Using a virtual medical scribe for your practice

[Marasmus1]

What is the opinion of using scribe services in private practice? Is this common in psychiatry? How much would they charge just to get a brief idea about overhead?

Considering medical documentation takes around 2 hours a day on average, these two hours can potentially be spent seeing one more new patient or 2-3 follow ups. Also personally, I would feel much happier ( despise charting) . However, I am not sure about the applicability of this in our field

---

Members don't see this ad.

 

[Alemo]

Hopefully this doesn’t hijack the thread before it’s even taken off, but I think this would be a good idea.

In fact, going further, recording sessions to be analyzed with natural language processing software would be ideal. What if certain phrases, syntax, speech latency, etc could be correlated with disorders (via gold standard diagnostic comparison)?

As I’ve said before, “correct” diagnosis (and, to the extent mental illness is treated with medication, success) depends MAINLY on the interview. Also, elements of psychotherapy could be more easily operationalized and studied with the NLP technique.

(Side note, some forensic psychiatrists record all their interviews)

But to answer the question, yes it would be very helpful even as things stand now. Probably disconcerting to some patients however.

 

[ObsequiousAplomb]

I agree with Alemo.

Maybe I'm overestimating the degree patients would be bothered by it, but I would be concerned that patients wouldn't be as forthcoming with a scribe present.

There's also the issue of the scribe not necessarily being able to accurately describe everything that was said. Subtleties of language and the mental status exam are especially problematic. Did that patient say "I hope to return to and eventually become the president of Maritius in 20 years" or "I hope to return to and everafter be the president of Mars in 20 years" ?? It's a far cry from the dermatology scribe getting down that the rash started 5 days ago on the hand before spreading up the arm and is itchy but not painful.

Also, the mental status exam isn't the type of thing you can dictate out loud to the scribe in front of the patient, so you would still be doing that part of the note. Assessment and plan tend to have more verbage and opinion in psych than the aforementioned dermatology exam where all they say is an icd-10 code and the specific topical steroid creme.

While I personally would not hesitate to see a dermatologist, surgeon, or even urologist who used a scribe, I would not be comfortable seeing a psychiatrist who uses a scribe. Forensics is different. In the same breath that you notify the patient of limits of confidentiality you can pull out and provide the explanation for the Dictaphone and it won't change much. In fact, it might enhance the message.

 

[tr]

You're spending 2 hours per day separate from patient care just to write notes? What all are you writing? Is it forensic or other specialty consult notes?

 

[Marasmus1]

You're spending 2 hours per day separate from patient care just to write notes? What all are you writing? Is it forensic or other specialty consult notes?

No I don`t spend a minute over 7.5 hours a day. However, for 30 minute follow ups, I end the session at 20th minute because it takes around 10 minutes to write the note for me. For intake H/P, I would need to end the session 20-25 minutes earlier again because of the charting. Added together, it comes to 2 hours of charting everyday that could be spent providing patient care.

 

[ObsequiousAplomb]

No I don`t spend a minute over 7.5 hours a day. However, for 30 minute follow ups, I end the session at 20th minute because it takes around 10 minutes to write the note for me. For intake H/P, I would need to end the session 20-25 minutes earlier again because of the charting. Added together, it comes to 2 hours of charting everyday that could be spent providing patient care.

Why does it take that long? Even at a leisurely 50 WPM that means you're writing 500 words. Before jumping to a virtual scribe I would work on templates and increasing typing speed.

 

[TexasPhysician]

Things to think about:

1. Scribes aren’t psychiatrists. You’ll have to train them quite a bit and review completed notes in detail with them for some time before they can pick up how you want the notes written. They’ll still miss the entire physical exam portion, aspects of sarcasm, etc. I tried a live scribe. I found it faster to hand write the note using my template during appointments and have them just type the entire thing afterwards using more complete sentences.

2. If you have to train, review, and still add the physical exam portion yourself, do you save much time? Speaking the note out loud with the patient present would be awkward unlike other fields like derm.

