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How medical scribing is utilized at the point of care [PODCAST]

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In this episode, Dr. Josh Hurwitz and Warren Johnson of Scribe-X discuss how scribes are being used at the point of care to improve the experiences of patients and physicians along with delivering financial benefits for clinics.
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Mike Passanante: Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast.

Today, I’m joined by two guests. The first one is Dr. Josh Hurwitz, the co-founder and medical director of Scribe-X. Dr. Hurwitz is a board-certified emergency physician practicing in the Portland, Oregon area. Prior to studying medicine, Dr. Hurwitz was a software engineer developing web applications for a host of small and large firms including Intel, Microsoft, Starbucks, Hewlett-Packard and Timberland.

I’m also joined by the CEO of Scribe-X, Warren Johnson. Prior to founding Scribe-X, Warren founded Stat Medical Services and grew it to over 650 nurses to become the largest medical staffing company in the Pacific Northwest. Warren also founded ShiftWise, now the largest medical staffing vendor management software company in the nation serving more than 500 hospitals.

Josh and Warren are here today to discuss how medical scribing is utilized at the point of care to help improve physician and patient satisfaction levels along with providing financial benefits to providers.

Joshua and Warren, welcome to the podcast.

Warren Johnson: Thank you very much.

Dr. Josh Hurwitz: Thanks!

Mike: So Josh, let me turn to you first. Can you briefly describe what scribing is and when it began?

Dr. Josh Hurwitz: Well, thanks! Medical scribing began about 20 years ago primarily in emergency department when emergency physicians realized that the medical documentation software, the EMR, was distracting them from their job as physicians in taking care of patients. It took them a long time to produce these medical documents that reflected how they cared for their patients.

Scribes took over in documenting those encounters. And a byproduct of that was increased patient throughput, increased doctor efficiency and the physicians, as it turns out, enjoyed their practice more because they weren’t distracted with all the requirements of the EMR.

So, scribes took off in the emergency department, and since then, have penetrated to out-patient clinic practice and into hospitals where scribes have now been shown, through a variety of modalities, to improve patient throughput, improve clinic revenue and improve doctors’ quality of life.

Mike: Josh, can you describe some of the environments where scribes are typically utilized?

Dr. Josh Hurwitz: Well, as I’ve mentioned, the emergency department is where they began. But since then, scribes have been incorporated into clinic practices both in primary care and specialty practice. For instance, you’ll see scribes in specialties ranging from cardiology to gastroenterology to urology and general surgery. Basically, all of the main medical specialties, if they haven’t adopted scribes, they have at least heard about it and are, in many cases, experimenting with it.

Mike: So, Warren, let me turn to you. Can you describe some of the financial benefits that practices and hospitals have experienced with scribing?

Warren Johnson: Absolutely! I’d be happy to.

This is one of the best levers I think in the industry. As you find clinics and hospitals having to add more people to their teams to improve compliance and run the operations of the company, there aren’t really a lot of good ways to impact revenue in any kind of dramatic way. But using a scribe and using them properly is a fantastic tool.

And the way that they impact the revenue of a clinic or hospital is really in three ways—and I’ll go through all three.

One is charge capture improvement, increased productivity, and then the last one, which is a little bit different (I will certainly explain it) is just improving access and how that has an impact for some organizations.

So, on the charge capture side, what we’re seeing is that the quality of charts are being improved because everything that happens in that room is being recorded—and recorded in a sense that the scribe is watching the interaction. They’re documenting what they see the doctor do as well as the things that the doctor comments on during the visit.

And because of that, the quality the charts are almost always better. In the low end of what I see in the data is an 8% improvement in the value of that encounter. Part of that too is that I think physicians in general or providers under code. About 85% of them are known to under code the charts. And when you have a scribe in there, you I think relax a little bit more because you know that everything that happens is being recorded, and you don’t have to worry about “Did I remember it right? Or did I do it or not do it?” or whatever. So, you’re just seeing the value of that record improve.

In the high end of what I see is a 27% improvement; and the average is about 15%. Typically, that Improvement pays for the service and more just by itself.

And what we’re also finding on the charge capture side—which is kind of interesting—is that primary care is where we’re getting the very best results. So, that’s probably not what most people would think.

The second way that we’re impacting revenue is really on the productivity side. And what that means is that the provider is able to see more patients in the same amount of time. And there are some different strategies you can use to get there—and I’ll go through those up here in a second. But the range of improvement and productivity that we’re seeing is, in the low end, a 15% improvement, on the high end, a 79% improvement with an average of about 35%.

I have to qualify that because this is for organizations where their goal is to improve access, improve productivity. Some providers are just selecting a scribe because they want improve the quality of their life. They don’t want to spend as much time documenting. And for them, you’re not going to see as dramatic of an impact.

