Effect of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act Scribes Trial on Emergency Department Provider Productivity and Patient Throughput Times.

BACKGROUND: To help improve access to care, section 507 of the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act of 2018 mandated a 2-year trial of medical scribes in the Veterans Health Administration (VHA). OBJECTIVE: The impact of scribes on provider productivity and patient throughput time in VHA emergency departments (EDs) was evaluated. METHODS: A clustered randomized trial was designed using intent-to-treat difference-in-differences analysis. The intervention period was from June 30, 2020 to July 1, 2022. The trial included six intervention and six comparison ED clinics. Two ED providers who volunteered to participate in the trial were assigned two scribes each. Scribes assisted providers with documentation and visit-related activities. The outcomes were provider productivity and patient throughput time per clinic-pay period. RESULTS: Randomization to intervention resulted in decreased provider productivity and increased patient throughput time. In adjusted regression models, randomization to scribes was associated with a decrease of 8.4 visits per full-time equivalent (95% confidence interval [CI] 12.4-4.3; p < 0.001) and 0.5 patients per day per provider (95% CI 0.8-0.3; p < 0.001). Intervention was associated with increases in length of stay of 29.1 min (95% CI 21.2-36.9 min; p < 0.001), 6.3 min in door to doctor (95% CI 2.9-9.6 min; p < 0.001), 19.5 min in door to disposition (95% CI 13.2-25.9 min; p < 0.001), and 13.7 min in doctor to disposition (95% CI 8.8-18.6 min; p < 0.001). CONCLUSIONS: Scribes were associated with decreased provider productivity and increased patient throughput time in VHA EDs. Although scribes may have contributed to improvements in other dimensions of quality, further examination of the ways in which scribes were used is advisable before widespread adoption in VHA EDs.

Comparison of Full-Time Equivalent and Clinic Time Labor Input Measures in Productivity Metrics.

GOAL: A lack of improvement in productivity in recent years may be the result of suboptimal measurement of productivity. Hospitals and clinics benefit from external benchmarks that allow assessment of clinical productivity. Work relative value units have long served as a common currency for this purpose. Productivity is determined by comparing work relative value units to full-time equivalents (FTEs), but FTEs do not have a universal or standardized definition, which could cause problems. We propose a new clinical labor input measure-"clinic time"-as a substitute for using the reported measure of FTEs. METHODS: In this observational validation study, we used data from a cluster randomized trial to compare FTE with clinic time. We compared these two productivity measures graphically. For validation, we estimated two separate ordinary least squares (OLS) regression models. To validate and simultaneously adjust for endogeneity, we used instrumental variables (IV) regression with the proportion of days in a pay period that were federal holidays as an instrument. We used productivity data collected between 2018 and 2020 from Veterans Health Administration (VA) cardiology and orthopedics providers as part of a 2-year cluster randomized trial of medical scribes mandated by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018. PRINCIPAL FINDINGS: Our cohort included 654 unique providers. For both productivity variables, the values for patients per clinic day were consistently higher than those for patients per day per FTE. To validate these measures, we estimated separate OLS and IV regression models, predicting wait times from the two productivity measures. The slopes from the two productivity measures were positive and small in magnitude with OLS, but negative and large in magnitude with IV regression. The magnitude of the slope for patients per clinic day was much larger than the slope for patients per day per FTE. Current metrics that rely on FTE data may suffer from self-report bias and low reporting frequency. Using clinic time as an alternative is an effective way to mitigate these biases. PRACTICAL APPLICATIONS: Measuring productivity accurately is essential because provider productivity plays an important role in facilitating clinic operations outcomes. Most importantly, tracking a more valid productivity metric is a concrete, cost-effective management tactic to improve the provision of care in the long term.

Costs and Productivity Benefits of the Department of Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act Scribes Trial.