3. Why not use dictation software after appointments if you want long detailed notes?

4. You’ll need a HIPAA compliant VA which is more expensive. Many VA companies refuse to sign a BAA.

5. Most importantly. 2021 billing changes significantly altered the details needed in notes. If notes require an additional 2 hours every day, you are way beyond the average. Most psychiatrists I know spend under 20 minutes at the end of the day completing other tasks/notes. A fair amount can beat the last patient to their respective vehicles.

I complete notes during appointments. This should meet criteria for 99214 and took me under 1 minute:

Name/Date
CC: “work stress”
S: Patient’s depression is stable, but work stress is leading to increased anxiety and irritability.
O: Mood “anxious”
Affect congruent
Denies SI/HI
A: 35 y/o M with Depression unspecified and GAD
P: Increase Zoloft to 100mg - Dep/Anxiety
Counseled on relaxation techniques.

With templates, your note could be 10x as long/detailed while still not taking more than 1 minute total.

No one reads medical notes. If longer notes don’t improve your billing and other specialties ignore all except your diagnosis and skimming the plan, why spend time charting so much? I even talked to some referral sources who said they’d prefer receiving a notice that included the diagnosis and meds over my full eval when thanking them. The counselors prefer I call to/from work to briefly update them if I have a concern. They don’t want to read my notes.

If documenting so much for medicolegal purposes, it is easy to add templated clauses where you see fit. I have a 1/2 page suicide risk assessment and plan template that is customized in 30 seconds.

While I handwrite notes in person, I’ve also put together a huge template that is essentially click boxes. When I desire, I can complete a follow-up note in my EMR without typing a single letter. Scrolling and clicking while on tele and I’m done. You’d never know it was all click boxes from reading it.

 

[birchswing]

Hopefully this doesn’t hijack the thread before it’s even taken off, but I think this would be a good idea.

In fact, going further, recording sessions to be analyzed with natural language processing software would be ideal. What if certain phrases, syntax, speech latency, etc could be correlated with disorders (via gold standard diagnostic comparison)?

As I’ve said before, “correct” diagnosis (and, to the extent mental illness is treated with medication, success) depends MAINLY on the interview. Also, elements of psychotherapy could be more easily operationalized and studied with the NLP technique.

(Side note, some forensic psychiatrists record all their interviews)

But to answer the question, yes it would be very helpful even as things stand now. Probably disconcerting to some patients however.

The rate at which medicine has adopted technology (some of my doctors' offices are still on paper charts) versus its acceleration in the consumer space, I would see this happening with consumer tech and probably more likely to be something continuous versus a single session. Like an EKG versus a holter monitor.

Amazon has a device that already does this in a rudimentary way:

Amazon’s new fitness tracker listens to your voice to figure out your mood

Amazon's new $99 fitness band has a pair of microphones that listen to your voice and analyze it to assess your tone and mood.

www.popsci.com

I'm not saying I think it will happen in either space. Just that if it were to happen, I think it would be more likely in the consumer space.

What companies already know about human nature that they haven't released due to ethical or creepiness concerns must be astounding, just by thinking of what they have chosen to release. Thinking of Gmail's auto-complete for example or it knowing when you might want an e-mail to be secure vs not baed on what you write. It's already a bit uncanny. I am sure they are holding back on their suggestions as to not appear too omniscient. (Apple on the other hand . . . well I think they're playing all the cards they have when it comes to AI, and it's not much.) Facebook was doing experiments testing human behavior based on what they showed people and how they responded in subsequent posts, but they supposedly stopped due to ethics of it.

I'm basing my assumptions on what I have not seen happen in the medical space and what I have seen happen in the consumer space. I'm not saying everyone should run out and self-diagnose, but as an example, it was so much easier and more possible for me to catch a sustained SVT episode using a cheap but FDA-approved-algorithm EKG device I bought myself (AliveCor) (the rhythm strip of which was later read and confirmed by a cardiologist) versus the much more expensive and old fashioned cumbersome testing (an ER trip and Holter monitor) that never caught it (converted to sinus tach by time I got to ER and didn't happen during Holter monitor). The consumer tech sensors right now are more rudimentary, but the investments in the algorithms are wider. If it weren't for privacy concerns, I wouldn't be surprised if a company like Google could already be quite predictive of human behavior if it used constantly listening microphones.

