In this episode of the AMA STEPS Forward® podcast, Elisabeth Stambaugh, MD, chief medical officer at Atrium Health Wake Forest Baptist, discusses how training medical assistants as “Encounter Specialists” can reduce physician burnout, close the value-based care gap and increase team efficiency and satisfaction. To learn more, read the full success story.
- Elisabeth Stambaugh, MD, chief medical officer, Atrium Health Wake Forest Baptist
- Jill Jin, MD, MPH, senior physician advisor, American Medical Association
Introduction: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Dr. Jin: Welcome to the AMA STEPS Forward® podcast. My name is Dr. Jill Jin. And today, I have the great privilege of speaking with Dr. Elisabeth Stambaugh, who is currently the chief medical officer at Atrium Health Wake Forest Baptist, a major academic health system based in Winston-Salem, North Carolina. Dr. Stambaugh, thank you so much for being with us today.
Dr. Stambaugh: Thank you for inviting me. I'm really excited to speak with you about this program. I am an OB-GYN by training, came from Chicago. Husband and I moved to North Carolina 23 years ago and started practice. Along the way, my practice started off as small independent practice, then joined a larger multi-specialty physician-owned group called Cornerstone Healthcare. And I became involved in leadership and ended up as the chief medical officer of that group.
We then became part of Wake Forest Baptist Health back in 2016 and all of Wake Forest became part of Atrium at the end of 2020. The part of it that I lead as chief medical officer is called the Wake Forest Health Network. And so we are the private practice arm of the Wake Forest part of the organization. So we're the non-faculty practices. And we have about 110 sites across Central North Carolina. About half of them are adult primary care and pediatrics and the other are different specialties. And so we have a total of about 450 providers.
Dr. Jin: So you are busy.
Dr. Stambaugh: A little bit.
Dr. Jin: Yeah. Okay, our topic of discussion today, as you mentioned, is a success story you recently wrote for AMA STEPS Forward® about a program you developed to train certified medical assistants as "encounter specialists" in order to help support physicians during their patient encounters. And, of course, the goal is to reduce physician burnout and increase practice efficiency. I definitely want to learn more about this. It sounds like a great idea. But let's first start by defining what an encounter specialist is.
Dr. Stambaugh: The best way to describe what an encounter specialist is, is it's a medical assistant on steroids. This role combines the normal medical assistant roles, and in most of our ambulatory sites, when we talk about our nurse we're really talking about our medical assistant. And so they're the ones who are rooming patients and doing most of the clinical activities, non-provider clinical activities in the practice. But this also then, this encounter specialist role adds in the capability to be a scribe. Part of this is also focusing on value-based gap closures.
Dr. Jin: Do medical assistants need any additional training to take on this role?
Dr. Stambaugh: They do. So we have a program that is quite strict, which I think is really important, that helps them, and it's really not just a medical assistant honestly, it also includes the provider. The reason we call it encounter specialist is because the ideal model is two encounter specialists for each provider, such that the encounter specialist welcomes the patient into the practice, does the normal rooming functions but stays with that particular patient through the entire visit.
When the provider's in the room, they act as the scribe. And then after the provider leaves, they also do any after-visit activities and help set up new appointments or explain some of what the provider was talking about. And so they stay with that patient through the entire encounter. At the same time, the second encounter specialist is working with another patient with the provider. So that's why it's called that encounter specialist.
We did have to train—our program trains the whole team. So that's the two encounter specialists plus this provider. It's been mostly physicians to this point but we do also have some advanced practice providers who use this program as well. That training is about how they can work better as a team, which I think is really important.
Honestly, this involves the provider letting go of a little bit of control, which isn't always so easy for us physicians. But also, really it's the scribe part is important, but they have to learn … because they are also a critically trained person and when you look at a scribe definition, it's supposed to be someone who's not clinically trained. So we have to be very careful so that they avoid any appearance or any activity that could be construed as medical decision-making because that's under the purview of the provider.
