August 2019

Transcription Trends: Reduce Keyboard Time to Help Cure Physician Burnout
By Dale Kivi, MBA
For The Record
Vol. 31 No. 7 P. 30

Physician burnout caused by the documentation burdens inherent to EHRs has become a significant industry problem. Fortunately, scribes are helping provide a solution.

Unlike technology-exclusive approaches such as computer-assisted physician documentation and front-end speech recognition, scribes—especially virtual scribes—can reduce physician burnout, increase patient satisfaction, improve document quality, and provide a boost to per-provider revenue generation.

A recent study by the University of Wisconsin and the American Medical Association revealed that physicians work an average of 11.4 hours per day when on duty, with 5.9 of those hours spent directly engaged with their EHR. Such unreasonable time balances directly lead to the following:

• physician burnout caused by the conflict between patient focus time and documentation time;

• marginalized patient satisfaction scores due to physician’s focus on EHR reporting requirements;

• poor report quality caused by minimal speech recognition proofreading and other time-saving shortcuts; and

• risk to patient care and potential allowable encounter revenue caused by poor document quality.

On the other hand, scribe-supported business practices deliver the following benefits:

• increased patient interaction during encounters gained by eliminating in-visit EHR distractions;

• reduced total time spent with each patient due to elimination of in-visit EHR data entry efforts;

• increased daily visits per provider enabled by time saved per patient and EHR support from scribe;

• improved document quality by eliminating documentation shortcuts while adding richer data; and

• improved revenue per encounter through better reporting of hierarchical condition category (HCC) codes and other claim-influencing data.

When scribes began to grow in popularity, the argument against them was that they were the type of resources used to generate documents before transcription, making their arrival a step back in time, not a step forward. The difference, however, is that unlike transcriptionists, who are inherently limited to generating narrative reports from recorded dictations post visit, scribes take on a considerably wider scope of real-time encounter support and EHR documentation responsibilities, such as preparing orders and scripts for physician approval.

Scribes also conduct previsit chart reviews to save the physician time and ensure comprehensive documentation with each visit, confirming HCC acknowledgements and other potential ongoing care and/or revenue-influencing details.

The EHR’s Impact
Following the shift to EHRs, numerous studies calculated the additional time required to document patient visits. Less attention was paid to the measurable financial impact the additional time had on physician income or the total revenue generated per physician for their employers.

A chief operating officer says he had uncomfortable discussions with a few longtime physicians who estimated their personal annual income loss directly attributed to their forced reduction in patient load resulting from increased documentation time at $80,000 to $100,000. The facility’s only option was to hire more physicians and support staff.

As part of the EHR’s objective to ensure report quality and deliver instantaneous availability, physicians were to complete the documentation themselves. It looked great on paper, but in practice required physicians to take on the role of glorified data entry clerks, distracting them from their primary purpose of patient care.

EHR vendors and other technology players developed a wide array of productivity improvement tools, some of which tacked on more to the cost of the overall solution and created additional points of potential quality failure. For example, front-end speech documents and cut-and-paste sections from previous reports may not be proofread prior to signature.

Cut-and-paste content and automated blocks of inserted text, which typically serve liability protection concerns more than ongoing care, add to report volumes (note bloat) and deliver negligible value to encounter specific conditions. They make resulting documents difficult to comprehend without improving physician efficiency or positively impacting patient care and financial outcomes.

Any real solution must relieve physicians from data entry and ensure all meaningful patient care and reimbursement content (such as HCC details) are included for each encounter.

Enter Scribes
Independent studies have indicated that scribes increase patient visits per day by at least 20%—although the percentage can vary by specialty—while simultaneously improving relative value units anywhere from 15% to as much as 50%, depending on pre-scribe practice results. Direct per-encounter patient contact time typically decreases about 20% while true direct patient interaction time (without multitasking/distractions with computer data entry) approximately doubles, contributing to improved patient satisfaction scores.

From a business model perspective, the cost of scribes is covered by the addition of one or two additional scheduled patients per day, depending on specialty. For some specialties, it is not uncommon to experience a gain of four to six patients per day following a ramp-up period during which the doctors and scribes learn to work together seamlessly as a team.

Comparing Scribing Solutions
Most onsite scribes are medical students earning income while enhancing their education. Therefore, their typical employment tenure is roughly equivalent to an academic year of nine months. Given the upfront time to get medical students trained and thoroughly integrated with a given physician, employee turnover and unsupported gaps between scribes is a constant battle for onsite scribing businesses.

In contrast, remote scribing businesses typically offer a better balance between medical students and former transcriptionists and other HIM-related staff. This balance can improve the average scribe tenure and enable a deeper organizational bench of support, one in which multiple scribes are used to support each physician client at different percentages of time so that when one leaves, others are prepared to step in.

The remote model also eliminates geographical barriers in areas where a steady stream of interested medical students is scarce.

Speech recognition–facilitated scribing solutions are a more recent entry into the market. As with any such leap of applied technology, the controlled environment demos are quite impressive. At the same time, the difference between a human-supported approach vs a pure technology solution is the ability of staff to be consistently proactive, conform to individual physician’s communication styles, and effectively minimize EHR record review and edit time.

Similar to the introduction of EHRs, the technology looks great on paper and demos well, but it has not yet proven itself to deliver the full physician time and document quality advantages of live or remote scribes.

The Future
Scribe programs work best at organizations that rely solely on physician-created documentation or that supplement those efforts with traditional medical transcription. These facilities are more likely to experience improvements in physician quality of life, patient satisfaction, document quality, and revenue per provider.

In addition to boosting key performance indicators, one organization has reported a revenue increase of $1 million per 20 scribes deployed across a variety of specialties.

There will always be a shifting balance between the contributions of technology and human effort to create and process medical records. Still, the cost-effectiveness and efficiency of the human contributions and their individual impact on quality must be considered.

In today’s health care environment, one-size-fits-all solutions are few and far between. All physicians have different levels of comfort and preference with the technology tools at their disposal. Scribes can help optimize the clinical documentation process while delivering measurably superior quality for ongoing patient care and brighter financial results.

It’s time the industry gave physicians help instead of more responsibility.

— Dale Kivi, MBA, is senior director of communications for Aquity Solutions.