Should primary care providers get scribes?

 How can systems lessen the burden on providers? Photo credit: https://healthitsecurity.com/

How can systems lessen the burden on providers? Photo credit: https://healthitsecurity.com/

Who wants to be a provider these days?

Today’s medical providers are increasingly “burning out,” resulting in reduced productivity, threatened clinical outcomes, and impacted patient experiences. Data suggests over half of all providers are pessimistic about the future of healthcare and suffer from low morale. In primary care, providers go to work each day challenged with being available, present, accurate, and relevant for up to 30 patient encounters.  In addition, providers are required to document each visit correctly in a complex electronic medical record (EMR) system. Just completing documentation in the EMR keeps physicians working, on average, over 2 hours after the day’s visits conclude. Doing this day-in and day-out for years, it’s no wonder that almost half are burnt out. Summed up by Dr. Danielle Ofri quoted in The New York Times: “Medicine has devolved into a busywork-laden field that is slowly ceasing to function. Many of my colleagues believe that we’ve reached the inflection point at which we can no longer adequately care for our patients. The EHR isn’t the only culprit, but it’s certainly the heavy-hitter.”

Primary care in the spotlight

Integrated healthcare systems have acquired primary care practices principally to ensure they capture market share and reap the benefits of encouraging patients to become brand loyal.  The more referrals into the affiliated system, the more revenue generated. Primary care clinics are equivalent to “retail storefronts” of the healthcare system and, as gate keepers, carry disproportionate administrative burden for accurate documentation and appropriate referrals based on a patient’s diagnosis.

So, what’s the primary care provider’s day like? Typically, primary care providers (PCPs) clinically care for 20 to 30 patients per day, document each visit, and follow up on past visits and new patient questions via a growing backlog of e-mail. It’s hard to think proactively about anyone’s health much less a group of patients (typically 1,700 to 2,000 patients are assigned to a PCP) when subjected to a large amount of transactional work. Not to mention that a provider does not become a clinician because of the excitement for administrative work.

In addition to administrative burden, economic incentives play a role in burn out. Today, the majority of reimbursement for healthcare services is on a “fee-for-service” basis; more patients equates to more money, incenting PCP’s to see more patients and systems aren’t likely to change these incentives wholesale. With ongoing economic pressures and a shortage of PCPs, efforts to make primary care more productive and sustainable are increasingly critical. One approach health system leaders are taking is “skill-task alignment”; basically separating the high value provider activities and finding other ways to get the lower value activities completed (you’ve likely heard the phrase: “work to the top of their license”).

Regardless of why burn out happens, it is a challenge worth solving. But how can systems lessen the burden on primary care providers, lower costs per capita, and meet patient expectations?

The atomic level

Healthcare is the fourth largest industry in America behind real estate, government, and finance, accounting for over $3.3 trillion of spend (approaching one fifth of GDP). The vast majority of that spend begins with the patient-doctor visit, essentially the “atomic level” of healthcare. That visit is rooted in traditions born centuries ago, a patient seeking an expert for advice on their health. However, while our ability to improve clinical outcomes is not in question, we’ve spent less time on improving the fundamental model of accessing care, leaving us with some unintended consequences. Given the critical nature of the visit, the burn-out phenomenon, and the strategic importance of primary care, systems must now focus more on improving the sustainability of the atomic level.

Lessening the burden

Many health systems are experimenting with ways to lessen the burden on primary care, including changing scheduling practices to accommodate different types of visits, implementing call centers, and creating value-based (rather than volume based) compensation plans. Some are providing scribes, a third person in the room (or virtually) documenting the visit in the medical record in “real” time. To date, these experiments have not produced definitive results, but are driving benefits for providers and patients. There is much more to do to improve the patient-doctor visit, and so far, there is no widespread agreement that the benefits outweigh the added costs of a scribe, but something eventually must change to lessen the burden.

What is a scribe?

