4/5/2018

YOUR DATA IS YOUR VOICE Scribing for Clinical Documentation Improvement Adele Allison, Director of Provider Innovation Strategies April 12, 2018

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AGENDA

• The Rise of the Scribe • Why Scribe? • Write and Wrongs of Scribing • Documentation/EHR Impact • Questions / Wrap-Up

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EARLY SCRIBING

• 3100 BC – Egyptian Scribes → Revered, educated in hieroglyphics and arithmetic

• 1100 BC – Ancient Israel → Distinguished professions (e.g., ran with lawyers, gov’t ministers, judges) − Today, Sofers still scribe the Torah by hand on parchment

• 500-1500 AD – Monastic Scribes → Specially trained to make books of classical/religious works − Took ~ 15 months to copy a Bible

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SCRIBES MORE RECENTLY

• Genealogies → Trained as scholars, translators and historians, traced hundreds of years of genealogies (e.g., Dubhaltach MacFhirbhisigh – mid-1600s)

• Religious Translations → E.g., Sidney Rigdon (1830s) – Helped Joseph Smith e-translate the Bible (Church of Jesus Christ of Latter Day Saints) • Legal Scribes → Court reporting and stenography used an evolving phonetic shorthand starting in the early 1600s – today computerized

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AGENDA

• The Rise of the Scribe • Why Scribe? • Write and Wrongs of Scribing • Documentation/EHR Impact • Questions / Wrap-Up

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IN A WORD … BURNOUT • “Joy of Medical Practice” Study − 168 physicians & advanced practice providers, 34 practices − Data → Baseline (74% satisfied) and 1 year later (only 16% reported increased satisfaction) − Healthy Work Place Factors: Levels of “Chaos,” Cohesion, Communication and Value Alignment − Results: The 16% 8x more likely to not seek to leave practice • Economic Impact of Provider Burnout − Organization of 450 physicians x 7.5% annual turnover rate (with $500,000 costs for MD replacement) = > $1,000,000/year if turnover decreased to 5%

Sources: Health Affairs, “Joy In Medical Practice: Clinician Satisfaction in the Healthy Work Place Trial, Oct. 2017; JAMA Network, “The Business Case for 7 Investing in Physician Well-being,” Dec. 2017

IN A WORD … BURNOUT • EHRs and Provider Time – Study − 142 family physicians using Epic − EHR interactions over 3-year period − Clinicians averaged 5.9 hours out of 11.4 hour day on EHR data entry − ~ 4.5 EHR hours during clinic, ~ 1.5 hours after hours • Inappropriate allocation of tasks? − 50% EHR tasks → Documentation, CPOE, billing, coding and system security − 50% inbox management

Source: Annals of Family Medicine, “Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion 8 Observations,” Oct. 2017

IN ANOTHER WORD … MACRANOMICS

Category 3 Category 4 Category 1 Category 2 Category 3 Category 4 FFS No Link to FFS Linked to Alternative Population-Based Quality & Value Quality & Value Payment Built on Payment (PBP) FFSCMS Arch. → 185,000 – 250,000 QPs in 2018 (More than 2x 2017 estimates)

Medicare Physician Merit-Based CMS Risk-Bearing CMS Risk-Bearing Fee Schedule Incentive Payment Alternative Alternative (MPFS) System (MIPS) Payment Models Payment Models • Frozen CY2019 • Budget Neutral • Advanced-APMs • Advanced-APMs • ~ 23% of Medicare Differential FFS • Includes ACOs and • Includes CPC+ and Provider Total Payment CJR Bundles Oncology Care Revenue • Earn > MPFS by • Must be a Qualified Model (OCM) • Traditional MPFS Payment CY 2019 Medicare Traditional comparative Participant (QP) • 5% Lump Sum performance obsolete • 5% Lump Sum Bonus • ~ 621,700 Clinicians Bonus • No MIPS impacted • No MIPS

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PHEW! THAT’S JUST TRADITIONAL MEDICARE!

Hold on a sec … let’s look at industry trends! 10

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U.S. PAYMENT TRENDS 2015-2016 • 2017 Public and Private National Health Plan Survey • Participants → > 245.4 million Americans, ~ 84% of Market − Represents ~ 84% of the total covered population − Data collected from 78 plans, 3 managed FFS Medicaid states, and FFS Medicare

• $354.5 Billion • ACOs Q1 2016 to Q1 2017 grew by 92 (Total 923)

• Private Cat. 1 = 4% ↓ • Private Cat. 2 = 1% ↓ • Private Cat. 3-4 = 5% ↑

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AGENDA

• The Rise of the Scribe • Why Scribe? • Write and Wrongs of Scribing • Documentation/EHR Impact • Questions / Wrap-Up

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WHAT IS A SCRIBE?

• Para-professional − Specializes in charting − Works in the Clinician’s “bubble” → Supports clinical documentation including encounters, letters, medical document management, eRx and data capture − Think “data” manager and patient info throughput • There are differences − Medical scribe – May be uncertified/non-credentialed − Certified Medical Scribe Specialist or Certified Medical Scribe Apprentice – certified/credentialed through the Am. College of Medical Scribe Specialists (ACMSS)

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WRITES & WRONGS

• Thou Shalt Not Work Independently – Ancillary staff to document the work performed • Thou Shalt Document Use of Scribe Services* − Who performed the service → include scribe ID in medical record − Signed/dated by treating clinician with affirmation of note – timing of entry is a best practice − Corrections must include provider’s signature to addendum • Thou Shalt Support the Clinical Workflow − Record information, retrieve past records, track consultant reports − Locate test results, enter discharge info as dictated

* CMS instructions regarding signature requirements when scribe services are used by a physician/non-physician practitioner, 14 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R713PI.pdf; Also, check your state laws.

