December 07, 2020 - CC

PIP Spotlight: Using Virtual Documentation to Increase Clinic Efficiency

The December PIP (Practice Improvement Project) was submitted by George Deimel, MD. Dr. Deimel is a fellowship-trained, non-operative sports and musculoskeletal medicine specialist at Ozark Orthopaedics in Arkansas.

Dr. Deimel's multi-disciplinary musculoskeletal practice had a process in place that required dictation of patient appointments to a third-party service for transcription. Dr. Deimel evaluated whether or not transitioning to a virtual scribe service to record patient encounters in real-time could increase cost-effectiveness, efficiency, productivity, and job satisfaction. At the end of the project, Dr. Deimel and his clinic found the implementation to a virtual scribe was an excellent choice for the practice, and the results even led to discussions about other changes for documentation in the clinic.

Thank you for sharing your PIP, Dr. Deimel!

The PIP Spotlight is a periodic feature on News Center to highlight exemplary Practice Improvement Projects submitted by your fellow diplomates (or residents) for continuing certification (CC) credit. Diplomates can use the PIP Spotlight as a tool to plan their own PIPs or as a way to connect with other diplomates doing similar work.

What is the problem you are trying to solve?

I focused on clinical efficiency with respect to documentation. Our multi-disciplinary musculoskeletal practice had a process in place that required dictation of patient encounters to a third-party service for transcription using a a smartphone application. I felt the process was costly and inefficient. Additionally, due to the number of hours spent after hours performing the dictation tasks, this aspect of my practice was leading to job dissatisfaction and contributing to feelings of physician burnout. I assessed whether or not transition to a virtual scribe service to capture clinical encounters in real-time could be cost-effective and efficient while maintaining clinical productivity.

What data (objective measurements) do you have that supports this as a problem?

Over the past three years, I had been documenting patient encounters using a dictation system followed by back end transcription. During the initial data collection period (1/1/2019-3/31/19), I tracked the number of hours spent dictating patient encounters via smartphone app usage times and documented dictation times per each encounter type prior to implementation. On average, a new patient encounter resulted in 5.15 minutes of documenting via dictation, while a typical follow-up visit required 2.40 minutes.

While a number of templates have been developed over time to make this process more efficient, the volume of patients, pace of the clinic, and time required to dictate each encounter had pushed this task to after-hours and on weekends. Another variable I tracked was the amount of time I spent dictating after-hours (nights through the week and/or weekends). For a typical half-day clinic with an average of 24 patients (eight new/16 follow up), the time spent dictating during off clinic hours was 79.6 minutes. I have 6 x 1/2 clinics per week which equates to an additional 7.94 hours of after-hour clinic dictation times.

A proposed solution to decreasing the number of after-hours work was to set aside "administrative" time during the week to document clinical encounters. Based on the number of hours required, an entire eight-hour day would be needed, which would amount to a 20% decrease in clinical productivity resulting in a $220,000 decrease in collections, and/or 3033 in missed wRVU. Additionally, the current system of dictation and back end transcription paying per line was costly. The cost of services per year for 2018 was $41,231.

Finally, it has been widely published that medical documentation requirements and EHR interface time are the leading causes of physician dissatisfaction, emotional fatigue, depersonalization, physician-reported stress, burnout, and desire to leave medicine. While I was not able to objectively quantify, the amount of time spent after hours documenting was definitely leading to loss of work/life balance, decreased job satisfaction, and feelings of cognitive fatigue/burnout.

Pre-scribe implementation (1/1/19-3/31/19)

  • Documentation per encounter-New patient: 5.15 minutes
  • Documentation per encounter-Follow up patient: 2.40 minutes
  • Time spent per day documenting after hours per half-day clinic: 79.6 minutes
  • Time spent per week documenting after-hours: 7.94 hours
  • Cost for transcription service for three months (paying per line): $10,307.75
  • Feelings of burnout/stress: High
  • Work/life balance: Poor

What is your opportunity statement? State the goal you hope to achieve.

