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Workflow and Process Module 0.5 Credit CME

Team DocumentationSpend more time caring for patients by sharing responsibilities with staff.

Team-Based Learning
Learning Objectives:
At the end of this activity, you will be able to:
1. List steps to effectively implement the team documentation process
2. Explain how to design an efficient documentation workflow
3. Identify methods to appropriately delegate administrative tasks to various staff
4. Describe ways to manage process improvements after implementing the team documentation process

STEPS Forward™ is a practice improvement initiative from the AMA designed to empower teams like yours to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment. Wherever you find your team on the practice improvement continuum, the American Medical Association can help you take the next steps – the right steps – to improve your practice. Learn more

How will this module help me successfully put team documentation in place?

  1. Eight steps to select a model, train staff and continue evolving the approach

  2. Answers to questions and concerns

  3. Advice on situations your practice may encounter during implementation

  4. Case studies describing how practices are using team documentation

Introduction
What is team documentation?

Quiz Ref IDTeam documentation, also referred to as “scribing,” is a process where staff assist with documenting visit notes, entering orders and referrals and queuing up prescriptions in real-time while in the exam room with the physician and the patient. This frees the physician to focus on the patient.

Why team documentation?

Electronic health records (EHRs) have altered the documentation process in physician practices. Tasks previously performed by staff (e.g., receptionists, medical transcriptionists, medical assistants, pharmacists and/or nurses) such as data gathering, organization and entry, have shifted to physicians.

Box Section Ref ID

Q&A

  • Under Medicare payment rules, can non-physician staff, such as a registered nurse (RN), licensed practical nurse (LPN) or medical assistant (MA), enter elements of an evaluation and management (E/M) visit without the physician present?

    Yes, certain elements, like the Review of Systems (ROS) and Past, Family, and/or Social History (PFSH), may be recorded in the EHR by non-physician staff. Medicare guidance specifically allows ancillary staff to enter information derived from the patient for the ROS and/or PFSH. However, the physician must provide a notation in the medical record supplementing or confirming the information recorded by others to document that the physician reviewed the information. For other elements of a visit, like the History of Present Illness (HPI) or Chief Complaint (CC), Medicare rules do not explicitly indicate who may enter documentation. However, several Medicare Administrative Contractors (MACs) currently interpret Center for Medicare & Medicaid Services (CMS) regulations to prohibit the physician (or non-physician practitioner (NPP), if billing for the service) from delegating these elements of the service. Practitioners should check with their respective MACs before allowing individuals other than the treating physician to document an HPI or CC. If the non-physician is entering information about an HPI or CC on behalf of the physician while the physician is present in the room with the patient, some MAC guidance suggests that this practice is allowable as long as the physician actually performed the E/M service billed, the scribe simply served to transcribe the service provided by the physician, and the scribe’s entry is authenticated by the physician. Other MACs, however, restrict this practice. Providers should consult with their MAC before using a scribe to complete entry of an HPI or CC.

What will the net savings of implementing team documentation be for my practice?

Enter the amount of time per day spent by physicians on documentation activities that could be eliminated by hiring a documentation specialist. The result will be the cost-benefit of implementing team documentation in your practices.

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Eight steps to team documentation

  1. Create a change team

  2. Decide who will help with documentation

  3. Determine the model: Clerical Documentation Assistant (CDA) or Advanced Team-based Care

  4. Start with a pilot

  5. Select the pilot personnel based on commitment

  6. Define your workflow

  7. Start small

  8. Meet weekly

Step 1 Create a change team

Select a high-level champion and a multi-disciplinary team, including representatives from administration, nurses, MAs, information technology, compliance and physicians. It is helpful if all representatives agree on the goals, such as improved patient and provider satisfaction, better quality and improved productivity.

Step 2 Decide who will help with team documentation

Will it be an MA, a nurse, a pre-med student, a former transcriptionist or a dedicated scribe? The type of assistant will determine their scope of work.

Box Section Ref ID

Q&A

  • Under Medicare payment rules, can an RN document a patient’s medication list in the EHR as part of medication reconciliation (MR) during E/M visit?

    Yes, where MR is part of the ROS or PFSH for the E/M service, under Medicare payment rules, the medication list may be recorded by any ancillary staff, and then signed by the physician. MR is included in the Advancing Care Information performance category in the Merit-Based Incentive Payment System (MIPS) as well as the Meaningful Use (MU) program.

  • Can licensed staff enter electronic orders, such as laboratory or x-ray requests?

