Efficient MD https://efficientmd.com Improving physician efficiency Mon, 10 Dec 2018 17:04:01 +0000 en-US hourly 1 https://wordpress.org/?v=5.0.1 140971972 Are Scribes The Solution To Our Documentation Woes? https://efficientmd.com/are-scribes-the-solution-to-our-documentation-woes/ https://efficientmd.com/are-scribes-the-solution-to-our-documentation-woes/#respond Mon, 10 Dec 2018 17:03:55 +0000 https://efficientmd.com/?p=113

In response to the increasing burdens of administrative work and cumbersome charting levied upon healthcare providers in recent years, medical scribes have been touted as a potential solution for streamlining the documentation process.  Interest in the use of scribes has certainly been increasing, with the American College of Medical Scribe Specialists estimating that the number of medical scribes nationally will increase from 15,000 in 2014 to more than 100,000 by 2020.

Who are medical scribes?

Medical scribes are often college students looking to gain exposure to the medical field, many of whom are planning on applying to medical or PA school in the future.  There are also those who work full-time as medical scribes. The salary of a medical scribe ranges from $13-18 per hour and the cost to hire a scribe is around $20 per hour.  While there are courses and certifications dedicated to medical scribing, medical scribes are not required to go through a certification process.

The precise role of the medical scribe will vary by institution, but they generally perform a variety of tasks with the goal of maximizing the provider’s workflow efficiency.  In addition to transcribing the medical chart, scribes may also obtain prior records, notify the provider of lab and imaging studies once resulted, and prepare discharge instructions.

A new twist to the medical scribe paradigm is the implementation of virtual scribes.  A virtual medical scribe remotely accompanies the physician during a patient interaction, documenting the encounter in the electronic medical records off-site.

Benefits

The most apparent purported benefit to having a scribe is increased productivity by minimizing the time spent on documentation and other secretarial tasks.  One retrospective study found that the use of scribes by emergency physicians was associated with improved overall productivity as measured by patients treated per hour and RVUs generated per hour.  A prospective cohort study at a tertiary academic ED, published in 2017, found that scribes enabled attending physicians to see more patients per hour, though they did not improve overall patient throughput.  In the primary care setting, the use of medical scribes has been associated with significant reductions in electronic health record documentation time and significant improvements in productivity.

Other  benefits to using scribes, as reported by physicians who have worked with them, include better patient interactions, improved physician satisfaction, and potential mitigation of physician burnout.  Some feel that the quality of the patient encounter is improved by allowing the provider to focus more on the patient interaction than data entry.

The costs associated with the implementation of a scribe program or hiring an independent scribe are significant.  In addition to the salary of the scribe, other expenses may include costs associated with training, hardware and tech support.  Proponents of medical scribes argue that the increased productivity that results from the use of scribes offsets these costs.

Downsides

From my personal experience working with scribes, the biggest downsides are the variability in the quality of the scribes and their rapid turnover.  I found that it would take some time for a particular scribe to understand how I structure my workflow and document my charts. Our working dynamic would steadily improve, right up until they left for medical school.  A new batch of scribes would come in and the process would have to start all over again. When working with an inexperienced scribe, I would often have to spend so much time modifying the chart to fit my documentation style or to make corrections, that I would have been better off documenting the chart on my own from the beginning.

Moreover, having an additional person in the room during the H&P also has the potential to negatively impact the provider-patient interaction.  It may even affect the accuracy of the history being obtained. I can certainly imagine a scenario where a young male would be less willing to discuss his penile discharge when a college-aged female is at the bedside transcribing the history, than if only the physician were present.  Patients are often in a very vulnerable state when presenting to an emergency department or clinic. It’s imperative that we try our best to create an environment that allows patients to speak comfortably about the most intimate details of their lives. Adding another person to the mix may hinder this.  While I have had patients tell me that they would prefer to be seen without the scribe present, some patients may not be as comfortable making such a request.

The Upshot

To answer the question, whether scribes are the solution to our documentation woes, I would have to say “no.”  I’ve had great experiences working with scribes and have seen first-hand their ability to save documentation time and streamline the charting process.  However, a solution that requires every physician to have another person following them on their shift, whether it’s in-person or remotely, is not truly a solution.  Rather, it is a stop-gap measure that does nothing to address the underlying problems, inefficient EMRs and burdensome compliance measures. The real solution will be the development of an EMR that is built with the focus on clinician usability, without sacrificing the ability to capture revenue.  With the advent of advanced speech recognition technology and artificial intelligence, which promise to simplify the way we will interact with our devices, I’m hopeful that such a system is on the horizon.