But generally, customers can see as many patients as they want. If you select them properly and properly train them, they can help you see as many folks as you’re willing to.

The real key in productivity that we’re finding though is that you really need to have a strategy for how you’re going to schedule those patients. There are three primary strategies there.

One is double-book the patients, so that you’re not having a lot of no-shows and a lot of idle time for the provider. The other way is to shorten the visit a bit. Sometimes, a new patient, you might shorten it from a 50-minute visit to a 45-minute visit.

And the other strategy which has been also used fairly successfully is just adding an hour or so of contact time. That’s more than enough time to see enough additional patients for that program to pay for itself.

And then, the last one which is a little bit more obscure, but if you’re an FQHC or really dealing with compliance and making sure that all the key quality measures are in the system, often, there’s additional reimbursement that’s available to help bring that revenue source in. And that’s certainly going to be the case as we move more and more towards the value-based payments model.

I think the way that we typically like to present a program before we ever get started is we do what’s called an ROI and break-even analysis. So we’re helping the customer understand what is it going to cost and what can they expect from a revenue perspective and what’s that return on investment going to look like.

And so, in the things that we’ve dealt with, it’s usually a 2 to 10 times return on investment.

For example, if you’re going to invest $40,000 in a scribe, having a scribe and working with a provider, you’re going to see an improvement in $82,000 to $384,000 in additional clinic revenue.

And so, again, the impact of that investment is like nothing else I’ve ever seen in healthcare. And this is part of what gets me excited to tell that story.

It does depend on your productivity goals, the specialty that you’re working in, the patient population that you’re working with, what your payer mix is, those kinds of things. And typically, when I’m measuring this, I’m not measuring anything other than the visit revenue. But if you’re in a specialty, let’s say cardiology, the downstream revenue that comes from the tests and things that those providers use, especially if it’s all done in-house, that’s something that is going to have a big effect.

But what we what we see consistently across the board is programs like ours pay for themselves. We’ve seen one to three additional patients. And again, it depends on whether you’re predominately Medicaid financed or commercial financed or those kinds of things.

And then, the last piece that I look at from a financial perspective—and what we do with the analysis that we do—is we try to calculate the break-even point. And so, what we do is take all the costs—the cost of the computer, the cost of let’s say a rolling cart if you’re going in another room with the computer, a camera if you’re using a telescribe solution like we offer, then you take all those expenses, and including training, et cetera, the break-even point happens within 3 to 17 days, clinic days.

So, let’s say the cost is a couple thousand dollars to get started. You’re going to recoup that investment in its entirety within that time frame. And then, from that point forward, throughout the year, it’s going to be a revenue increase, a revenue driver in the organization.

But generally, the break-even point can happen without seeing more patients. It can happen just by improvements in charge capture.

Dr. Josh Hurwitz: I’d like to jump in if I may just real briefly and touch on the concept of adding content time in the day. And this has to do with the philosophy behind medical documentation in general.

The chart is a very precisely formatted document that can be developed either really thinly or very verbosely depending on what your documentation style is. And a scribe will learn to mimic that style. But traditionally, doctors have taken the end of the day to complete their charts because they’re so busy during their day or during their shift. And that can take two or three or four hours at the end of the day.

A lot of family practice doctors, emergency doctors, specialists will all agree with me that that time is very onerous.

By using a scribe, you eliminate most of that time. So at the end of the day, instead of producing and documenting, your editing a document that’s been made contemporaneous with all of the visits that you’ve done during the day, by adding an hour of patient contact time at the end of the day, you’re not extending the length of your work day. You’re actually decreasing it probably by…

Warren Johnson:  Two hours…

Dr. Josh Hurwitz:   …a couple of hours. But instead of taking that time to simply produce charts, you’re actually seeing patients, rendering healthcare and generating revenue.

Warren Johnson: And I think something that really ties into that that also has another financial impact on the organization is you’re decreasing the backlog of patients.

Let’s say when I walk into a specialty clinic like endocrinology or something like that, the clinic administrator or the doctor is telling me that they have a 5- or 6-month wait period before they could see these people who are generally very sick, not always well-maintained, et cetera.

And so what I have done on a number of occasions is I’ll go through the process of calculating the value of that backlog. By increasing the flow or the throughput of patients through the clinic, that backlog is getting decreased. And sometimes, you can quantify that backlog even in a 6-, 7- or 8-provider practice. It could easily be over a million dollars sitting there. You’ve got it scheduled, you’re not able to bring it into the clinic until you see the patient. But by improving access, you’re improving the quality of care, but you’re also significantly improving the financial benefit.

And I think what people forget is that patients are only willing to wait so long. And sometimes, they have choices, and they could choose to go to another clinic.

