IN THIS ISSUE
Fall 2017  
Can Virtual Scribes Solve our EHR Frustrations?
By Trudie Bruno, Nancy Gagliano, MD, MBA
With the proliferation of electronic health records (EHRs), physicians have been assigned an unwanted administrative burden. Despite the original hope that, with experience, increasing usability, templates, and macros, physician frustration with the EHR would fade away and productivity would increase. Instead, physician burnout is at an all-time high with EHR documentation blamed at its core. Studies reveal that physicians are spending up to 50% of their day doing administrative tasks, including EHR documentation, and over 11 hours a week afterhours and on weekends documenting. The financial impact of burnout and its effect on turnover is considerable. Productivity suffers as physician ask to reduce productivity expectations due to documentation time. Although voice recognition helps, physicians often complain that it has limited value because of the time required to edit and correct mistakes. Obviously, physicians are highly valued resources, not only for the quality of care that they provide, but also as the revenue generator in their practice. We need to solve the EHR documentation problem. Here enter scribes, individuals who can complete documentation and administrative tasks on behalf of physicians. In this article, we explore medical scribes and weigh their benefits and costs, as well as introducing newly available virtual scribes and the software tools which make this solution more accessible and affordable than ever before.
The two types of scribes we consider are the “in person scribe” and the “virtual scribe.” While both types of scribes complete similar tasks, they do so by distinct methods that can make one type significantly more advantageous depending on resources and setting. We will cover these details momentarily. In general, a scribe will partner with an assigned physician and attend patient encounters with them throughout each day, documenting notes from each interaction and completing administrative tasks as instructed. They essentially serve as personal assistants to the physicians through supporting documentation and other tasks such as inbox management. In this way, a physician can focus on the patient during the encounter and only needs to review and sign off on the documentation completed by the scribe. Using medical scribes allows a physician to work more efficiently, spending less hours working on documentation and experiencing a higher quality of life, while practices become more productive.
First, in-person scribes will be considered. These are scribes who are physically present with the physician while completing patient encounters and travel with them through the health setting. Being physically present has advantages, requiring little workflow change from the physician as well as the ability to serve as a chaperone in the exam room. However, there are also considerations to be made. For example, will the patient be uncomfortable with their physical presence, will the scribe have a dedicated office, or will another body make the clinic or exam rooms too crowded? Additionally, there is a high cost to having an in-person scribe, as they must be recruited/hired, trained, paid hourly (approximately $15/hour + benefits) or salaried (approximately $40K/year + benefits), and will require sick and personal time off. Giving a medical scribe time off means that most physicians cannot simply have one scribe, they must train and employ multiple scribes to have enough resources available to cover the busy physician’s schedule. In addition, there may be down time, when physicians are between patients, have sessions off, are on vacation. What happens when a clinic runs late, does the scribe just leave when their shift is over? To complicate matters, good scribes are often aspiring healthcare professionals or other pre-professionals and have a very high turnover rate. Thus, the practice must be constantly hiring and training new scribes, which requires in-house infrastructure for recruiting, managing, as well as training. Training is particularly important to consider, as scribes must work with physicians to learn their unique documentation style and workflow to maximize efficiency. Thus, because of the cost and infrastructure required to support in-person scribes, many organizations do not consider in-person scribes a viable option.
Here enters the concept of a virtual scribe; a remotely located medical scribe which is made available to a physician for documentation purposes. These scribes are often contracted through a company which specializes in providing remote scribe services to physicians and health systems. With contracting through a virtual scribe company, the traditional concerns of staffing, scheduling, and coverage are no longer a concern for physicians who wish to use virtual scribe services. Rather, those concerns are outsourced to the virtual scribe company and scribe services are provided for a fee. Scribes can be available at the convenience of the provider if the physician has an internet connection. The services are provided synchronously or asynchronously, with some virtual scribe companies using scribes located all over the world. Synchronous scribes provide the advantage of supporting administrative tasks, such as updating a med list or ordering a referral, in real time. There is also the advantage that a virtual scribe will never require office space, make a room too crowded, and coverage is always guaranteed by the virtual scribe company. In general, virtual scribes are less costly, than hiring in person scribes. Physicians can expect 1-2 hours of administrative time savings per full clinical day, depending on their current practice. The innovation of virtual scribes is a wonderful solution for physicians looking to reduce administrative and documentation burden. It is an elegant solution to a complex problem.