    Yes, certain credentialed individuals may enter orders for diagnostic tests in an office (non-facility) setting. Medicare generally requires that services provided/ordered be authenticated by the author. A physician’s failure to properly authenticate an order could lead to denial of payment by a MAC. However, there are circumstances where Medicare does not require a physician signature, such as for diagnostic tests (e.g., clinical diagnostic laboratory tests and diagnostic x-rays), when ordered in an office setting. While these orders need not be signed by the physician, he or she must clearly document in the medical record his or her intent that the test be performed. Providers should also check state, local, and professional guidelines.

Step 3 Determine the model: clerical documentation assistant (CDA) or advanced team-based care

Clerical Documentation Assistant (CDA) Model: The CDA accompanies the physician during each patient visit and assists only with record-keeping. Separate staff (nurses, medical assistants [MAs] or other clinical staff) or the physicians are responsible for the clinical aspects of care, such as obtaining vital signs, performing medication reconciliation or providing patient education. Typically there is one CDA per physician. In addition, the practice employs MAs and nurses to perform the clinical support functions.

  • Example: Non-clinical staff in the geriatric practice at the University of California, Los Angeles, serve as Physician Partners (P2s). The P2s document aspects of the office visit, facilitate the flow of patients through the office and improve the efficiency of ordering and/or scheduling tests and medications. Under the direction of the physician, the P2s enter all aspects of the patient encounter into the electronic health record (EHR), including the patient history, physical exam findings that are verbalized by the physician, procedures and clinic charges. They also queue orders that were discussed during the visit for the physician to sign. At the close of the visit when the physician leaves the room to see the next patient, the P2 stays behind to review the after-visit summary with the patient, conduct any needed care coordination with other support staff and provide patient education. If labs are required, the P2 may also escort the patient there to improve patient flow through the clinic. After the P2 concludes the visit with the patient, they complete the encounter in the EHR and send the documentation to the physician for review. With this approach, the physician ultimately saves time because s/he only needs to review and sign documentation and queued orders.

  • In this practice, there are three P2s to every two physicians. This 3:2 ratio minimizes interruptions in the workflow by allowing continuous rotation of P2s in the clinic.

Advanced Team-based Care Model: A specially-trained nurse or MA accompanies each patient from the beginning to the end of their appointment to provide team care services, such as health coaching, care coordination and in-reach panel management. In addition, the nurse/MA assists with the clinical documentation while the physician conducts his/her portion of the patient visit. Typically there are two to three nurses/MAs per physician and they perform all of the clinical support functions in addition to assisting with the documentation.

  • Example: In Dr. Kevin Hopkins’ family medicine practice at the Cleveland Clinic, trained nurses and/or medical assistants follow a three-step process. There are two MAs per physician.

    • Step 1 (Pre-visit): The physician and team design protocols and templates for specific patient complaints and chronic conditions common to their practice. The MA uses these tools to guide the initial history they record during rooming. During this step the MA also updates the past medical, social and family histories, reviews and sets up orders for any health maintenance items that are due and reviews the patient’s medication list and refills. She then exits the room and huddles with the physician to share what she has learned.

    • Step 2 (Visit): The MA and physician enter the exam room together. The physician confirms and expands upon the preliminary history and examines the patient, which the MA records in real-time. The physician then makes a diagnosis and crafts a treatment plan with the patient and MA. The MA continues to record the assessment and treatment plan and queues any orders for the physician’s signature. The patient asks any further questions he or she may have and then the physician moves on to the next patient.

    • Step 3 (Post-visit): The MA remains with the patient to reinforce the treatment plan, provides an updated medication list and visit summary, engages in motivational interviewing and provides self-management support. She will then assist with appointment and referral scheduling.

Learn more about the expanded nurse/MA role in the expanded rooming and discharge protocols module.

“So the cost of the additional personnel will always be somewhat of an issue, but, get this - we are actually making a profit (!) the first three months, despite the increased cost.“

James Jerzak, MD Family Medicine, Bellin Health System Green Bay, WI

James Jerzak, MD Family Medicine, Bellin Health System Green Bay, WI

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Q&A

  • Who should assist with documentation?

    The team member who assists with medical documentation varies across practices and specialties. The model may include clinically trained staff (e.g., MAs, LPNs, RNs, physical trainers, ophthalmology technicians, PAs and NPs) who can conduct elements of the patient visit themselves. The degree of task-sharing varies according to state and local scope of practice regulations, which may include taking visit notes, submitting prescription requests and/or renewals, entering laboratory test orders, administering immunizations and providing patients with supplemental health coaching. Alternatively, the model may include non-clinically trained staff, for whom the term “clerical documentation assistant” (CDA) can be used rather than “scribe.”