WRITES & WRONGS • Thou Shalt Manage and Monitor Scribes − Setup clear policies and authentication guidelines − Understand federal and state regulations/guidance − Establish minimum level of acceptable knowledge & qualifications • Thou Shalt Support Ongoing, Continuous Training − Seek certification, credentials and support CEUs − Setup documentation protocols and audit • Thou Shalt Establish Privacy & Security Protocols − Role-based EHR security − Clear policies and training

* CMS instructions regarding signature requirements when scribe services are used by a physician/non-physician practitioner, 15 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R713PI.pdf; Also, check your state laws.

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MEDICAL SCRIBE TRAINING & CERTIFICATION

• Requirements Vary, But Recommend − Minimum of High School Diploma or GED • American College of Medical Scribe Specialists (ACMSS) − Sponsored by one of the largest scribe vendors – ScribeAmerica − Provides CMS compliant certification − Complies with MACRA certified/credentialed through the Medical Scribe Certification & Aptitude Test (MSCAT) • ACMSS information → https://theacmss.org

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CAUTION: MEDICAL SCRIBE INDUSTRY UNREGULATED

• No monitoring/regulating State or Federal Agency – So … Who’s Watching this Industry? • The Joint Commission Standards − Job description with qualifications & responsibilities − Training & Orientation − Performance evaluations & competency assessments − Meets all information mgmt., HIPAA, HITECH, confidentiality & patient rights standards − Signing (including name, title, date, and time) of all entries − Provider authentication (signature stamp – “rubber stamp” – not permitted) − Authentication prior to leaving the patient care area − Authentication cannot be delegated

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AGENDA

• The Rise of the Scribe • Why Scribe? • Write and Wrongs of Scribing • Documentation/EHR Impact • Questions / Wrap-Up

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CONCERN: EHR ADVANCEMENT & COMPLACENCY

• EHRs must evolve in usability – Are Scribes a Workaround? • Provider Mentality Risks − “Yay! I don’t have to use the EHR” − “My scribe can deal with it” − Intentional/Unintentional Scribe functional creep – E.g., CPOE – purpose is to integrate clinical decision support − “Just check the box” → Unsafe use of Technology – E.g., Documentation of certain activities not performed such as smoking cessation counseling

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MACRANOMICS IS ALL ABOUT THE DATA

• 2010 → Affordable Care Act (ACA), “Value” mentioned 219x • 2015 → MACRA, “Measurement” mentioned 171x, “Data” 103x

Health Value Measurement

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ALTERNATIVE PAYMENT – SWIM LANES

Shared-Savings Episode Payment Population-Based

• Upside/Downside • Retrospective/ A • Inclusion & C A Financial Risk F A Prospective Exclusions • Total Cost of Care F A Payment • Patient Attribution A A • Episode Spend F A • Patient Attribution O • Performance A • Risk-Adjustment C F A • Inclusions & C A Period Exclusions C F A • Quality Measures C F • Risk-Adjustment O A O • Quality Measures C F • Stop Loss F A A O • Quality Measures C F A O C Clinical Data F Financial Data A Admin. Data O Other Data 21

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ECONOMICS AND ADVANCED ANALYTICS

Data Availability Claims EHR Clinical Records Demographics Yes Yes Race/ethnicity Limited Limited Diagnosis(a) Yes Yes Procedures Yes Yes Eligibility Yes Limited • Mile Wide, Inch Medications Medications dispensed Medications prescribed • Inch Wide, Mile Deep Socioeconomic data Zip‐code derived Coded and zip‐code derived Deep • CPT, ICD Family history Not available Yes • CPT, ICD, LOINC, Nomenclatures Problem list Not available Yes SNOMED, NDC • ANSI X12 Procedure results Not available Yes Nomenclatures Laboratory results Not available Yes Standards Vital signs Not available Yes • HL7 Standards Behavioral risk (e.g., ADT, VXU) Not available Limited factors Standardized Limited Limited surveys Categories 1 & 2 Transaction‐Oriented Analytics‐Oriented Categories 3 & 4

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STRUCTURED DATA • 4 ways to enter data in technology − Scanning − Narrative / Text − User-Defined Structured − Object-Oriented, Codified Data • ICD-10-CM Structure

Category Category, Anatomic Category Site, Severity Placeholder Illness for More Disease Etiology Body Part Severity Specificity 23

IMPACT OF DOCUMENTATION & CODING

Estimated Diagnosis Description Cost of Care E11.8 – E11.9 Type 2 Diabetes w/ no complications $1,400 Diabetes with Ophthalmic E11.311 –E11.39 $2,239 Manifestations Diabetes w/ neurological E11.40 – E11.49 $3,527 complications E11.21 – E11.29 Diabetes with renal or peripheral $4,391 E11.51 – E11.59 circulatory complications Source: BCBSAL, Complete Picture of Health Documentation and Coding Improvement Initiative 24

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THANK YOU! Adele Allison | [email protected] | 205.563.2210

@Adele_Allison | Adele Allison

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