While the concept of virtual scribes may seem straightforward, it is important to understand there are significant differences in services offered by companies. One end of the spectrum is the recording of the physician patient interaction with asynchronous translation of the interaction into a visit note. On the other end is a combination of asynchronous and synchronous interaction between provider and scribe through innovative software to support both visit documentation and administrative tasks.
In conclusion, the solution of using medical scribes is an excellent move for physicians who wish to reduce their administrative burden or for health systems looking to maximize EHR/practice productivity. Careful consideration must be given to deciding whether to invest in a physical scribe or a virtual scribe, pending the unique costs and benefits of each. Virtual scribe companies are making significant headway at the intersection of medicine and technology by connecting remote scribes with physicians, flaunting thoughtfully designed software with a carefully trained team of scribes. However, their impact remains to be seen as the technology is relatively new and developing.
Two Epic quick wins: Monitor Provider Efficiency and Prevent
Revenue Leakage

By Jaffer Traish
Spotlight Article
As organizations returned from Epic’s UGM this year, the normal airport chatter was well underway. Operations leaders excited to use data insights, IT leaders adding to their growing list of optimization and implementation features, executives with a better grasp on broad challenges such as cybersecurity and hosting. Often, leaders return home with a list of wishes (or demands), and do not always feel empowered to champion projects forward. Epic has been working on making it easier for leaders to influence and gain insights into user behavior – two of those deserve a mention, and we’re excited to be helping some of you down this path.
The provider efficiency profile was highlighted as a ‘spell’ in the land of Epic wizards to help organizations develop keener insights into their clinical community. The PEP as it’s called, provides clinician-level data about workload, system usage, specific number of tools adapted, amount of time in certain activities, time spent during specific hours of the day, and much more. The efficiency can be determined looking in comparison to others, as well as in comparison to specific workflows (example: disposition in the ED).
Epic is releasing an ASAP physician efficiency profile as well, and work is underway in the inpatient realm, too. The PEP must be turned on by the build team, though in a few weeks’ time, it can be focused on the providers or clinics you choose. In one case study, Culbert found identifying opportunities at 5 clinics to improve specific smarttools, improve inbasket training and share high efficiency provider notes with others reduced the average time after work completing and closing encounters by 30 minutes per day. The PEP is a powerful tool for after go-live and for continuous monitoring and clinical satisfaction.
Empowering your PAC committees, Med Exec teams and provider champions with this data enables identification of those needing help, those excelling who can share successes, and those who work long and hard though remaining quieter in the field.
Epic’s Revenue Guardian is a tool on the revenue cycle side to aid in preventing revenue leakage. Revenue Guardian is a secondary check of the system to prevent lost revenue, missing charges, and target areas you know your organization needs to keep a close eye on. (Epic also announced a new Payment Guardian expected soon.)
Simple build checks Epic provides includes evaluating claims to ensure there is a contrast charge, missing observation charges, or even missing rev 391 rev codes. Epic uses the best practice advisory functionality many organizations are familiar with to accomplish these checks. As of a few weeks ago, there were 25 examples in Epic’s foundation system, though now we have over 100 pre-built examples to leverage. Requirements to implement are to have Epic’s HB module as well as either EpicCare Ambulatory or Epic Inpatient. Revenue Guardian checks are only for hospital accounts and hospital billing charges at this time. While you can configure these checks to trigger a DNB, this should be carefully discussed with your revenue integrity lead and team.
Reports, workqueues and other data can be produced from these checks, with the goal of eliminating revenue leakage and improving front and back-end training where missing charges can be automated or corrected by workflow. Putting the appropriate governance into play to support the check findings is essential to turning the data into action.
We at Culbert are excited that we’ve been able to help organizations implement and draw conclusions to forward progress from both the PEP reports and implementation as well as through Revenue Guardian installs.
Culbert works with organizations from design, build, testing and training of both tools. We’re excited to share lessons learned and continue to help organizations empower staff to be more productive, happy and efficient in caring for patients and their caregivers.