  • Will I need more space in the exam room to implement this process?

    The size of the exam room is important. There needs to be enough space for the patient, one or more caregivers or family members, the physician and the CDA, nurse or MA. However, most practices may find they do not need to alter the size or configuration of existing exam rooms.

Step 4 Start with a pilot

Developing collaborative care is hard work. It is best to start small. We suggest a pilot of one or two physicians. As institutional knowledge grows and bugs are worked out, the process can be spread to more physicians. Many practices report a three-to six-month learning curve.

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Q&A

  • Does the extra person interfere with the physician-patient relationship?*

    We find that the extra person actually improves the physician-patient relationship because the physician is able to provide his or her full attention to the patient and is not distracted by data entry.

  • How do you position assistants in the exam room so they aren’t intrusive?*

    In an advanced team-based care model, the assistant helps interact with the patient during the visit and does not need to “disappear.” In one practice, the nurse and physician position themselves according to the care needs. When the patient is seated at the desk, the physician is also at the desk, and the nurse stands at the counter. When the patient is on the exam table, the physician stands at his or her side at the counter, and the nurse is at the desk. There is subtle choreography and the providers switch places automatically now depending on how they need to interact with the patient. Positioning also depends on the available technology infrastructure and hardware. Some practices use tablets for better mobility, but this can certainly be done with laptops or desktop computers as well.

Step 5 Select the pilot personnel based on commitment

The physician should be willing to invest in training the staff and learning a new model. Staff should be enthusiastic about assuming new responsibilities and being trailblazers within the organization. They should also be eager to help shape the new process.

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Q&A

  • What qualities or skills should I look for in an assistant in the team care model?*

    The most important skills are being personable, putting the patient at ease, and eliciting the preliminary history. It is also important to have good keyboarding skills and EHR-navigating skills. A minimum typing competency and timed typing test may be a good idea. An understanding of billing requirements also helps individuals document accurately.

  • Does the assistant perform all of the medical recordkeeping duties or do physicians still play a role?

    This varies according to specialty and physician preference. In some practices, the assistant records the majority of the patient’s medical history, exam, diagnoses and plan of care as indicated by the physician. In others, the assistant records portions of the patient’s medical history, exam and administrative data. The physician may document key elements of the patient’s medical history and medical decisions. In each example, the physician reviews and signs off on the medical record before the patient’s visit is closed.

  • Doesn't Meaningful Use Stage 2 (MU2) require that only the doctor enter the orders?

    No. According to MU2, “Any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE [computerized provider order entry] if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant.” For more information, please visit the Centers for Medicare & Medicaid Services website regarding MU2 requirements.

Step 6 Define your workflow

Identify who will perform which responsibilities during each patient visit. Will template notes be used? How will the provider sign the team notes and orders?

Determine which devices the assistant and physician will use. Will you use one computer or two? Will the computer be a laptop or a desktop? Consider your EHR features and functionality. Some EHRs allow only one user in the record at a time. Others allow the record to be “passed” from one user to another without being closed. Choreograph the work, and expect that it will be refined with experience.

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Q&A

  • How do I train existing staff in my practice to implement the team documentation process?

    Some physician practices contract companies that train medical documentation specialists. Others train their own staff. While the second option is a considerable investment of time, staff will learn exactly what is needed as it pertains to the specific practice. In both examples, training is ongoing. For instance, early in the implementation phase, the change team can consider debriefing daily to discuss what went well and identify opportunities for improvement. They can meet weekly for 30 to 60 minutes to review and adjust the workflow of the documentation process. They may also provide educational opportunities to learn more about clinical issues, billing and coding.

Step 7 Start small

For the first few days, you might do team care for only half of your scheduled patients, or for all of your patients only a few days per week. Use the rolling start to refine the process and avoid change fatigue.

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Q&A

  • Do patients mind discussing private issues with the assistant in the room?*

    We have found that if the physician explains that the assistant’s role is to ensure accurate documentation and handling the computer so the physician can remain focused on the patient, most patients accept and welcome the additional medical professional helping with their visit. Many patients even see it as an opportunity to have another advocate for their health care. When introducing the team care process, it may be reassuring to let patients know that it is no problem if they want to be alone with their physician. In addition, if the physician or assistant senses that the patient is uncomfortable—such as during certain sensitive parts of the visit—the assistant may leave the room. Exam rooms may also be fitted with curtains or screens that can provide additional patient privacy.