Privacy is a concern, though, and is obviously different with mental health than heart health. There's an AI service (and there are many like this) called Woe-Bot that does CBT on your phone. It came out from psychologists at Stanford, but I think they are collecting data to improve the service, so I'm wary of giving it too much information. That's probably an area where traditional medicine services still have an edge--the willingness to disclose. On the other hand, and with regard to passive continuous collection, when I was on facebook (which I haven't been for years), people were really willing to put their business out there. It wouldn't be too difficult to imagine with that volume of data they could start making a lot of inferences that could relate to mental health.

It also seems like tech purpose built for medical utility is always more expensive (vs consumer tech, including consumer medical tech), I suppose due to the lower volume of sales.

 

[ObsequiousAplomb]

The rate at which medicine has adopted technology (some of my doctors' offices are still on paper charts) versus its acceleration in the consumer space, I would see this happening with consumer tech and probably more likely to be something continuous versus a single session. Like an EKG versus a holter monitor.

Amazon has a device that already does this in a rudimentary way:

Amazon’s new fitness tracker listens to your voice to figure out your mood

Amazon's new $99 fitness band has a pair of microphones that listen to your voice and analyze it to assess your tone and mood.

www.popsci.com

I'm not saying I think it will happen in either space. Just that if it were to happen, I think it would be more likely in the consumer space.

What companies already know about human nature that they haven't released due to ethical or creepiness concerns must be astounding, just by thinking of what they have chosen to release. Thinking of Gmail's auto-complete for example or it knowing when you might want an e-mail to be secure vs not baed on what you write. It's already a bit uncanny. I am sure they are holding back on their suggestions as to not appear too omniscient. (Apple on the other hand . . . well I think they're playing all the cards they have when it comes to AI, and it's not much.) Facebook was doing experiments testing human behavior based on what they showed people and how they responded in subsequent posts, but they supposedly stopped due to ethics of it.

I'm basing my assumptions on what I have not seen happen in the medical space and what I have seen happen in the consumer space. I'm not saying everyone should run out and self-diagnose, but as an example, it was so much easier and more possible for me to catch a sustained SVT episode using a cheap but FDA-approved-algorithm EKG device I bought myself (AliveCor) (the rhythm strip of which was later read and confirmed by a cardiologist) versus the much more expensive and old fashioned cumbersome testing (an ER trip and Holter monitor) that never caught it (converted to sinus tach by time I got to ER and didn't happen during Holter monitor). The consumer tech sensors right now are more rudimentary, but the investments in the algorithms are wider. If it weren't for privacy concerns, I wouldn't be surprised if a company like Google could already be quite predictive of human behavior if it used constantly listening microphones.

Privacy is a concern, though, and is obviously different with mental health than heart health. There's an AI service (and there are many like this) called Woe-Bot that does CBT on your phone. It came out from psychologists at Stanford, but I think they are collecting data to improve the service, so I'm wary of giving it too much information. That's probably an area where traditional medicine services still have an edge--the willingness to disclose. On the other hand, and with regard to passive continuous collection, when I was on facebook (which I haven't been for years), people were really willing to put their business out there. It wouldn't be too difficult to imagine with that volume of data they could start making a lot of inferences that could relate to mental health.

It also seems like tech purpose built for medical utility is always more expensive (vs consumer tech, including consumer medical tech), I suppose due to the lower volume of sales.

I tried the Halo out for a little over a year. It was surprisingly helpful. But that's a psychiatrist who's in analysis saying that. Idk if the average person would find it helpful / would be that open to another data point telling them they may have had a slightly harsh or sarcastic tone for 20 seconds between 11 and 12.