One of the gentlemen here in our community had literally calculated that number, and he said what they found is about 25 days is the longest that the patient was willing to wait. And so, he knew that if that backlog was any larger than that, he was losing those patients to other clinics which isn’t good for care, it isn’t good for the doctor, it isn’t good for the financial position either.

Mike: You mentioned value-based payment programs, and certainly, that’s an issue that’s on the mind of providers around the country particularly because over the next several months, physicians will be participating in one of the two MACRA pathways as part of how they get paid from Medicare. Can you talk about how scribes can help them more effectively participate in that program?

Warren Johnson: What we’re seeing now is many of our FQHC’s and other clinics that really rely on data collection to be in compliance for payment are getting excited about value-based payments and looking at the scribe program as a way for them to really improve their reimbursements.

And what’s happening there is that the model for which they’re going to get paid is really almost turbo-charged with the fact that they can collect all the data, elements that are required in order to maximize that payment.

It’s something that I haven’t seen before until just recently. But it is something that we’re seeing trend pretty strongly in the market.

Mike: So, let’s turn to hospitals. Hospitals have, again, increased their levels of physician practice acquisition and partnering. And when these entities come together, there’s often a need to align the documentation practices to fit hospital standards for compliance, billing and so on.

How can scribes help make this process go smoother?

Dr. Josh Hurwitz: I’ll take that. This is Josh. A lot of doctors will agree with me that the prospect of changing EMR’s or changing documentation systems and integrating into a healthcare bureaucracy is really overwhelming.

And the way that scribes can offset that sense of doom is by taking on the burden of the documentation system, learning the documentation system, and having at their fingertips all the power of these new EMR’s (because for all of their drawbacks, they do have some pretty powerful advantages).

The scribes are able to use their knowledge to assist doctors in streamlining their practice around the EMR, including order entry (which some doctors are using scribes to do).

But in terms of documenting the visit and navigating the digital bureaucracy that underpins a lot of the healthcare organization’s infrastructure, the scribe is able to very seamlessly use those tools and free up the doctor to actually engage in healthcare and talk with patients and examine them and help them make healthcare decisions without having to run around talking to tech support and learn why whatever button in the EMR isn’t working the way they thought it should.

Warren Johnson: I can give an example of that. We recently signed a contract with a large health system here in our community to do what they call EMR support. Another term for it is at-the-elbow support.

And so they have acquired a community hospital that owns several clinics as well. And they’re moving off of nine different EMR’s that they use for various functions within their organization to EPIC which is the most common one in our area. And what they really want from a scribe is they want the scribe to be there for a few weeks while the doctor is becoming familiar with it.

So, the doctor has gone through the training of how to use the EMR, but they’ve not had opportunities to really utilize that tool in the course of their daily practice.

And so, the scribe is really there just to answer questions, help them navigate the system and kind of do the base level support. Whereas the IT department would troubleshoot at a different level (other issues that maybe the EMR’s aren’t performing in the way that they have anticipated).

So, it’s a very common thing. And scribes can play a key role in that process.

Dr. Josh Hurwitz:  They function essentially as a super user would in supporting the doctors. They navigate the new EMR.

Mike: Before the podcast, we talked a bit. And you mentioned to me that hospitals are using scribes to help recruit physicians. Can you explain more about that?

Warren Johnson: We see, particularly in rural communities, that physicians are difficult to find. And so it’s hard to compete with, let’s say, an urban center for some of these physicians—really, in all areas, specialty physicians and primary care.

And the other aspect of what these organizations are struggling with is they may have a provider who is near the end of their practice lifetime, and they want to extend that in some way while they spend time trying to recruit and replace this person.

And so we’re seeing many organizations now utilize us really as a strategy to encourage physicians to come and work in their communities. And so it’s attractive to physicians to have a scribe program in place because from a quality of life perspective, they’re able to reduce the amount of time they’d spend documenting generally by two or three hours a day. That improves the quality of their life. And if they choose to use the scribe to see more patients, it can also improve the level of compensation that they get from the organization that they’re signed up with.

And so, we’re seeing this as a competitive tool for both recruiting physicians or providers of all types; and in some cases, just holding on to them a bit longer.

Dr. Josh Hurwitz: Here’s an anecdote. One doctor we worked with was basically working four days a week as opposed to five. He cut his workload down, so that his documentation time was more manageable. He was spending four and five hours a night just doing documentation and time on the weekends. And it was upending his life.

When he brought a scribe into his practice, his documentation time was reduced so much that he was going home on time, having dinner with his family, and decided to add that work day, fifth work day, back into his schedule and see patients on that day.

It was a huge improvement in his quality of life. And it made for a lot better running of the clinic obviously. He was able to see more patients and make revenue for the clinic.