What are your thoughts on medical scribes?  Comment below or head to the Facebook group to let us know.

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Speech Recognition Software Will Change Your Life https://efficientmd.com/speech-recognition-software-will-change-your-life/ https://efficientmd.com/speech-recognition-software-will-change-your-life/#comments Wed, 28 Nov 2018 18:33:59 +0000 https://efficientmd.com/?p=105

Over the past few years I’ve noticed more and more of my colleagues in the emergency department using speech recognition (SR) software to dictate their notes rather than type them.  Although I consider myself a technophile and I love experimenting with new technologies that could allow me to work more effectively, I resisted jumping on the SR bandwagon for a couple of reasons.  

 

Firstly, I had convinced myself that I was proficient enough at typing that SR software was simply unnecessary.  I can type at approximately 80 words-per-minute (wpm) with a high degree of accuracy and didn’t think that SR software would provide much of an advantage beyond what I was already doing.  (If you’re curious to check your own typing speed you can test it here: https://www.typingtest.com/test.html)

 

The other major reason I was reluctant to try it out, as silly as this may sound, is that I was self-conscious about having other people overhear me dictating.  I can’t explain exactly why I felt this way. Was I worried that others would judge how I worded my HPI and MDM? Was I concerned that someone would overhear my plan and disagree with it?  I can’t tell you for sure but there was something off-putting about verbalizing my documentation out loud.

 

I regret allowing these hangups to put me off of trying SR software for as long as I did because it has truly been a game-changer for me.  Little did I realize that today’s SR software can accurately dictate twice as fast as I can type. According to Nuance Communications Inc., a manufacturer of Dragon Medical software, voice dictation averages 150 words-per-minute.1  Regarding the concern about other people overhearing me while I dictate, I initially dealt with this by seeking out secluded locations where I could dictate in private.  After a while, though, I realized that dictating in a room with others doesn’t really bother me like I thought it would. When I finally fully embraced SR dictation software I found that I was completing my charts in a fraction of the time that I had previously.  Since integrating it into my practice I can’t imagine working without it.

 

HOW ACCURATE IS SR SOFTWARE?

I haven’t been able to find much literature looking at the accuracy of SR software in an emergency department setting.  A study done by Goss et al2 reviewed a random sample of 100 notes dictated by attending emergency physicians using SR software.  They found that 71% of notes contained errors or some sort. 15% of the charts contained one or more critical errors, meaning they could have affected providers’ decisions about patient care.  It’s important to point out that the notes that were analyzed in this study were from 2012. I imagine that SR technology has evolved significantly since this study took place.

 

NUANCE DRAGON MEDICAL VS M*MODAL

There seem to be 2 market leaders in the medical SR software industry: Nuance Dragon Medical and M*Modal.  I’ve had the opportunity to use the SR software made by each company while on shifts in the emergency department.  While they have both have created remarkable products that will dramatically improve the efficiency of your workflow, if I had to choose one to work with on a daily basis it would be the software made by M*Modal.  Their software seemed to have an edge when it came to accuracy, especially when it came to recognizing obscure medical terminology.

 

TIPS FOR USING SR SOFTWARE

  1. Enunciate clearly — While SR software has become remarkably good at deciphering my mumblings that tend to occur towards the end of my shift, there’s only so much you can expect from it.  Enunciate clearly to minimize the number of times that you’ll have to go back to correct misspellings.
  2. Don’t speak too quickly — Another limitation of any SR software is the speed at which it can accurately detect your speech.  As long as you speak at a normal conversational speed, or even slightly faster, the software will have no trouble following along.   If you start speak like the Micro Machines guy the software will likely struggle to keep up.
  3. Minimize ambient noise — Another thing that really impresses me with the current SR technology is the ability of it to filter out ambient noise.  That being said, it will occasionally pick up surrounding voices, so the less ambient noise, the better.

 

START USING ASAP

If you have access to SR software and aren’t already using it, try it out on your next shift.  If your department hasn’t integrated it into your EMR, talk to your administrators about doing so.  It’s well worth the investment and will improve the productivity and well-being for everyone in the department.