I never tested it out to see if it could accurately tell the difference between me and my brothers - who even our wives can't tell apart if we make sure to use the same cadence and vocabulary.

I do wonder how well that type of algorithm works / what gold standard we could use to say someone did or did not sound this or that way. It's so subjective, individual to the speaker, individual to the listener, and individual to the relationship.

Like, how does it tell if the speaker is mocking the other speaker? Obviously a virtual assistant can't tell if someone is rolling their eyes vs looking up while thinking vs interacting with visual hallucinations.

 

[Marasmus1]

Things to think about:

1. Scribes aren’t psychiatrists. You’ll have to train them quite a bit and review completed notes in detail with them for some time before they can pick up how you want the notes written. They’ll still miss the entire physical exam portion, aspects of sarcasm, etc. I tried a live scribe. I found it faster to hand write the note using my template during appointments and have them just type the entire thing afterwards using more complete sentences.

2. If you have to train, review, and still add the physical exam portion yourself, do you save much time? Speaking the note out loud with the patient present would be awkward unlike other fields like derm.

3. Why not use dictation software after appointments if you want long detailed notes?

4. You’ll need a HIPAA compliant VA which is more expensive. Many VA companies refuse to sign a BAA.

5. Most importantly. 2021 billing changes significantly altered the details needed in notes. If notes require an additional 2 hours every day, you are way beyond the average. Most psychiatrists I know spend under 20 minutes at the end of the day completing other tasks/notes. A fair amount can beat the last patient to their respective vehicles.

I complete notes during appointments. This should meet criteria for 99214 and took me under 1 minute:

Name/Date
CC: “work stress”
S: Patient’s depression is stable, but work stress is leading to increased anxiety and irritability.
O: Mood “anxious”
Affect congruent
Denies SI/HI
A: 35 y/o M with Depression unspecified and GAD
P: Increase Zoloft to 100mg - Dep/Anxiety
Counseled on relaxation techniques.

With templates, your note could be 10x as long/detailed while still not taking more than 1 minute total.

No one reads medical notes. If longer notes don’t improve your billing and other specialties ignore all except your diagnosis and skimming the plan, why spend time charting so much? I even talked to some referral sources who said they’d prefer receiving a notice that included the diagnosis and meds over my full eval when thanking them. The counselors prefer I call to/from work to briefly update them if I have a concern. They don’t want to read my notes.

If documenting so much for medicolegal purposes, it is easy to add templated clauses where you see fit. I have a 1/2 page suicide risk assessment and plan template that is customized in 30 seconds.

While I handwrite notes in person, I’ve also put together a huge template that is essentially click boxes. When I desire, I can complete a follow-up note in my EMR without typing a single letter. Scrolling and clicking while on tele and I’m done. You’d never know it was all click boxes from reading it.

Name/Date
CC: “work stress”
S: Patient’s depression is stable, but work stress is leading to increased anxiety and irritability.
O: Mood “anxious”
Affect congruent
Denies SI/HI
A: 35 y/o M with Depression unspecified and GAD
P: Increase Zoloft to 100mg - Dep/Anxiety
Counseled on relaxation techniques.

I do agree that notes should be like above. However, where I am training, they would kick me out from fellowship for writing this as a progress note. It would have to look more look like below;

CC'' work stress''
S: Patient noted that her depression is stable. She has not identified any new stressor. However, noted that work related stress is piling up and she finds herself overall more anxious and irritable. She noted that she had to skip her individual counseling session because she was quite busy to meet the deadline for the project. She noted that she tried some breathing exercises during the week which slightly helped but did not relax her enough to fall asleep faster and she ended up tossing and turning until 3 am most of the nights. She complains of feeling quite tired during the daytime. She notes taking her prozac 20 mg daily and denied any significant adverse effect. She asked about the potential risks/benefits of going up on her prozac to address anxiety symptoms. She noted that she has not experienced any change in her appetite since last visit. She denied any thoughts of suicidal ideation/self harm/harm to others.
O : There would be full Mental Status Exam and Columbia suicide risk assessment here ( they ask us to use EMR clicking and scrolling here which itself takes around 2-3 minutes to complete)
A: 21 yo patient with Past psychiatric history of Major Depressive Disorder and Anxiety Disorder presenting for follow up. Patient`s depressive symptoms are under partial control with the support of pharmacotherapy while patient experiences increased anxiety and irritability due to work related stress. Discussed about the potential benefits/risks of further dose increase in Prozac. Patient agreed with increase to 40 mg po AM daily
P: Increase Prozac to 40 mg from 20 mg
Continue individual counseling
Follow up in 4 weeks