Assembling a “Dream Team” for GE CBO Implementation
By Kiera O’Neil
Culbert recently engaged with a client to assist them with their new GE CBO implementation. This client had never embarked on a project of this magnitude prior to this. Adding to the multitude of challenges, this client has a unique patient base, regularly accepting patients from all 50 states and policies that prohibit all patient billing. This client is implementing the Combined Business Office application, but currently has two separate and distinct billing offices. Adding to the complexity is the policy that all charges must be reviewed to ensure they are not related to a research study or grant. And, this new implementation will include a charge interface from the clinical system that did not previously interface with the legacy practice management and hospital patient accounting systems.
Assembling a team to complete a big implementation is challenging to many organizations. Maintaining day-to-day responsibilities, managing a large-scale project with many resources, learning a new system, assembling decision makers to make key decisions, building, testing, and training are all key tasks that need to occur during this 18-month time line. Organizations need to make the decision on whether to handle all these responsibilities internally or seek external resources. Relying too heavily on internal resources can create a great strain on already stretched resources, but relying too heavily on external resources can create a knowledge vacuum when the project ends. This organization made the decision to utilize key internal resources for critical decision making and build work, but partnered with Culbert to help lead many of these critical tasks. By partnering with Culbert the client is making sure there is 100% focused attention on these critical roles:
Project Manager – Managing the large scale implementation of a new system requires the precise calibration and execution of all tasks on the project. Frequently there are multiple project managers leading this effort. The vendor will assign a project manager to make sure the overall project milestones are being met and all vendor tasks are on schedule. Also critical to the success of the project is the project manager on the client side to manage all the tasks delegated to the client. Both project managers must align themselves to the same milestones and deadlines.
Change Management – Change management is a critical role during the implementation of any new large-scale system. Replacing a new system should not be an exercise in ‘making the new system work like the old’. The new system requires new workflows, new processes, and new procedures. The Change Manager is responsible for ensuring organizational readiness for the new solution; aligning policies and procedures with the new systems functionality. The combining of business processes between the hospital and professional business offices is a significant change that requires political, policy, and process management.
Testing & Training Leaders – The creation of robust testing and training plans is essential for the success of any implementation. Bringing on external resources with experience will ensure these two critical tasks are completed correctly and effort is not wasted building these plans from scratch. The leaders must work closely with the organization to make sure the knowledge gained from exercises is transferred appropriately to the client.
Technical / Interface Lead – The coordinating, planning, configuration, testing, and implementation of the interfaces begins early in the implementation. Using a resource familiar with the Centricity Business system ensures the receiving and sending systems are prepared for these transactions.
A strong partnership between GE resources, consultants, and the client organization will drive the organization to an on-time and successful live date. Communication and transition planning post-live will ensure the client is ready and prepared to maintain their system after the implementation resources have left.
MACRA Merit-Based Incentive Payment System (MIPS) – Know
Your Path

By Paulette DiCesare, RN
If your organization has not decided the level of participation your organization should take in reporting MACRA for 2017, then perhaps taking the minimum path is your best option. The Medicare Quality Payment Program (QPP), which began in January 1, 2017 applies to physicians, NPs, PA, CRNs, Nurse Anesthetists (not hospitals or facilities) and must participate in either the Merit-Based Incentive Payment System (MIPS) or in an advanced Alternative Payment Model (APM). Because greater than 50% of Clinicians are MIPS-eligible, we will focus on MIPS. In April of 2017, CMS began sending out correspondence to all individuals or groups with a Taxpayer Identification Number (TIN) enrolled in Medicare to communicate whether an individual or group is MIPS-eligible, and CMS also has a MIPS-eligibility look up tool here. In addition, CMS is finalizing requirements for 2018.
You are not MIPS-eligible if any of the following apply:
  • You are newly enrolled in Medicare
  • You see 100 or fewer Medicare Part B patients per year
  • You have less than or equal to $30,000 allowed Medicare Part B charges annually
  • You are on the participant list on at least one of 3 snapshot dates (3/31, 6/30, or 8/31) for a model that CMS has deemed an Advanced Alternative Payment Model (AAPM) for purposes of QPP participation. See the Centers for Medicare & Medicaid Services (CMS) list of AAPMs
Unless you have an exclusion from MIPS due to any of the reasons mentioned above, you must participate in the program in 2017. Understanding the different requirements in all 3 categories is essential in deciding your level of involvement for 2017. Those categories are:
  • Quality: The Quality category accounts for 60% of MIPS score (up to 60 points) and report on quality data on clinician-selected measures. This category is a replacement for CMS’ Physician Quality Reporting System (PQRS) and includes nearly 300 possible Quality measures (for example, providing receipt of specialist report or documentation of current medications in the medical record). Additional measures may be available through your specialty society’s Quality Clinical Data Registry (QCDR).