 

Do you already use SR software?  Do you find it as helpful as I do?  Let me know at theefficientmd@gmail.com

 

  1. https://www.nuance.com/content/dam/nuance/en_us/collateral/healthcare/demo/dmo-nuance-dragon-medical-infographic-en-us.pdf
  2. https://www.ncbi.nlm.nih.gov/pubmed/27435949
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Dramatically Speed Up Your Charting Using The Autocorrect Dictionary https://efficientmd.com/dramatically-speed-up-your-charting-using-the-autocorrect-dictionary/ Sat, 10 Nov 2018 23:43:46 +0000 https://efficientmd.com/?p=61

The autocorrect dictionary in your EMR can be used to significantly increase the speed of your documentation. This is the tool that corrects inadvertent mis-spellings.  For example, “paitent” would be automatically corrected to “patient.”  However, this tool can also be used to change letters into words and short phrases.  This can allow you to create a type of shorthand which minimizes the number of keystrokes needed when documenting.  Common examples of this include “pt” becoming “patient” and “hx” becoming “history.”  If there are multiple two-letter abbreviations that you commonly use, you can distinguish them by making one lower-case and the other in CAPS.  For example, “pt = patient” and “PT = physical therapy.”

The autocorrect dictionary can also be used to create entire phrases from just a few keystrokes.  For example, I found that I was constantly typing the phrase “…who presents to the emergency department for the evaluation of…”  Using the autocorrect dictionary I can turn this into the  3-letter shorthand “wpt.”  The current build of Epic that I use allows me to create phrases up to 64 characters in length.

Using some of the autocorrect shorthands that I’ve created, here is a demonstration of how powerful this feature can be:

 

Mr. Smith is a 46yo m waho htn, cad, dm, and chf, wpt cp.  Hdp as a “pres” sen that does not rad.  Pt rtp as 7/10 in sev.  The pain is exac w exer.  He den f, c, n, v, or sob.  Pt den hhs.” (188 keystrokes)

becomes

Mr. Smith is a 46 year-old male with a history of hypertension, coronary artery disease, diabetes mellitus, and congestive heart failure who presents to the emergency department for evaluation of chest pain.  He describes the pain as a “pressure” sensation that does not radiate.  Patient rates the pain as 7/10 in severity.  The pain is exacerbated with exertion.  He denies fever, chills, nausea, vomiting or shortness of breath.  Patient denies having had symptoms like this in the past.” (481 keystrokes)

 

In this brief example the autocorrect dictionary decreases the number of keystrokes from 481 to 188 keystrokes.  This is a 61% decrease in the number of keystrokes used to create the same document.  How does this translate to real world benefit?  If it takes you 10 minutes to complete a typical chart, implementing this single change to your documentation would save you 4 minutes per chart.  If you see 20 patients on a given shift this would free up 80 minutes!  How would you spend those additional 80 minutes that you gained?

If you decide to implement a shorthand system such as this using the autocorrect dictionary you will find that your charting will actually be slower than usual when you start using it.  This is because you will frequently have to stop and recall the shorthand abbreviations that you had created. Before long, though, the muscle memory will kick in and you will start using the abbreviations automatically.

Do you already use your autocorrect dictionary to speed up your documentation?  Have you found it to be helpful?  If you have any additional autocorrect tips and tricks to add I’d love to hear them.

If you’d like a spreadsheet with the autocorrect abbreviations that I use in my own documentation just email me at theefficientmd@gmail.com and I will send you a copy.  Please write “autocorrect dictionary spreadsheet” in the subject line.

(note that the specific functionality of your autocorrect dictionary will differ depending on the particular EMR that you are using.  The examples that I provide here are specific to Epic)

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8 Strategies To Help You Leave Your Shift On Time https://efficientmd.com/8-strategies-to-help-you-leave-your-shift-on-time/ Fri, 02 Nov 2018 23:37:49 +0000 https://efficientmd.com/?p=59 It’s 1am.  My 12-hour shift ended an hour ago but I’m still in the hospital working on my incomplete charts.  I’m exhausted and my brain is fried.  I desperately want to go home and get a good night of sleep before returning for my shift tomorrow. However, leaving now means I will have to come back early tomorrow to finish my documentation before the start of my next shift.  I take a deep breath and power through until the last chart is finally complete.