Warren Johnson:  I think in a small community, that has an impact on the quality of care in that community as well because you’ve got more clinical support available to the patients that need it.

Mike: So, you just gave a great story about helping to improve the productivity and lifestyle of physicians. Can you talk a little bit more about that?

Warren Johnson: Yeah, absolutely. What we see most often is we’re being asked to come in and put a program in place when physicians have felt like their quality of life has been compromised.

And in our minds, it’s far beyond having more time to do hobbies like skiing. It really encompasses a number of other areas I think which are really important to touch on.

First of all, when physicians/providers are trained to become care providers, they don’t think about documentation necessarily as part of what they ought to be doing. They see that really as a clerical task. And they want to spend their time focused on the patient. They want to spend as much time as possible with that patient, and as little time documenting as possible. And so the quality of life component really starts in the room with that patient.

And the other critical aspect of that is that, in many cases, if you’re a physician practicing medicine, you walk into a room either with a computer in your hand (or there’s one in the room) and you’re, in essence, being asked or you’re asking yourself to document during the visit which really takes the focus off the patient and makes it more difficult to deliver the care and certainly didn’t do it in an efficient manner.

And so, there’s that aspect of really being a better care provider. It’s less stressful for the physician. They’re happier to come to work and do their job because they’re not doing the clerical thing at the same time as they’re looking to take care of the patient.

And then, I think Josh had touched on this before. But what we’re consistently seeing in the work that we do is that we’ll walk into a clinic, and three hours is generally the minimum amount of time they’re spending documenting throughout their day. So, either they’re doing that after they’ve seen the patient. They’re going and dictating, and then having to come back and edit those notes. That’s often happening at the end of their day. So, they may start their day at 7 and finish at 10 or 11. And then they might be documenting on the weekends.

We can get that time down on a per day basis from, let’s say, three hours to about 30 minutes on average. So there’s a substantial amount of time that’s added back into their their day.

I’ll give you a quick example. I had lunch with a clinic, a rural clinic. And the doctor had said, “Oh, my God! I didn’t have a scribe this morning, and I’m already exhausted. With a scribe, the day passes so quickly. And sometimes I’m just surprised that the day is already over. And without one, just the quality of my experience and my energy and what I bring to my practice is so just so much different.”

Dr. Josh Hurwitz: This is why I’m excited about scribes. I use them in my practice as an emergency doctor. And the scribe allows me as the doctor to do doctoring things and not have to do clerical things. I don’t want to have to push buttons and type all day long. I got out of software engineering for a reason. I was bored looking at a computer all day. I want to take care of patients. And scribes allow me to focus on that.

And they allow me to be more efficient to the tune of, for instance, if without a scribe, I’m able to see 1.7 or 1.8 patients per hour (in the emergency department, we look at patients per hour), a scribe will allow me to see 2.2 patients per hour or 2.5 patients per hour depending on where I’m situated in my department.

Every situation is unique. But there’s no question that there are proven efficiency gains when you bring a scribe into your practice.

And what that does for me is it allows me to build rapport with my patients. Instead of looking at a computer, I’m looking my patient in the eye. And instead of thinking about “Oh, I have to capture this piece, I have to remember this piece of data that the patient told me when I’m reviewing systems or I’m gathering history of present illness,” I don’t have to worry about that. It’s all captured. I get to review it and edit it later and think about it and not have to worry about interacting with a computer.

And furthermore, what makes me even more excited about it is that by improving my efficiency and by improving my throughput, I’m rendering more healthcare. I’m taking care of more patients who need that care, who aren’t able to get in to see whoever their primary care doctor is for instance. If you’re a gastroenterologist or if you’re a urologist, you’re able to see more patients who are referred to you in a given volume of time. And that can only have a public health benefit.

So, when we talk about the efficiency gains and the implications for clinics, it goes well beyond those instances. It really can touch on public health if we harness the power of this resource.

Mike: Josh and Warren, that was great information. Thanks for helping our audience understand more about the benefits of medical scribing.

If our listeners would like to find out more about Scribe-X, where can they go?

Warren Johnson: You can go to our website. It’s www.Scribe-X.com. Or you can reach out to myself, Warren at warren@Scribe-X.com. Or you can reach out to Josh at josh@Scribe-X.com.

Dr. Josh Hurwitz:  We’re also on Facebook and LinkedIn.

Warren Johnson:  The direct line to me is 503-896-8440. I’ll be happy to provide any additional information, answer any questions you might have and certainly serve as an advisor as best I can.

Mike:  Josh and Warren, thanks again for spending some time with us today on the Hospital Finance Podcast.

Dr. Josh Hurwitz: Thank you for having us.

Warren Johnson:  Thank you for the opportunity. Have a good day.

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