These days the years seem to roll around really fast, which means so does my annual physical exam. I have a super nice primary care physician (PCP), but as I age the annual list of health maintenance items grows longer and longer. In addition to the usual annual assessments, I’m now in the tetanus booster, shingles vaccine, and bone density era. I dread the once-a-year intensive review and think it would be more useful to have ongoing continuous daily monitoring, but that’s a blog post for another day.
This year, my annual physical exam started with a nurse check-in and the usual blood pressure, heart rate, temperature, and oxygen saturation measurements. The nurse then asked if I would agree to my PCP using Scribble to record the encounter in the exam room. I had no idea what Scribble was, but I agreed and gave consent by signing the iPad with my finger. My observation during the clinic visit was that my PCP used the computer to check old notes and previous labs. She also ordered tests and labs online, but she did not complete any notes or templates. This created more face-to-face conversation time which seemed more natural and satisfactory for both of us.
The IT productivity paradox and physician burnout
While EHRs have brought unquestionable value to the healthcare delivery system, the “IT productivity paradox” has also been well described. Some provider tasks are faster when done manually than when completed electronically. Recall how quickly you could dash off a prescription for Lasix. EHRs have clearly impinged on provider time and caused inefficiencies in patient care delivery.
Electronic documentation is a contributor to physician burnout. In the “Medscape Lifestyle Report 2017” data showed an increase in physician burnout from 2013 to 2017, with over 50% of nephrologists reporting burnout issues. AMA and other groups note that physician burnout is a systemic problem requiring examination and improvements in the system-of-care delivery. Mayo Clinic identifies these clinical workplace stressors as top health system issues contributing to burnout:
- Loss of physician control and flexibility
- System inefficiencies including EHR documentation, Computerized Physician Order Entry (CPOE), and clerical work
- Poor work-life balance
A 2016 Annals in Internal Medicine article reported the results of a time-motion study of physicians. The study examined activities for 57 physicians from 4 specialties including internal medicine and cardiology. On average the physician clinic day included 27% direct clinic face time with patients, 49.2% of time on EHR and desk work, and the remainder on administrative and miscellaneous other tasks. While in the exam room with a patient, providers spent 53% of the time with direct face-to-face interaction and 37% of the time interacting with the EHR.
Essentially, for every 1 hour a physician spends face to face with a patient, she/he will spend 2 hours doing EHR documentation and desk work. Solutions to this disproportionate time spent interacting with the EHR include increasing use of medical assistants or scribes, improving EHR efficiencies for documentation, or use of documentation assistance services. In my recent exam-room experience my PCP had pretty good face-to-face time because of Scribble, a documentation assistance service. Here’s a look at why and how it helps.
The scoop on Scribble
Scribble is part of the trend to shift to voice. You’ve probably been doing this in your personal life. I use my smart speaker, Amazon’s Echo Dot, to ask Alexa to play music, tell me the weather, search the internet, and place orders. You may be talking to your TV remote to change channels. Personal technology has advanced along a continuum from typing to point-and-click to touch screens on mobile devices, and now to voice. Voice is not only the fastest input action, but it is also hands free and eyes free. In a recent national survey, over 50 million people reported using smart speakers and it’s anticipated that 50% of all internet searches will soon be voice activated. We are entering the “voice era.”
In recent years some practices have used medical assistants or scribes to partner with providers to document patient encounters in real time. Live scribe systems work, but add the complexity of having another person taking up exam-room space and listening in on the conversation. In addition, people get sick and often just having 1 scribe per provider isn’t enough to be efficient. Scribble is an asynchronous virtual scribe service. The exam room is equipped with a microphone tied to a secure Scribble app. The encrypted audio is available for a remote physician scribe to listen and create an encounter note.
With Scribble, each exam-room provider is partnered with a Scribble documenting physician. The first weeks of Scribble implementation include daily calls between the partnered physicians to discuss personal preferences for capturing clinical information and documenting it in a preferential and personal style for the treating provider. This evolves to a weekly touchpoint call between the physician partners and a 24-hour turn-around cycle for EHR note review, edit, and sign off. Scribble reports that the physician partnership results in a 60% decrease in treating physician EHR documentation time and saves providers 1-2 hours of EHR and desk work a day. In a case study from CareMount Medical, a large multispecialty practice in New York state, all of the physicians using Scribble decreased documentation time by at least 50% and the organization documented a significant increase in patient experience scores.
Acumen 2.0 and the shift to voice
Dr. Sharif’s videos, “Be in the know with Acumen 2.0,” demonstrate the progress EHRs are making in improving customization and efficiency. Acumen 2.0 powered by Epic offers enhanced interoperability using with Epic’s Care Everywhere. Epic’s “My Chart” patient portal provides patient-centered access supporting patient engagement and control. Interoperability and patient-centered access are key features to improve EHR usefulness and effectiveness, and Acumen 2.0 customization for nephrology improves EHR documentation efficiency and experience for providers. The “shift to voice” may layer on to further enhance EHR documentation efficiency.
After my nephrology fellowship, my first job in private practice was to follow behind a wonderful older retiring nephrologist. I clearly remember meeting each of his patients and reviewing his notes in the paper chart. His patients loved him and I’m sure he spent clinic visits listening well, taking a good history, and doing a thorough physical exam. A typical chart note would be, “Feeling well. BP controlled. RTC 6 months.” It was quick for him and satisfying for the patients, but not very helpful for me taking over his practice. EHRs support vital data portability and opportunity for data insight. Novel, creative, and innovative EHR documentation assistance may get us back to the good old days of quick documentation without losing the value of information. I’m looking forward to the “voice era.”
Dugan Maddux, MD, FACP, is the Vice President for CKD Initiatives for FMC-NA. Before her foray into the business side of medicine, Dr. Maddux spent 18 years practicing nephrology in Danville, Virginia. During this time, she and her husband, Dr. Frank Maddux, developed a nephrology-focused Electronic Health Record. She and Frank also developed Voice Expeditions, which features the Nephrology Oral History project, a collection of interviews of the early dialysis pioneers.
Image from www.canstockphoto.com.