 

The early stages of burnout

I had only been out of residency for a few years but I was already starting to feel the effects of burnout.  I found that I was beginning to feel cranky and agitated all the time.  I would get depressed at the thought of having to go back to work.  I would routinely spend an hour or more after each shift, or occasionally on my days off, completing my charts.  I knew that this extra time spent on documentation was contributing to feelings of burnout that I was experiencing.  “If I’m feeling like this after working for just a few years, how could I possibly sustain this for the next few decades?” I’d routinely ask myself.  Realizing that this was absolutely not sustainable I committed to figuring out strategies that would allow me to leave my shifts on time with my charts completed.

 

Some things are out of your control

There are numerous factors affecting the throughput of patients in the emergency department but it is important to realize that many of these factors are out of your control.  These include things like department space, staffing, sick calls, lab processing time, delays for imaging studies, etc. Todd Beel, MD, FACEP, notes that “fifty percent of efficiency is a systems issue.”1 While there’s always the option of joining the administrative team to effect change on an operations level, most of us would be best served to focus on the things that are within our immediate control.

 

Focus on the things you can control

I try to adopt this as a life philosophy but it certainly applies to the work environment. After accepting the fact that there will always be systemic issues related to department flow that I won’t be able to change I decided to figure out what I could do to improve my own efficiency and allow me to leave my shifts on time.  Here are some of the things that I have found to be helpful in my own practice.

  1. Adopt a “pre-shifting” strategy – When I did my internal medicine rotation in medical school I was introduced to the concept of pre-rounding. This involves checking the newest test results, reading the most recent progress notes, and assessing your patients before rounding with your team.  This allows you to be as prepared as possible for your presentation and help to streamline the rounding process.  The better prepared you were, the smoother the rounds would go.

I refer to “pre-shifting” as the period of time just prior to the start of my shift that similarly allows me to mentally prepare for the work day.  I allow around 15-20 minutes for this process.  I use this time to grab some coffee and a snack, review the final results and studies from my previous shift, do follow-up calls with patients, clear my inbox, and take care of other tasks that I would otherwise try to squeeze in during the course of my shift.

Before adopting this strategy I noticed that the start of my shifts often followed a similar pattern.  I would walk in several minutes before my scheduled shift and would immediately be pulled in multiple directions: the outgoing doc looking to sign out, the ED tech asking to get some EKGs signed, the charge RN notifying me of the cardiac arrest that is 5 minutes out, etc.  The hunger pangs would start to kick in about 2 hours into my shift and make me deeply regret not arriving early enough to grab a bite before the shift began.  Meanwhile, I’m ruminating about a patient I had seen the day prior and trying to figure out when I can find a few minutes to make a follow-up call.

As a medical student I was advised by one of my attendings to start each shift with “a full stomach and an empty bladder.”  I think this is great advice but I would expand it and recommend that each shift should also begin with a clean mental slate.  Minimizing the number of tasks that you need to complete and the number of times that you task-switch during your shift will allow you to better focus on the patients in front of you.  Pre-shifting helps you accomplish this and ultimately leads to more efficient charting, quicker dispositions, and ultimately more effective use of your time.

 

  1. Minimize distractions and interruptions – Easier said than done, I know. A study by Chisholm et al2 found that physicians working in an emergency department were interrupted a mean of 31 times in 180 minutes. While it is impossible to eliminate all distractions and interruptions while on your shift there are steps you can take to minimize them.  Do you typically do your charting in a workroom and find yourself getting sucked into work gossip? Find a more secluded place to escape to focus on your charting.  Getting frequent calls from nurses to find out what the plan is for your patients?  Speak with your nurses at the beginning of each patient encounter to discuss the plan up front.  Pay attention to the most common distractions that you encounter on a typical shift and figure out ways to minimize or eliminate them.

 

  1. Delegate when possible – There are certain tasks that only you, as the provider, can do.  I consider these to be the essential tasks. These include things like charting, placing orders and discussing patients with consultants.  The greater the percentage of your shift that you spend on these tasks the more efficient your work will be.  This is something that I have struggled with in the past. With the intention of trying to expedite patient care I would often find myself transporting my patients to X-ray, putting in IV’s, etc.  While performing these tasks on your own may speed up the throughput for that particular patient, keep in mind that every minute spent on a task that could be done by another staff member translates into another minute that could otherwise have been spent completing your essential tasks.