I hope to implement an efficient, cost-effective, and sustainable system to capture important and necessary clinical information while performing clinical encounters that will allow for continued clinical productivity, decrease the amount of time spent on after-hours documentation, and potentially decrease practice costs associated with current dictation/transcription services. The ultimate goal is to restore work/life balance while maintaining clinical productivity.

What is the underlying cause of the performance/quality problem?

The primary cause of the current problem stemmed from the functional, but out of date, medical record-keeping system in place. The primary workflow was designed for an orthopedic provider with succinct, problem-focused notes that could be easily dictated and transcribed into a Microsoft Word document after each encounter. With the growth of the practice, the addition of non-surgical providers who see a range of problems and more complex neurological conditions, and the continued expanding requirements of documentation for medical, legal, and reimbursement purposes, the current system was no longer an efficient means to capture clinical information. The cause was determined after collaboration and discussions with other non-operative providers, surgical colleagues, clinical staff, administrative staff, and IT professionals.

What change(s) did you implement?

For a variety of reasons, the practice decided to transition to a cloud-based electronic medical record system on April 1, 2019. This allowed for evaluation of our clinical workflow, including how we each documented clinical encounters. I had previously dictated clinical encounters using a third-party transcription service. The service was adequate, but also time-intensive, inefficient, and costly. I researched several different options and ultimately decided to use a real-time, virtual scribe through MModal transcription services. A change was including a mobile cart with a laptop and speaker to taken into each clinical exam room. I had to explain to each patient that an assistant was listening to each encounter to help with documentation of the encounter. A scribe remotely listened to each patient-clinician encounter during the course of the clinical visit to document directly into the patient chart. The service used CDI to make sure each encounter was accurately and completely captured. During the initial implementation (training phase), collaboration between the clinician and scribe occurred after each encounter to ensure that the necessary information was captured. After initial implementation, the encounter was reviewed and closed finalizing all documentation at the completion of the clinical visit.

Did you achieve your goal or target from your opportunity statement? What data do you have to support your conclusion?

Yes. With the change in our EMR to a cloud-based system, I was able to implement changes to the clinical documentation workflow. I contracted with a virtual scribe service to provide real-time documentation of clinical encounters. Since the initiation of this service, I have had 0 hours of after-hour documentation of clinical encounters. I did not dictate at nights or on weekends during the data collection period of August 1, 2019 to October 31, 2019.

Pre-scribe implementation (1/1/19-3/31/19)

  • Documentation per encounter-New patient: 5.15 minutes
  • Documentation per encounter-Follow up patient: 2.40 minutes
  • Time spent per day documenting after hours per half-day clinic: 79.6 minutes
  • Time spent per week documenting after-hours: 7.94 hours
  • Cost for transcription service for three months (paying per line): $10,307.75
  • Feelings of burnout/stress: High
  • Work/life balance: Poor

Post-scribe implementation (8/1/19-10/31/19)

  • Documentation per encounter-New patient: 0 minutes
  • Documentation per encounter-Follow up patient: 0 minutes
  • Time spent per day documenting after hours per half-day clinic: 0 minutes
  • Time spent per week documenting after hours: 0 hours
  • Cost for scribe service for three months (paying per hour): $6,048
  • Feelings of burnout/stress: Low
  • Work/life balance: Great

Will you continue with the changes you have implemented?

Yes. Overall, the implementation to a real-time, virtual scribe for clinical documentation has been an excellent choice for my practice. I plan to continue with this arrangement going forward as it has allowed me to re-balance work/life commitments, continue to maintain clinical productivity, and decrease practice costs. Most importantly, it decreased some of the mental fatigue caused by the added work time per week and feelings of burnout due to the overwhelming documentation requirements. Evaluating this part of our clinical practice workflow as part of the PIP has led to discussions about how we could implement other changes to documentation, including ultrasound guided and fluoroscopically guided procedure notes and EMG reports, which are documented using other formats.