 

[splik]

Name/Date
CC: “work stress”
S: Patient’s depression is stable, but work stress is leading to increased anxiety and irritability.
O: Mood “anxious”
Affect congruent
Denies SI/HI
A: 35 y/o M with Depression unspecified and GAD
P: Increase Zoloft to 100mg - Dep/Anxiety
Counseled on relaxation techniques.

This is not sufficient documentation and does not qualify for 99214 even (although neither does your example meet it). If someone was audited for this, they would get put on prepayment review.

 

[TexasPhysician]

This is not sufficient documentation and does not qualify for 99214 even (although neither does your example meet it). If someone was audited for this, they would get put on prepayment review.

I’d love to hear your thoughts. It now meets MDM according to the AMA with 2 chronic conditions. I guess I could write (chronic) next to the diagnoses just in the case the insurance company can’t clearly see this.

According to the AMA: “Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service.”

 

[VA Hopeful Dr]

I’d love to hear your thoughts. It now meets MDM according to the AMA with 2 chronic conditions. I guess I could write (chronic) next to the diagnoses just in the case the insurance company can’t clearly see this.

According to the AMA: “Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service.”

Yeah it looks to me like it meets it. You have one chronic condition that is stable and one chronic condition that is uncontrolled. Your prescribed a medication. Under the new coding rules that's level 4 all day long.

 

[tr]

Name/Date
CC: “work stress”
S: Patient’s depression is stable, but work stress is leading to increased anxiety and irritability.
O: Mood “anxious”
Affect congruent
Denies SI/HI
A: 35 y/o M with Depression unspecified and GAD
P: Increase Zoloft to 100mg - Dep/Anxiety
Counseled on relaxation techniques.

I do agree that notes should be like above. However, where I am training, they would kick me out from fellowship for writing this as a progress note. It would have to look more look like below;

CC'' work stress''
S: Patient noted that her depression is stable. She has not identified any new stressor. However, noted that work related stress is piling up and she finds herself overall more anxious and irritable. She noted that she had to skip her individual counseling session because she was quite busy to meet the deadline for the project. She noted that she tried some breathing exercises during the week which slightly helped but did not relax her enough to fall asleep faster and she ended up tossing and turning until 3 am most of the nights. She complains of feeling quite tired during the daytime. She notes taking her prozac 20 mg daily and denied any significant adverse effect. She asked about the potential risks/benefits of going up on her prozac to address anxiety symptoms. She noted that she has not experienced any change in her appetite since last visit. She denied any thoughts of suicidal ideation/self harm/harm to others.
O : There would be full Mental Status Exam and Columbia suicide risk assessment here ( they ask us to use EMR clicking and scrolling here which itself takes around 2-3 minutes to complete)
A: 21 yo patient with Past psychiatric history of Major Depressive Disorder and Anxiety Disorder presenting for follow up. Patient`s depressive symptoms are under partial control with the support of pharmacotherapy while patient experiences increased anxiety and irritability due to work related stress. Discussed about the potential benefits/risks of further dose increase in Prozac. Patient agreed with increase to 40 mg po AM daily
P: Increase Prozac to 40 mg from 20 mg
Continue individual counseling
Follow up in 4 weeks

Interesting. I am constantly begging our trainees to write shorter notes. I don't have time to read all that nonsense.
Here's my version of the above:

ID: 21F with MDD/GAD exacerbated by work stress

S: Pt returns for f/u after 1 month. Still on Prozac 20 mg/d, denies SE, but endorses ongoing depression, anxiety, and irritability in context of work stress. Sleep still disrupted but she does not think affected by Prozac. Trialed breathing exercises on several occasions but did not find helpful.

