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Learn how training medical assistants (MAs) to use detailed note templates to provide pre-visit and in-room support improves efficiency of care and accuracy of documentation.
In dermatology, accurate diagnosis and treatment require careful focus on the patient’s skin. Mistakes occur when the physician’s focus is interrupted as they move back and forth between the patient and the computer. It is also inefficient and impersonal to focus on the computer, particularly in such a visual specialty. The goal was to:
Emphasize accurate diagnosis and treatment plans
Do this in a way that was satisfying to the patient
The team-based care model was first piloted at 1 Intermountain Healthcare location by Cort McCaughey, MD. Each dermatologist works with 3 MAs in 3 exam rooms while in clinic, with 1 MA per exam room. During the pre-visit, the MA:
Pulls the past medical history into the note
Updates the social and family histories
Selects the specific initial note template based on the patient’s chief complaint
For example, if the patient is there for evaluation of hair loss, the MA pulls up the initial hair loss template. This template guides the MA to ask:
Relevant questions about the duration and location of the hair loss
If there is any associated pruritus or scalp tenderness
About the use of particular medications
For an understanding of the patient’s hair care practices
This template empowers the MA to ask appropriate questions without possessing deep knowledge of the condition or chief complaint. The practice has built approximately 40 such templates to guide the MAs as they room each patient.
“Now while I am in the room, I spend nearly the entire visit face-to-face with the patient.” -Cort McCaughey, MD
After this initial information is gathered and recorded by the MA, half of the note is already built (which includes the History of Present Illness (HPI), past medical history, and allergies). The MA then presents
the patient to the physician, and they both return to the room together. Once the physician makes a diagnosis, the MA pulls up the template for that specific diagnosis and inserts it below the information that was created prior to the physician entering the room.
For example, if the physician identified that the patient’s hair loss is related to lichen planopilaris, the MA pulls up this template, which is pre-populated with the physical exam typical of this condition, the medications that are commonly prescribed, the standard discussion the physician should have with patients about this condition, and the appropriate ICD-10 code. The diagnosis and ICD-10 codes (part of the template that is pulled in at the time of diagnosis) are then copied from the note and pasted into the patient’s problem list for billing. This way, the MA can draft the documentation without having to manually type in technical nomenclature (for example, lichen planopilaris) or lengthy descriptions of the physical exam.
At the conclusion of the visit, the physician spends 60-90 seconds customizing the documentation to the individual patient encounter.
Despite data showing that this process, when implemented correctly, will cover the additional staff costs, a barrier to implementing this process may include the need for organizations to tightly monitor and control budgets. A common complaint heard from colleagues in other organizations is that administrators want to see increased patient volumes prior to hiring additional staff. This is not a safe and/or effective way of implementing scribes into practice; however, it is understandable that an organization trying to stay financially viable would want to see a return on their investment.
The initial pilot program was quite successful and has had overwhelming support from the organization within Dermatology. Dr McCaughey estimates that he has cut his total documentation time down from 3.5 hours per day to 1 hour per day. He indicated that his dictation is also more accurate. In his own practice, patient volumes increased by approximately 10-15 patients per day. Other colleagues within the organization have estimated that losing access to MA-scribes would cut their daily patient volumes in half.
To achieve the same results, physicians should be willing to invest the upfront time in developing the templates that MAs can use because it dramatically improves overall efficiency and satisfaction. In addition, during the pilot phase, the clinic learned of the importance of bringing in other stakeholders. For example, compliance professionals and individuals from leadership weighed in on the workflow. It is important to receive buy-in from stakeholders so that they can champion the spread of the model to other physicians and specialties.
Intermountain Healthcare is a team of nearly 40 000 caregivers who serve the health care needs of people across the Intermountain West, primarily in Utah, southern Idaho, and southern Nevada. Intermountain Healthcare is an integrated, not-for-profit health system. Dermatologists at Intermountain see 40-47 patients per day on average. This includes patients of all ages and with a wide variety of diagnoses.
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