Dr. Jin: Why did you first feel the need to develop this program?
Dr. Stambaugh: Well, interestingly, the program has really evolved over the years. Initially, it was actually created by one of our cornerstone practices that was a very busy―still is―one of our best and very busiest primary care practices. And this is back when we were pretty much all fee-for-service before we started making our transition to value-based care.
And they were so busy and so popular, they obviously had trouble getting patients in as new patients. So one of their strategies for making them more efficient and being able to have the physicians spend less time in the medical record and be able to get a couple of extra patients in per day per provider was to develop this model.
So it was really developed in that old fee-for-service world. We did find that as long as the provider added on an extra two patients a day in a primary care practice, that they would pay for itself by adding that extra medical assistant. But we also found that they could do that pretty easily when they had this team where a lot of the documentation was being done by someone else.
So, that's where it came from and then it evolved over the years. As Cornerstone got deeper and deeper into value-based care we realized we could really expand the program and have it be for a lot of other reasons besides just seeing more patients.
Dr. Jin: So the program was initially developed for a smaller practice and then since scaled up. It sounds like two different parts of the organization.
Dr. Stambaugh: And we originally, when it first started getting expanded, we kind of stuck―hell led with that―you have to see two patients extra a day in order to pay for it. In one situation in particular, we had a physician who had actually considered the program previously but wasn't quite willing to give up that level of control, so hadn't implemented it. But then she was so burnt out and so honestly ready to leave the organization, and at the same time was failing her coding audits. And so we had to do something and we said, "Look, before you leave, let's just give this a try and see if it helps."
And again, that wasn't about seeing more patients. That was about getting her to be less burnt out. But also, I mean, we have to be realistic about it. If the coding and the documentation aren't matching, we're not even being able to bill for the visits she did do. So lots of great reasons to say, "This is also a place that we could try this."
Oh my gosh, the success was unbelievable. It happened to be that we implemented this program for her right at the same time as her practice was going live on Epic. And so that could have really destroyed that start and made it be not successful. However, it was incredibly successful. Matter of fact within a couple of weeks, she was saying, "I'm home by six o'clock, I have no charge to do at home." Of course, she was passing her compliance audits at this point. And she even then decided she was so much less burnt out that she was willing to open up an extra half day a week to see patients because it was just such a better process. So we really kind of expanded sort of the why we would implement it beyond just this is an access way, or a way for doctors to see a couple more patients a day.
Dr. Jin: Interesting. Did you give providers initially the chance to opt-in or opt-out?
Dr. Stambaugh: My goal would be to be able to say to everybody, "This is what we're going to do unless you opt-out.” Because there is a training program and a team that goes in and works with this practice, it's not something you can do everywhere at once. But we have streamlined our training a little bit so we can train more.
Well, the problem is now there aren't more people. This is, I think, what everybody's dealing with. We simply don't have enough staff. And so to try to get that two-to-one ratio has been a real struggle. Up to this point, it has all been, if you ask, we have a team that goes in and evaluates would this work in certain practices. And they have some criteria that they look at. Some of it's about teamwork, some of it's about what the current volumes are, what the current plugs in the process are that can slow things down. And they make a really great recommendation as to what would work in that practice. And where we can, we love to implement the two-to-one model as long as we can find the people.
Dr. Jin: Right. Right. Okay. You have to be selected to be a part of it.
Dr. Stambaugh: Yeah. And again, I think we will eventually get to the point where we basically say, "We want this everywhere unless you give us a good reason why it won't work for you because we think it's so good." But we just haven't been able to get there.
Dr. Jin: Yeah. Yeah. I mean I would jump at the opportunity to have two encounter specialists work with me. That would just, yeah, I would be thrilled. I do want to go back to the point you were saying where how you led initially with the, you have to see two more patients a day and how that was a little bit of a turn-off.