O : MSE yes (takes 10 sec to update note copied forward from last visit), CSSRS no. Note there is a suicidality item on the PHQ.
PHQ9: 15
GAD7: 12

A: 21F hx MDD, GAD, currently exacerbated in context of work stress and only partially controlled with Prozac 20 mg/d.

Multiaxial assessment (yes I still do these, copy forward, mostly doesn't change except the GAF):
Axis I: MDD 5 lifetime episodes, GAD
Axis II: defer
Axis III: IBS
Axis IV: work stress
Axis V: 61-70

P:
- Increase Prozac to 40 mg/d
- Sleep hygiene discussed and handout provided; pt will implement regular bedtime, AM sun exposure, avoid PM screen time. If ineffective may consider sleep aid or switch to less activating antidepressant
- Breathing exercises: practice daily
- Bring up plan for workload management with supervisor as discussed in session
- Continue individual counseling with Therapist X
- Follow up in 4 weeks

I would complete this note in the visit by modifying the copied-forward version from last visit and hit 'sign' right after she walks out the door and before I go get my next patient. Note-writing outside the visit is only for consults where I need to get a lot of information across to the consulting psychiatrist. New intakes a bit as well but no more than 5-15 min charting time outside the visit usually.

I think you have too much verbiage in the Subjective. If you reduce it to bullet points I think it should be able to be completed in session assuming most of it would have been copied forward from the previous one. Can you not click the MSE boxes while you talk to the patient?

 

[FlowRate]

I think you have too much verbiage in the Subjective. If you reduce it to bullet points I think it should be able to be completed in session assuming most of it would have been copied forward from the previous one. Can you not click the MSE boxes while you talk to the patient?

FWIW this is very very close to what I do. I write slightly more assessment (3-5 sentences) for patients where it's justified or when I want coverage to know what I want to do next / what worked previously.

My normal MSE is a bunch of precompleted smartlists that I just hit enter repeatedly for. Common abnormals can be easily selected from the smartlists. I also copy forward.

 

[Merovinge]

FWIW this is very very close to what I do. I write slightly more assessment (3-5 sentences) for patients where it's justified or when I want coverage to know what I want to do next / what worked previously.

My normal MSE is a bunch of precompleted smartlists that I just hit enter repeatedly for. Common abnormals can be easily selected from the smartlists. I also copy forward.

I use copy forwarded notes and write a lengthy subjective (admittedly for PHP/IOP the insurance seems to want to see more of this than OP work) but I do this concurrent to appointment so it adds zero minutes to my day. I complete the MSE like you mentioned, write the scripts, and update the plan in my note all in session. I then will spend a few minutes per patient writing a 3-5 sentence assessment around interval history and MDM (this takes cortical function that I cannot easily multitask while engaging fully with the patient). With 30 minute appointment slots but most having 25 min of facetime along with 2-3 minutes to document at the end of the appointment, I rarely have more than a few minutes to finish notes by the end of the day.

Initial assessments are a different beast, I find it important to spend 10ish minutes after seeing the patient to write these up. I am fortunate to have the time budgeted into my day to do so, but I can see someone doing a lot of new evals getting behind a bit if the schedule is full. Certainly use any N/S to complete these.

Edit: I should add, high volume specialties that are less personal (e.g. surgery) make a lot of sense for scribes. I think they can definitely have a place in the practice of medicine. I would not personally have any interest in using them in psychiatry, I think rapport is better 1:1 even if I am typing rather then looking a patient in the eyes the whole time but with the awareness someone else is listening to the conversation. I just cannot imagine seeing a computer screen of a scribe typing along as someone reveals their childhood sexual abuse to me.