  • Advancing Care Information (ACI): Report on performance on certain Electronic Health Record (EHR) measures which has a 25% weight towards your total MIPS score. This is the replacement for CMS’ EHR Incentive Program (Meaningful Use) and requires use of Certified Electronic Health Technology (2014-CEHRT).
  • Improvement Activities (IA): Attests to performance on certain CMS-designated improvement activities (for example, annual registration in a Prescription Drug Monitoring Program or improvements to care transition in the 30 days following patient discharge) which accounts for 15% towards your MIPS total score.
To avoid a 4% penalty on your 2019 Medicare reimbursement, you must choose your level of participation in 2017. You should choose your participation track based on how you think you will perform on Quality, ACI, and/or IA performance categories. The tracks are:
  1. Minimum Participation: Avoid any penalty obtain a minimum of 3 points by reporting performance on either:
    • 1 Quality measure; or
    • 1 IA (Improvement Activity), either high or medium weight (depending on practice size); or
    • 4 or 5 base score ACI (Advancing Care Information) measures (depending on whether you have a 2014 or 2015 certified EHR, respectively)
  2. Partial Participation: Report on as many activities as feasible to be eligible for upside bonus. Keep in mind that because the program is based on a balance budget and virtually no penalties will be distributed, there will be very limited upside bonus available.
    • More than 1 (6) Quality measure; or
    • More than one IA (2-4); or
    • Base score ACI measures plus at least one additional ACI measure (core EHR measures plus up to 50 points in additional reporting)
  3. Full Participation: Excellent performers are eligible to share $500 M across the country but will be competing among organizations that have been focused on quality measurement for years:
    • 6 Quality measures, including one outcome measure; and
    • A combination of high- and medium-weight IAs (exact number will vary based on practice size and rural or non-rural location); and
    • Base score ACI measures plus any additional performance or bonus measures
You do not have to elect a participation pace as CMS will determine your pace based on the data that you submit. Still unsure of the pace or your involvement in 2017? To better understand how you may perform in the MIPS program and tailor your participation in 2017, review your past performance in other Medicare quality programs, such as PQRS, the EHR Incentive Program (Meaningful Use), and the Value Based Modifier (VBM). You can use your September 2016 Quality Resource Use Report (QRUR) or your 2016 PQRS Feedback Report to assess future performance. These reports have drill down tables that feature performance by group and individual, and can help you understand how you’ve done in the past and how you might do in the future.
Eligible Providers (EPs) in a large multispecialty group can report either as an individual or as a group. When reporting as a group, all EPs reporting under the group’s TIN will be included. A group cannot elect to report some EPs as a group and others report as individuals. Under the group reporting option, all EPs must report on the same measures through the same reporting mechanism. The good news, this year, is that unless you are using the CMS web interface or reporting on CAHPS, you do not need to pre-register to report as a group.
You might consider minimum participation if you have no PQRS or just implemented your CEHRT. Partial participation might be the path if you have been on a CEHRT and have reported PQRS in the past, but are facing some physician resistance. You can also use 2017 as your trial run to prepare you for 2018.
Regardless of the path you choose to report in 2017, remember that this is a 2-year process. You will be working on your 2018 process before you know your 2017 results. Lastly, remember that you can successfully participate in the Minimum Participation track and avoid the 4% penalty by reporting one Quality measure. However, if you plan to participate in the Full or Partial Participation tracks, CMS requires a minimum 90 day participation period, which means that you would have to have started participating in those activities by October 2, 2017. CMS has also indicated that you may be more likely to achieve a higher score if you report data over a longer period. In addition, physicians who have participated in the PQRS and Meaningful Use programs in the past, may do better over an entire year because there is more time to meet individual measures and achieve a positive score.
For reporting year 2018, the requirements and process will be similar. However, the current CMS proposal is to increase the minimal performance threshold to 15 points, out of 100, needed to avoid a penalty. In addition, CMS plans to raise the minimal number of Medicare patients seen and/ or Medicare charges submitted in 2018 which will require QPP participation. We recommend checking the CMS website on the Quality Payment Program to look for further updates on 2018 requirements.
Resources:
ama-assn.org
qpp.cms.gov
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