I think that is a key point to say that's not the reason we're doing it. But really it's to increase efficiency, reduce burnout, increase team-based culture, and the increased morale, I guess as well. And as a result of all that, the seeing more patients will come naturally. As you said with that one example where that physician just opened up a half-day of clinic just because naturally she had more time. But yeah, I think that leading with the "This is how many more patients you need to see to make it work probably …”
Dr. Stambaugh: But it's interesting. Just about every time when we go out and talk to practices, before the end of the conversation, they'll say, "How does this make sense? I mean, how do we pay for this?" And so, that gives us the opportunity to say, "Well, we're going to follow it, and if it works well, you're going to be seeing more patients a day, but it shouldn't feel that way. If anything, it should feel like you're seeing fewer." It comes up, but we don't lead with it anymore. So that was a big change.
Dr. Jin: I guess you don't want to lead with that to the physicians, but maybe to the CEOs?
Dr. Stambaugh: Yes, and that's very true. But there's also been a lot more focus. I mean we are a physician-led organization at many, many levels. And so there's also been more of a focus on reducing burnout so that we don't lose physicians, which also pays for itself when you don't lose physicians.
And so we've really been able to show decreased pajama time for providers. But also closing more of the value-based care gaps. And we are very far along in our value-based journey, so that has real dollars attached to it, too. There's lots of ways to show the financial success of the program.
Dr. Jin: The program has been going on for a while now. You mentioned how recently there's the staffing shortages. Is this something that has been COVID related, or has the program had to change and adapt with COVID and telemedicine? Any other recent challenges?
Dr. Stambaugh: Yeah. But COVID has been the biggest challenge. We really haven't adapted the program for telemedicine yet. Where we are, we all had that big uptick in spring of 2020 with telemedicine, but ours has settled out at the best of places, down between 10 and 15%. We haven't really developed an encounter specialist program specifically for telehealth.
Now having said that, we did also have to adapt the program during the worst of times in terms of staffing, which we're hopefully starting to see some turnaround on. And so, we did develop a hybrid model. I mean, part of the issue is we had folks who had two encounter specialists who lost done during this crisis. They love the program. They know it, they know what they can get from it. And so they're saying, "Oh, what do I do? We can't find another person." And so we actually adapted the program to create what we call a hybrid encounter specialist, where they don't necessarily do all of the function of the encounter specialists, especially not as much of the in-room scribing, because that one person has to go and room the next patient.
But because the folks who have been through this hybrid training program are given the ability to scribe, that means things like they can enter the history of present illness, which they're already getting as they're rooming the patient anyway. They are able to do more of those things and enter orders for the physician and those things that a non-encounter specialist cannot do.
That's been our adjustment. And actually now, when a practice asks for an evaluation, if we don't think that they're quite at the point where they really need two, where we can really justify two encounter specialists, we will sometimes offer that hybrid method, too, to try to help streamline things a little bit.
Dr. Jin: The encounter specialists you were saying can enter into HPI versus a non-encounter specialist cannot. And is that just a function of the extra internal training that you do as opposed to some fundamental certification difference?
Dr. Stambaugh: Especially when Cornerstone came to be part of Wake Forest, the compliance department was very resistant to allowing us to continue this program because of that definition as a scribe being a non-clinical person. And really, the concern about some clinical decision-making sort of slipping through.
We don't turn on the ability for them to document like that unless they've been through the program and are certified by our training program. Because CMS doesn't allow a medical assistant to do a lot of that sort of stuff. So they have to have that extra scribe role, and that's our encounter specialist role.
Dr. Jin: Using an MA instead of hiring a separate scribe, I think that's the direction we're trying to get practices to go in, in general. Because like you said, a medical assistant should be able to do it.
Dr. Stambaugh: It drives both patients and providers crazy when the provider has to say again, "So tell me why you're here." And they're like, "I just told the medical assistant, didn't she tell you?" And you feel like, "Yes, but you have to tell me so I can write it down because that's when it counts." I mean that—I'm so glad that that's starting to change because for years, that just drove our folks crazy.
