By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If you have knowledge, let others light their candles in it.”

-Margaret Fuller,
American Journalist and Women’s Right Advocate

Most organizations that implemented Electronic Medical Record (EMR) systems in the last two decades found that this implementation led to increased clerical workload of clinicians, leading to increased burnout and job dissatisfaction. Additionally, overuse and misuse of templates led to longer but less accurate and less useful clinical notes.

Several primary care organizations in our region added a new position to address these issues like medical scribes, who perform real-time electronic health record documentation, in the exam room (or video call) with the clinician.

A survey of the published literature on medical scribes have shown increased efficiency, clinician productivity and provider experience, while patient experience with scribes is mixed.

Shasta Community Health Center (SCHC) reports that the increased efficiency of scribes leads clinicians to finish their work earlier at the end of the day, with administrative tasks completed which allows them to go home to their families on time. Since first implementing a scribe program over a decade ago, SCHC has refined their model to increase the quality of documentation in the medical record and to drive quality performance in the Primary Care Providers Quality Incentive Program (PCP QIP) measures.

1. Training: SCHC has developed a training curriculum to train promising candidates in medical language, standards of documentation, etc., which is now being adapted to be offered in community college courses.
2. Continuity: a clinician-scribe diad often develops short cuts and non-verbal communication methods to work rapidly as a team to support the patient. This may include sending instant messages to the clinician during the visit, such as ordering preventive screenings.
3. Quality focus: Assigning the scribe responsibility for measures amenable to their intervention, like ordering labs that are due or scheduling well child visits.
4. Incentives: A pilot showed that a small incentive for scribes linked to a single measure worked well, but Shasta CHC is cautious about unintended negative consequences, such as removing intrinsic motivation for improving quality.

This “tip from the field,” was collected by Partnership HealthPlan of California’s (PHC’s) Medical Directors, Dr. Robert Moore and Dr. Jeff Ribordy, at our first trip to Redding in many months. We will be working our way out to visit other counties and providers in the months to come.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Ancient medicine had once had a name for this something present in the living body but missing from the corpse. Spiritus was the breath, the regular, rhythmic breathing of the live body that is so shockingly absent from the dead.”

-Dr. Victoria Sweet, Author and Medical Historian

October is National Lung Health Month, sponsored by the American Lung Association. Why October? Possibly to coincide with the prime season for influenza vaccination.
Here are few ways (besides flu vaccination) primary care clinicians can support our patient’s lungs.

1. Asthma Treatment: Use combination formoterol-corticosteroid inhalers (such as Symbicort or Dulera) instead of albuterol or levalbuterol for short-acting relief of mild to moderate asthma. International and national guidelines and a strong evidence base support this approach.
2. Asthma Misdiagnosis: Be on the lookout for the 10% of patients with a diagnosis of asthma who have other conditions. Order spirometry or pulmonary function tests if the diagnosis is unclear, especially if not responding as expected to usual asthma treatment.
3. COVID: About 20% of patients hospitalized with COVID develop long-term lung damage, causing dyspnea and decreased exercise tolerance. Prevent permanent lung damage caused by COVID by encouraging all eligible patients to be vaccinated, especially pregnant women and teens. Consider use of monoclonal antibodies to treat early COVID infection to prevent it from becoming severe.
4. COPD: Ensure that patients discharged from emergency departments and hospitals for COPD exacerbations receive prescriptions for tapering oral corticosteroids and combination bronchodilators (long acting beta agonists and long acting muscarinic agonists).
5. Action Plans: Ensure that patients with COPD and Asthma have action plans to allow them to self-manage exacerbations.
6. Pneumococcal Vaccination: When giving annual influenza vaccine, co-administer pneumococcal vaccine for those who have not been previously vaccinated. Who are eligible? Adults over age 65, those with immuno-compromising conditions, chronic CSF leak, and those with cochlear implants.
7. Smoking cessation: ask about smoking status, provide counselling to those using tobacco products, and prescribe smoking cessation medications when appropriate.

Although these are core primary care activities, we sometimes are distracted by other clinical issues that come up in our visits. Please pass this along to your clinicians to remind them to think about more than just flu vaccine, this month.