 

  1. Chart more efficiently – Of all the factors that can impact your work efficiency this is the one that will likely be the most impactful for the majority of providers.   Whether you love or hate them, electronic medical records (EMRs) are here to stay. While it’s easy to get bogged down in the endless number of checkboxes and compliance regulations that accompany EMRs there are numerous ways to harness the power of these systems to not only make your charting faster but more accurate as well.  From utilizing autocorrect dictionaries and building macros to using scribes or voice dictation to speed up your charting, there are numerous tools and strategies you can take advantage of to not only lessen the burden of EMRs but to also actually use them to your advantage.

 

  1. Complete charts in real-time – You just finished seeing a patient and would like to sit down to write your HPI while it’s fresh in your memory but you see that there are 10 new patients waiting to be seen.  Do you begin charting on the patient you just saw or start seeing new patients and postpone the charting until later?

While everyone needs to determine the workflow that best suites them I’d argue that in most cases you are better off writing the chart as soon as possible after having seen the patient.  Have you ever left your charting until the end of your shift and then found yourself mixing up the details of different patients you had seen that day who had presented with the same chief complaint?  I would guess that my charts take 50% longer to complete when I leave them until the end of my shift because of this extra time spent trying to recall the details of each case.

By doing your charting in real time, immediately after seeing the patient, not only do you save the time that would later be spent trying to recall the details of the case but you will likely include important details that may have been forgotten completely.  Charting as soon as possible after a patient encounter not only results in faster documentation but it also results in the most accurate documentation.

 

  1. Batch tasks – Before getting up to go reassess your patient, ask yourself, “what else can I do while I’m walking through the department?”  Are there other patients you could reassess as well? Do you need to speak with a nurse about repeat labs that need to be done?  Frequent laps around the department may allow you to burn more calories but it certainly doesn’t help with your work efficiency.

 

  1. Minimize “multitasking – As much as we like to pride ourselves on our ability to juggle multiple tasks simultaneously while on shifts, a study by Skaugset et al3 shows us that we often aren’t multitasking after all, but rather task-switching.  Cognitive load theory tells us that you have a limited amount of working memory available at any given time and that the less cognition that is required for a given task, the more things you can fit into your working memory.  Be conscious of the interruptions in your tasks that take place while on shift and think of ways to minimize them. These strategies may include creating lists of tasks that need to be completed in the future, following checklists when performing procedures, and finding a place to document where interruptions will be less likely.

 

  1. Initiate dispos ASAP – As soon as you have seen a new patient you should be immediately thinking about their ultimate disposition and determining the information that you will need to make that disposition.  To borrow advice from the efficiency master Stephen Covey, “begin with the end in mind.”4 Order all necessary studies up front.  If you know that a consultant will need to be involved, contact them early.  If there are pending studies for a patient who you know will need to be admitted to a particular service regardless of the test result, contact your inpatient colleagues to let them know about the admission and the pending studies.  The cognitive unloading that occurs with each disposition allows us to more effectively use the limited working memory that we have available at any given moment, allowing us to work more efficiently.

 

Start working more efficiently

My purpose for writing this post is not to help you find ways to cut corners at work or to sacrifice patient care in order to leave your shift on time.  The goal is to provide the excellent patient care and documentation that you normally would but in a way that is as efficient as possible.  I challenge you on your next shift to begin implementing some, or all, of these strategies.  Which do you find the most helpful?  Which strategies of effective working have I left out?

 

  1. http://www.epnotoledo.com/wp-content/uploads/2015/08/June-2012-Efficiency-in-the-EmergencyDepartment.pdf
  2. Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. 2000;7:1239-1243. 4. France DJ, Levin S, Hemphill R, et al. Emergency physicians’ beh
  3. Skaugset, LM et al. Can you multitask? Evidence and limitations of task switching and multitasking in emergency medicine. Ann Emerg Med. 2016  Aug;68(2):189-95. PMID: 26585046
  4. Covey, Stephen R. The 7 Habits of Highly Effective People: Restoring the Character Ethic. New York: Free Press, 2004. Print.
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