With physicians spending 20 percent of their time on nonclinical paperwork, the need to improve efficiency is becoming more acute.

Payer audits, disability forms, quality reporting, DME forms, certification, transfer forms, compliance, preferred supplier lists, the complete revenue cycle …

According to the 2014 edition of the Physicians Foundation’s biennial survey, physicians spend 20 percent of their time (10.58 hours a week) on nonclinical paperwork. Contrary to popular assumptions, and despite the additional infrastructure available in health systems, employed physicians spend 7.9 percent more time than practice owners, perhaps because the former have more organizational paperwork pertaining to reimbursement, legal compliance, and performance improvement. Interestingly, in light of the trend toward financial risk sharing, a survey published in 2014 in the International Journal of Health Services showed that physicians in large practices and those with financial incentives to focus on appropriateness of care spend more time on administration.

Five to 10 years ago, says Wayne Hartley, vice president, AMGA Consulting Services, many physicians in the clinic setting were expected to put in four or four-and-a-half days of clinical time, with administrative time built into each week.

“Over the years, we’ve seen a decline in the amount of time available for that administrative work, because of the push to improve access and the economic imperatives of practice today,” he says. “So I do think we’re seeing an increase in the total work week.”

What can practices to do alleviate some of the administrative burden?

Provider Support

“What we want is for the people who take care of patients—the physicians and other providers—to be able to do that and for the people who are behind the scenes to do what they do best,” says Susan Turney, MD, CEO, Marshfield Clinic Health System, headquartered in Marshfield, Wis.

The idea is to separate the providers from financial and other administrative tasks that involve nonclinical judgment, and also to cut down on clinical paperwork. For example, the administrative burden on physicians can be reduced by having staff manage and complete many of the insurance and credentialing forms, based on the provider’s documentation and on electronically available statistics.

“But there has to be active dialogue between the two sides about changes in work flow,” Turney says. “Because what may look really good from an administrator’s perspective may actually disrupt patient flow from the physician’s perspective.”

An example is the increasing use of voice recognition software by physicians to dictate, an investment many healthcare systems are making. “What appears to be operational efficiency, with dictation closer to the point of care, actually increases the administrative burden—with physicians serving as their own transcriptionists rather than seeing patients—while being counterproductive financially," Turney says.

The shift to accountable care has helped by moving services to less acute settings where the physician need not be involved in as much documentation, Turney says.

“If a patient is on anticoagulation therapy, which requires close monitoring, someone in home health can draw that patient’s blood and take it to the lab,” she says. “The nurse or medical assistant, working under physician-developed protocols, can review the results and then just share with the physician what he or she needs to make a decision: Is this the best medication? Do we need to change the dose? How should we follow up with that patient? This uses each person’s time most effectively.”

Spectrum Health Medical Group in western Michigan is working on building advanced medical home care teams in each of its 63 primary care practice sites to relieve providers of work that others can do and to improve the patient experience, says Philip Henderson, MD, division chief, primary care. Spectrum Health has embedded pharmacists in its primary care offices to provide services such as medication reconciliation and follow-up visits with patients diagnosed with diabetes, hypertension, and other chronic illnesses. The teams also include behavioral health professionals, care managers, PAs and NPs, and medical assistants.

Many states recently have either expanded the scope of practice for certain advanced practice providers or changed supervisory requirements, says Hartley, which may allow PAs and NPs to work more independently. Practices need to ask: Are our advanced practice providers working to the full scope of their licensure?

EHR Optimization

Given the large investment most groups have made in their electronic health record (EHR), Hartley says, performing periodic reviews is vital to make sure processes keep up with system upgrades and care expansion.

“It’s not just hospitals and clinics today,” Hartley says. “Can you connect electronically with subacute care or rehabilitative aftercare facilities? Can you make the transfer of information easier? A lot of times groups get used to a set of procedures, but the technology is moving so quickly that it could do even more for them—but they need to make sure their changes are HIPAA-compliant.”

When physicians say they do not understand why they need to fill out certain fields or where a form goes once they are done with it, a Lean event or other process improvement activity may be warranted to identify non-value added work that can be eliminated or done by someone else. For example, says Hartley, if the drug formularies in the EHR are not updated as insurance plans make changes, providers may need to use workarounds after the fact.

Realizing that much of the frustration with the EHR stems from a lack of understanding, Spectrum has hired a number of tech-savvy providers as part of its EHR optimization team to train its physicians, Henderson says. “They’re right at the person’s elbow so they can see the work flow up close and show that person a better, faster way to do something, rather than having the physician have to take time out of their day to experiment,” he says.

Cutting Down on Provider Keystrokes

A time-saving strategy used by a number of the Spectrum group’s specialists is the scribe system, which Henderson says is almost like having a transcriptionist in the room. The scribe, who has medical training and knows medical terminology—e.g., a medical assistant or an athletic trainer—types the conversation between physician and patient as it happens.

There is, of course, a cost-benefit ratio to consider, Henderson says.

“How many extra patients do you need to see a day to offset that cost? You also have to take into account professional satisfaction and physician burnout, because the cost of hiring new providers is exceedingly high and documenting visits takes up the majority of their time,” he says.

Another Spectrum strategy is “standard work,” which refers to standardizing a process so that support staff do as much as they possibly can within their licensure without wasteful variation.

An example is setting up ambulatory patients in rooms. “Our medical assistants have a set protocol for rooming patients, so that when the physician gets there, he or she knows all the boxes have been checked—medication, past medical history, vitals—and can focus exclusively on face-to-face patient care,” Henderson says. “We’ve also embedded the standard work process of a patient visit into the work flow of our EHR, which makes it more intuitive for providers and thus allows them to spend more time interacting with the patient instead of the screen. This makes for a better patient experience.”

Just Part of the Job

For Henderson, the fundamental solution is conceptual rather than technological or process-oriented: substituting the word expectation for burden.

“When we hire providers, we make sure to tell them that these duties are part of the expectations of your employment,” he says. “As we get away from ‘paying-per-widget,’ it gets much easier to say, ‘Part of your salary includes this type of work.’ It becomes much more rewarding when, instead of one more thing you’re not going to get paid for, it’s seen as part of your job.”

Lauren Phillips is president of Phillips Medical Writers, Ltd., in Bellingham, Wash.

Interviewed for this article: Wayne Hartley, vice president, AMGA Consulting Services, Alexandria, Va.; Susan Turney, CEO, Marshfield Clinic Health System, Marshfield, Wis.; Philip Henderson, MD, division chief, primary care, Spectrum Health Medical Group, Grand Rapids, Mich.

Publication Date: Monday, December 07, 2015