OBJECTIVES: To improve access, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 mandated a 2-year study of medical scribes in Veterans Health Administration specialty clinics and emergency departments. Medical scribes are employed in clinical settings with the goals of increasing provider productivity and satisfaction by minimizing physicians' documentation burden. Our objective is to quantify the economic outcomes of the MISSION Act scribes trial. METHODS: A cluster-randomized trial was designed with 12 Department of Veterans Affairs (VA) medical centers randomized into the intervention. We estimated the total cost of the trial, cost per scribe-year, and projected cost of hiring additional physicians to achieve the observed scribe productivity benefits in relative value units and visits per full-time-equivalent over the 2-year intervention period (June 30, 2020 to July 1, 2022). RESULTS: The estimated cost of the trial was $4.6 million, below the Congressional Budget Office estimate of $5 million. A full-time scribe-year cost approximately $74 600 through contracting and $62 900 through VA hiring. Randomization into the trial led to an approximate 30% increase in productivity in cardiology and 20% in orthopedics. The projected incremental cost of using additional physicians instead of scribes to achieve the same productivity benefits was nearly $1.7 million more, or 75% higher, than the observed cost of scribes in cardiology and orthopedics. CONCLUSIONS: As the largest randomized trial of scribes to date, the MISSION Act scribes trial provides important evidence on the costs and benefits of scribes. Improving productivity enhances access and scribes may give VA a new tool to improve productivity in specialty care at a lower cost than hiring additional providers.

Effect of a National VHA Medical Scribe Pilot on Provider Productivity, Wait Times, and Patient Satisfaction in Cardiology and Orthopedics.

BACKGROUND: Section 507 of the VA MISSION Act of 2018 mandated a 2-year pilot study of medical scribes in the Veterans Health Administration (VHA), with 12 VA Medical Centers randomly selected to receive scribes in their emergency departments or high wait time specialty clinics (cardiology and orthopedics). The pilot began on June 30, 2020, and ended on July 1, 2022. OBJECTIVE: Our objective was to evaluate the impact of medical scribes on provider productivity, wait times, and patient satisfaction in cardiology and orthopedics, as mandated by the MISSION Act. DESIGN: Cluster randomized trial, with intent-to-treat analysis using difference-in-differences regression. PATIENTS: Veterans using 18 included VA Medical Centers (12 intervention and 6 comparison sites). INTERVENTION: Randomization into MISSION 507 medical scribe pilot. MAIN MEASURES: Provider productivity, wait times, and patient satisfaction per clinic-pay period. KEY RESULTS: Randomization into the scribe pilot was associated with increases of 25.2 relative value units (RVUs) per full-time equivalent (FTE) (p < 0.001) and 8.5 visits per FTE (p = 0.002) in cardiology and increases of 17.3 RVUs per FTE (p = 0.001) and 12.5 visits per FTE (p = 0.001) in orthopedics. We found that the scribe pilot was associated with a decrease of 8.5 days in request to appointment day wait times (p < 0.001) in orthopedics, driven by a 5.7-day decrease in appointment made to appointment day wait times (p < 0.001), and observed no change in wait times in cardiology. We also observed no declines in patient satisfaction with randomization into the scribe pilot. CONCLUSIONS: Given the potential improvements in productivity and wait times with no change in patient satisfaction, our results suggest that scribes may be a useful tool to improve access to VHA care. However, participation in the pilot by sites and providers was voluntary, which could have implications for scalability and what effects could be expected if scribes were introduced to the care process without buy-in. Cost was not considered in this analysis but is an important factor for future implementation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04154462.

Delivery system emergency department capacity and its effect on nonsystem service utilization.