Today’s scribe is a pre-med student, or someone interested in a career in medicine, who’s duties are primarily to correctly document the visit as it happens and then to route the note for the provider’s review and sign-off, reducing the documentation effort and freeing the provider to perform the assessment, diagnosis, and treatment plan. Some scribe pilots are experimenting with additional ways to incorporate scribes into the clinical work flow, for example helping prep the room and patient, addressing patient’s initial concerns to the extent of their training, prioritizing e-mail, and following-up on routine matters. Some organizations are deploying licensed Medical Assistants as scribes to be able to increase the scope of their duties. 

Do benefits outweigh costs?

This is where system leadership will have to weigh in and the answer depends on how leaders value the provider’s time. There are many variables to consider in each practice (e.g., reimbursement model, patient population, etc.), and few concrete ways of measuring the impact of scribes.  Thus, each system’s leadership needs to assess the opportunity on a per case basis.  Some leaders believe that leveraging an hour of a doctor’s time is worth investing an additional $15-$30 per hour in a scribe to optimize that time but undoubtedly, the additional cost must be justified and a plan to create value beyond that cost must be agreed upon. 

Leaders must first consider how they want to create that value: solely on direct short-term benefits like increased revenue, or indirect long term benefits like improved patient and/or provider satisfaction, some of which may be considered loosely linked, but worth considering and ultimately measuring.

Direct:

•    Higher productivity leading to higher revenue. The most common and sometimes the only justification of a scribe investment is increased productivity, seeing more patients per day. While common, this metric may be misaligned with improving provider sustainability.

•    Improved coding resulting in higher reimbursement.  Physicians are notoriously poor coders.  In some models, a highly trained scribe is able to participate and facilitate appropriate billing thus fully capturing all of the potential diagnoses.

Indirect:

•    Higher clinical quality leading to better patient outcomes and reduced long term costs. Ideally a scribe frees the provider to develop a better relationship with patients, spending time to fully diagnose and engage the patient. This has the biggest payoff for integrated systems, Accountable Care Organizations, and Medical Homes in better managing chronically ill patients, measured by fewer visits to the emergency room, no unnecessary referrals to specialty care, and less overall medical expense per capita.

•    Improved provider satisfaction leading to greater retention. Addressing burn-out by lightening the administrative load has a direct impact on provider satisfaction. While it makes intuitive sense, a direct cause-effect relationship has yet to be found that proves that more satisfied providers stay longer. However, reducing unwanted provider turnover by a few percentage points has a significant payback, especially since estimates of replacing a physician in a large system range deep into six figures.

•    Improved provider recruiting. With the expected shortage of providers, particularly physicians, it is likely that attracting physicians will require increased investment and an opportunity for sustainable work-life balance, so in addition to retention, the presence of a scribe becomes a recruiting tool.

•    Better documentation leading to lower regulatory risk exposure and less liability for misdiagnoses or improperly coded services. The additional support in appropriately documenting the encounter and review by a less-burdened attending provider can result in fewer errors, less exposure to billing audits, and, ultimately lower patient claims. 

•    Higher patient satisfaction leading to higher patient loyalty and more referrals. Many health systems have patient satisfaction and service excellence initiatives. Essentially surveying patient on their experience and monitoring social media comments and Yelp reviews. Many systems are only starting to think about how to quantify the value of patient loyalty.

Most systems justify the additional expense of a scribe by mandating an increase in provider productivity (number of patient visits). While easiest to measure, it creates unintended consequences that undermine the value delivered. Rather, a holistic approach, deliberately incorporating a balanced set of metrics and simultaneously monitoring negative consequences, better aligns the vision of what outcomes the system intends to achieve and captures a complete picture of the value of a scribe. This approach recognizes the complex nature of the problems to be solved, while leaving room for the day-to-day decisions on how to realize value to the individual provider and practice.

Thanks to John Corman, MD who enthusiastically shared his perspective on this article.

For more information on how we helped a national integrated healthcare organization create a clinical data entry solutions roadmap, please see our case study here.