “pockets of functionality”. Rounding up this information into one arena or a series of tools for objective decision making is an ongoing and iterative process during the project. A sample of data categories that could be initially collected might include:

  • Business objectives vs. system capabilities (a correlation or mapping)
  • Cost Data (cost of practice acquisition, current support costs, integration needs)
  • Full Application Inventory (includes all systems and metadata regarding those systems)

Be prepared to engage key resources in the organization to hunt this information down using a variety of collection techniques:

  • Direct Observation
  • Interview
  • Questionnaires
  • Database/Data Center mining

For additional information, feel free to check out Part 1 of this blog series and please don’t hesitate to contact us!

How Are We Improving Patient Quality of Care and Reducing Cost?

header

Honey, where are my paaaaaaaants?

If you haven’t seen the Lego movie yet, you’ve either been in a coma, or just don’t have time for good cinematography. OK, it’s a movie geared at children, but it’s just good. While I do have a fondness for anything Lego, that’s not why I wrote this. This article is intended to spark thought, to start a conversation, to start formulating a plan, or review where you are in your current plan. What am I referring to? QUALITY IMPROVEMENT. Specifically, programs designed to lower cost while increasing the quality of care, including Medicare-sponsored initiatives like PQRS, MSSP, private payer programs, and health even internal quality improvement plans. Yes, they loom over all of us in the healthcare industry with dry, vague language, seemingly impossible benchmarks, and so many moving pieces it’s tough to know if we’re getting coffee or putting on pants.

Clinical Quality Reporting

After being in the field and getting a taste of what a quality improvement program are and how they work, they’re not that bad. In fact, watching actionable data be turned into a plan with measureable outcomes is ALMOST better than watching the Lego movie. Almost. Yet, so many organizations struggle with the who, what, where, when, and how that a solid QI program never gets off the ground, let alone implemented.

I’ve been involved in many QI programs, ranging from very small internal programs focused on workflow efficiencies, to huge multi-million dollar undertakings. In all instances, success, or the lack there-of, was not determined by one group or department within the organization. No, success is the result of a lot of hard work by members across the organization, including staff, providers, data analysts, business analysts, IT engineers, and leadership.

So I ask you, what does your quality improvement strategy look like? Do you know where your relevant data is? Do you have access to it? Do you have physician champions or advocates ready to push the boundaries and try new things? Is your staff comprised of people with a wide range of acumen? Do you have business analysts, data analysts, data scientists, workflow analysts, implementation teams, and Quality Improvement Experts? If you answered no to any of those, you might want to take a moment to think about how a Quality Improvement program fits your organization. It’s no longer a question of “Should we do this?”, it’s “When will we start doing this?”

In the coming months, I’ll be discussing more topics related to Quality Improvement and how Galen can help you meet and exceed your goals. It takes passion, and we have [IT]. I’ll take you through how we can help you plan for new QI programs, or help you pick the right one. I’ll also be discussing our many offerings, including, but not limited to, data integration, data warehousing, quality reporting, workflow analysis, data gap analysis, EHR optimization tips, staff augmentations. I’ll also touch on partnership opportunities to help implement, monitor, report and manage entire quality improvement initiatives from business and data analysts, data scientists, physician advocates and direct reporting to leadership.

If you have any questions regarding quality improvement, please contact us using the form below:

Next Page »