Step 8 Meet weekly

Quiz Ref IDTraining is ongoing. The physician and team should meet at least weekly for 30 to 60 minutes to review and adjust the workflow. The meetings can also be used to continue the educational process about clinical issues, billing and coding.

Box Section Ref ID

Q&A

  • Is using an assistant more likely to result in documentation errors than doing it yourself?*

    Accuracy and completeness of the documentation depends on training and a close working relationship between the physician and the assistant. In some ways, the documentation is likely to be more accurate because the assistant is focused on documentation while the physician is focused on providing care. In addition, the documentation is done in real-time, so there are fewer chances for details to be misremembered or confused between different patients. Some teams adopt a hybrid approach where the assistant does most of the documentation, especially those elements that are most suited to structured text entries, while the physician types or dictates a few additional lines explaining the medical thinking and more complicated details of the care plan.

“We set aside one hour every Friday morning to go over the week: what worked well, what didn’t and what changes we need to make. We edit our note templates during those meetings as well. We do some education, for example, why we do microalbumin testing on diabetic patients and other important clinical items. Learning why we do certain things gains buy-in. The new model has not only been good for patients and the physician, it has also been good for the MAs. The MAs are more fully engaged in patient care than they have ever been and they enjoy their work. They have increased knowledge about medical care in general and about their individual patients in particular.”

Kevin Hopkins, MD Family Medicine, Cleveland Clinic, Strongsville, OH

Kevin Hopkins, MD Family Medicine, Cleveland Clinic, Strongsville, OH

Conclusion

Both the clerical documentation assistant (CDA) model and the advanced team-based care model benefit the practice as a whole. Team documentation instills a sense of cooperation among staff at all levels of your practice, empowering them to take an active role in managing patient visits. Through ongoing training and weekly meetings, team documentation processes can evolve with your practice.

Glossary Terms

In-reach approachIn-reach approach: Planning in advance so that gaps in care are closed at the time of each face-to-face visit.Panel ManagementPanel Management: Panel refers to the patient panel, or the patient population of the individual physician or practice. Panel management is managing the patient population by monitoring it for important preventive and chronic care based on guidelines set by the practice.

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Where CME credit is designated, the activity is part of the American Medical Association's accredited CME program. The AMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Article Information

*Disclaimer: Reprinted with permission from the journal Family Practice Management (Fam Pract Manag. 2014;21(6):23-29).

Target Audience: This activity is designed to meet the educational needs of practicing physicians.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, quality improvement and informatics.

Conflict of Interest Disclosure: The content of this activity does not relate to any product of a commercial interest as defined by the ACGME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

Planning Committee:

  • Kevin Heffernan, MA— AMA CME Program Committee

  • Ellie Rajcevich, MPA— Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

  • Sam Reynolds, MBA— AMA Director, Professional Satisfaction and Practice Sustainability

  • Christine Sinsky, MD— Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

  • Rhoby Tio, MPPA— AMA, Senior Policy Analyst, Professional Satisfaction and Practice Sustainability

Author Affiliations:

  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

Faculty:

  • David Eltrheim, MD, Family Physician, Mayo Clinic Health System–Red Cedar; Michael Glasstetter, AMA, VP Advocacy Operations, Advocacy Planning & Management; Thomas Healy, JD, AMA, Vice President and Deputy General Counsel; Kevin D. Hopkins, MD, Family Medicine, Cleveland Clinic; Michelle M. Johnson, RN, BSN, Patient Care Director, Caledonia Clinic, Mayo Clinic Health System; Anton J. Kuzel, MD, MHPE, Chair, Department of Family Medicine and Population Health, Virginia Commonwealth University; Jeffrey Panzer, MD, Medical Director, Oak Street Health; Sara J. Pastoor, MD, MHA, Director, Primary Care Center, University of Texas Health Science Center at San Antonio; David B. Reuben, MD, Archstone Professor of Medicine, David Geffen School of Medicine, University of California–Los Angeles; Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA; Sam Reynolds, MBA, AMA Director, Professional Satisfaction and Practice Sustainability; Gordon Schectman, MD, MS, Primary Care Chief Consultant, Veterans Affairs Central Office; Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA; Rhoby Tio, MPPA, AMA, Senior Policy Analyst, Professional Satisfaction and Practice Sustainability; Rachel Willard-Grace, MPH, Research Manager, Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California, San Francisco

About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure statement: The content of this activity does not relate to any product of a commercial interest as defined by the ACGME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

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