BACKGROUND: Emergency department (ED) use is often seen as a source of excess health care spending, prompting managers to limit ED capacity in their health systems. However, if limited ED capacity in a delivery system leads patients to seek emergency care elsewhere, then health care quality and efficient management may be compromised within the system. OBJECTIVE: The objective of this study was to explore the effect of the Veterans Health Administration (VHA) in-house ED clinician capacity on VHA community care (CC) ED claims. METHODS: We used administrative data from the VHA to identify CC ED claims and Department of Veterans Affairs emergency physician (EP) capacity for 2014-2019. We used quasi-experimental instrumental variables approach with two different instruments: percent weekday federal holidays and VHA EP full-time equivalents (FTEs). We controlled for VHA ED variables such as ED wait times (door to triage, door to doctor, and door to admission) and demand variables such as alternative insurance coverage, driving time to VHA care, and demographic variables (employment, age, household income, race, gender, and VHA priority status). RESULTS: After instrumenting for capacity with percent weekday federal holidays, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 61 CC ED claims per 10,000 enrollees. After instrumenting for capacity with EP FTE, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 48 CC ED claims per 10,000 enrollees. Both of these results are statistically significant at p < 0.001. CONCLUSIONS: Our findings imply that offering more in-house ED care, in the form of clinician capacity, can substantially reduce out-of-system ED use. The results may be of interest to integrated health care system managers who prefer their patients to stay within network.

Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals.

BACKGROUND: Care leakage from health systems can affect quality and cost of health care delivery. Identifying modifiable predictors of care leakage may help health systems avoid adverse consequences. Out-of-system emergency department (ED) use may be one modifiable cause of care leakage. Our objective was to investigate the relationship between out-of-system ED use and subsequent specialty care leakage. METHODS: We used the Veterans Health Administration's (VA) Corporate Data Warehouse data from January 2021 to July 2021. A total of 330,547 patients who had at least one ED visit (in-house or community care [CC]) in the index period (January 2021-March 2021) were included. Outcomes were the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from the index ED visit. Instrumental-variables regressions, using VA ED physician capacity as an instrument for Veterans' CC ED use, were utilized to estimate the proportions of subsequent specialty care visits in the community. Estimates were adjusted for patient and facility characteristics. RESULTS: A CC ED visit was associated with increases in the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from index visit. Within 30 days from index visit, CC ED patients were estimated to have a 45-percentage-point (pp; 95% confidence interval [CI], 43-47 pp) higher proportion of CC specialty care visits than patients with an in-house ED visit (p < 0.001). We observed similar, though slightly attenuated, results over long time periods since the index visit. CONCLUSIONS: Veterans who have a CC ED visit have a greater proportion of subsequent specialty care visits in CC hospitals and clinics than Veterans with a VA ED visit. This relationship persists when we examine Veterans whose decision to go to a CC ED is influenced by VA ED physician capacity rather than general preferences for CC.

Design and implementation of a cluster randomized trial measuring benefits of medical scribes in the VA.

BACKGROUND: Medical scribes are trained professionals who assist health care providers by administratively expediting patient encounters. Section 507 of the MISSION Act of 2018 mandated a 2-year study of medical scribes in VA Medical Centers (VAMC). This study began in 2020 in the emergency departments and specialty clinics of 12 randomly selected VAMCs across the country, in which 48 scribes are being deployed. METHODS: We are using a cluster randomized trial to assess the effects of medical scribes on productivity (visits and relative value units [RVUs]), wait times, and patient satisfaction in selected specialties within the VA that traditionally have high wait times. Scribes will be assigned to emergency departments and/or specialty clinics (cardiology, orthopedics) in VAMCs randomized into the intervention. Remaining sites that expressed interest but were not randomized to the intervention will be used as a comparison group. RESULTS: Process measures from early implementation of the trial indicate that contracting may hold an advantage over direct hiring in terms of reaching staffing targets, although onboarding contractor scribes has taken somewhat longer (from job posting to start date). CONCLUSIONS: Our evaluation findings will provide insight into whether scribes can increase provider productivity and decrease wait times for high demand specialties in the VA without adversely affecting patient satisfaction. IMPLICATIONS: As a learning health care system, this trial has great potential to increase our understanding of the potential effects of scribes while also informing a real policy problem in high wait times and provider administrative burdens.