Dr. Jin: Okay. You were talking a little bit before about outcomes and how this program has already been a huge success. Do you have any metrics or data to support that? For example, turnover, burnout rates?
Dr. Stambaugh: Yeah, we have a pretty low turnover rate in general, anyway. And we actually looked at the huge group of folks who have encounter specialists versus folks who don't have encounter specialists. And one of the problems we realized with that is, oh my gosh, there's such individual variety of folks in terms of like their pajama time. And so really, we have started now going back and looking at before and after encounter specialists and are seeing a significant reduction in pajama time.
But we also—things like making sure that their schedule for their colonoscopy and their mammogram and when was the last hemoglobin A1C and all these things that we are measured on in our value-based contracts. Those metrics, when we compare the folks in the encounter specialist program to the folks that don't have encounter specialists, across the board those are better.
Interestingly, recently we realized that a couple of the functions that are normal medical assistant, normal rooming functions had gotten below that. I mean things like the questions about falls that every medical assistant is supposed to ask and those things. We had to remind them, "Don't forget your regular duties, too." They were getting so good at their encounter specialist duties that some of those things were falling by the wayside. So we had to go back and do a little retraining.
Dr. Jin: Have you found that it helps a little bit with medical assistant retention as well?
Dr. Stambaugh: Yes, in general. And that's more anecdotal just because there has been so much turnover in general the last few years. But definitely, we hear from the individual encounter specialists that they feel that their role within the team has been elevated. And it really makes it more the team's practice as opposed to just the physician's practice. So that has really been good.
The other thing that we fought for, for quite a long time and finally got through a few years ago, is that we have shifted the pay scale for these encounter specialists. Just notched it up a little bit. If you're an encounter specialist, the range is just shifted up just slightly to account for the fact that it is extra training, it is a higher level of duty. That has really helped as well.
Dr. Jin: Great. And that is so important. Yeah, I think part of the issue with medical assistants is that there's not a great professional development ladder. But this is one, and I love the term encounter specialist. Whoever came up with that, I don't know if it was you, but it's such a great term.
Dr. Stambaugh: I'm not even—I'll have to go back and find out. It wasn't me. I wish I could take credit for it.
Dr. Jin: But right, it sounds so empowering. Like you said, it just sounds like they own it. They are an integral part of this team. They actually own this encounter and I love that.
One final question for you. What pearls of wisdom would you give listeners who are interested in implementing a similar program at their own practice?
Dr. Stambaugh: Well I certainly feel for any pilot, you do need to pick the right teams. You need to have folks who have buy-in, not just folks who want two medical assistants. The physicians need to be bought into the program, because they do have to give up a level of control. Some physicians are so particular about their notes, maybe to an extreme, such that those of us that read those notes, there's almost too much information in them.
But there are templates that the encounter specialists use. Physicians, you can help develop them together, but you have to be willing to give up a little bit of that control. Certainly for the pilots you have to choose the right teams. Definitely use standard training and insist on following those processes. I mean that's going to be huge in terms of reassuring your compliance department, but making sure that everybody's following those processes is really key.
And then the last thing is, in an ideal world I would implement this on a practice level because it's much easier to cross-cover for encounter specialists if one's out sick. I mean, that's always an issue. If we have a five-physician practice and only one person has encounter specialists and their schedule is set such that they have encounter specialists and so they see more patients, if their encounter specialist is out, you still have those extra patients. It's much easier to implement on a practice level. Now having said that, I wouldn't say that that's what we've done across the board, but that would be my advice.
Dr. Jin: Well, thank you so much, Dr. Stambaugh, for taking the time to speak with me today. It was so great to hear your experiences and insights on this topic.
Dr. Stambaugh: Well, I really appreciate it, Jill. And I'm such a huge believer in this model, so I would love to see it everywhere.
Dr. Jin: Yes, as would we.
Outro: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.