Hospice News Palliative Care: How to Keep Your High-Valued Clinicians From Becoming Full-Time Note Takers

This article is sponsored by nVoq. This article is based on a discussion with Jason Banks, Post-Acute Business Development Vice President for nVoq. The conversation took place on April 20, 2023 during the Hospice News Palliative Care Conference. The article below has been edited for length and clarity.

Hospice News: We’re going to talk about how you can keep your high valued clinicians from becoming full-time note takers. As essential as documentation is, they of course, have other things to do and Jason is here to help figure that out. Jason, can you tell us a little bit about what your experience has been on palliative care and the continued pressures of the workforce shortage?

Jason Banks: I had the good fortune of serving on the provider side running a palliative care organization in Chicago for a number of years. We had approximately 1,200 palliative care patients that we were serving across the Chicagoland area. We provided it in a multi-site format. We provided it in hospitals, in senior living communities and in the home. We had a multi-disciplinary approach with doctors and advanced nurse practitioners. We also had social workers, licensed social workers, music therapists, other paraprofessionals as well. Additionally, we had two outpatient palliative care clinics as well that we provided care through.


My experience has been that these clinicians are incredible both in palliative and hospice care. As Dr. Mayo and Rory pointed out, their focus is on caring for the patient. That’s what their primary focus is. Particularly over time in hospice and home health and starting to bleed into palliative care, they’re spending a lot of their time doing documentation and charting. Some of it is really valuable. As Rory pointed out, there’s good standards that can be followed and that includes documentation, but the pendulum has swung really far in the other direction.

It was no more evident to me than I had a health scare myself in the month of March, which I won’t go into, but it’s a great weight loss plan. I had these incredible nurses, incredible doctors, but it became very robotic where they would come in the room, they’d poke their prod, they’d read the things, they’d go and chart for half an hour. Probably four days into my hospitalization, I said, “Hey, can you go grab the doc? I want to have a meeting with you and her?” I said, “I need to be out of here and I need the strainer removed from me and all of this within a week. I want to go on spring break in Florida.”

It was the most meaningful conversation that I had. You saw both of their eyes light up and they started to try to figure out how to make this happen. This guy’s got goals of care. How do we make that happen? They’re so sucked into the documentation. Again, I’m not saying it’s not important, but I think the pendulums swung the other way and it’s causing burnout. There’s a number of studies on this that show that after hours documentation is a main cause if not the main cause of clinician burnout and turnover within organizations. How do we alleviate some of that so that the providers, the clinicians get back to what they do best and what they love and what they got in the profession to do.


HSPN: What are some of the ways that speech recognition is being used in palliative care and across the post-acute?

Banks: I’m sure if you’ve gone to your doctor or you are a doctor, you’re very familiar with speech recognition. If you go to the hospital or you go to an ambulatory, a specialist, it’s very second nature to them. The thought was– and nVoq has been in that space as well for the better part of 20 years. About three years ago, they started getting interest from palliative care providers, from hospice providers, from home health providers saying, “Would this work in a home-based setting? Would it work in what we do, the type of medicine that we provide?”

They started to get more and more interested. I got a call a little over two years ago saying, “What do you think, Jason? You think this would work?” Lo and behold, I was already starting to look into that. I had this hare-brained idea that I would make clinicians wear Google glass and a scribe on the backend would chart on their behalf.

I thought speech recognition is a nice entryway into something like that. If I could help the clinician speed up that process with equal or higher quality to the documentation, boy that would be a win. We decided to join nVoq almost two years ago and partnered with many of the tremendous EHR vendors in the room and bring speech recognition to clinicians that are in the palliative care service line.

HSPN: What can you tell us about some of the ROI or some of the results that you’ve been able to achieve for clinicians, for patients and for the provider companies?

Banks: The first thing I was focused on was, can we save the clinician time? That was the most important thing to me. If we’re not saving the clinician time, this isn’t going to work. They’re not going to use it, they’re not going to adopt it. We did a number of studies on time savings and are we saving the clinicians’ time charting at the bedside? Are we saving them time charting at home specifically, as that was the number one driver of burnout.

We did a number of studies on that across various business lines, across disciplines and across types of visits and, lo and behold, we were absolutely saving clinicians time. Clinicians that used it in earnest were saving sometimes, depending on their discipline and type of visit that they were making, 45 minutes to an hour and a half of after hours charting a day. That was significant.

The next question that we wanted to try and answer was, ‘are we achieving the time savings at the cost of quality?’ Let’s try to go measure the quality of the documentation now that we see an increase in efficiency. We started to do a number of studies with a handful of clients and concluded an increase in efficiency, and a better-quality note. How do we increase quality? We have some tricks and little features in our solution that give the clinician a cue card of what to document when they’re in the EHR.

Clinicians are amazing. They provide really great care, but they don’t always know how to verbalize the patient’s story. It’s how do you give them a guide to go tell that patient’s story in a logical way that makes sense and is also meeting the regulatory compliance standards. We gave them a little guide, a little cue card or cheat sheet to say or to dictate what was going on to tell that patient’s story.

What we found was we were improving the quality of the note and those had impacts across the board. They were reducing QA costs, they were preserving revenue in hospice, specifically the CTI note that is directly tied to medical eligibility of the hospice patient. CMS certainly wants to see the prognostic statement in the note, as well as the PPS score and the disease progression. If these elements are not in the documentation, you’re at risk of not being paid, and so we have a set standard of key elements that we can go look for and measure. Were these elements there before the clinician started using our speech recognition solution? Were they there after speech recognition? Turns out we had more people documenting all the appropriate and necessary elements when they were telling the patient’s story through narrative and being guided by our speech recognition solution.

We improved the time savings, we improved the quality, and then a third thing that we really wanted to measure was clinician satisfaction. Yes, clinicians were saving time by documenting less, but is that going to directly impact their satisfaction? Or their work-life balance? We started to measure that.

Then the last piece, which we’re not yet measuring, but I anticipate that we will, and that is the impact on the patients and families themselves.

In your hospice CAHPS and other patient satisfaction surveys, there’s one key question that guides how that patient and most likely the family member or caregiver is going to answer every other question on that CAHPS. That question is, ‘how did the care being provided make you feel?’ That will dictate the answer to every other question on the CAHPS report. A little secret there.

What we found was that hospice and palliative care clinicians were dictating the note and for the first time ever, patients and families could actually hear what was going into the medical record. We saw a lot of clinician feedback saying, “This has enhanced my relationship with the patient. It’s enhanced my relationship with the family. It’s enhanced my relationship with the caregiver.” We haven’t done formal studies on that yet, but I think that’s the next step for us.

HSPN: Jason, what does it take to implement one of these systems and get it integrated into the EMR?

Banks: For us, it’s simply an app, and I would check with your EHR provider. We’re partnered with many of them, but if by chance we’re not partnered with them today, it’s simply downloading an app. We have in-app training on how to use the system. I tell people it’s five minutes to install from your Google Play Store and another probably 15 or 20 minutes to train a clinician. Clinicians are brilliant, they will get it right away.

The challenge for many clinicians is they don’t even have 15 minutes to go to the bathroom, Jim. So how do you get them to stop and take notice of this? Many of them are very skeptical of technology, and I get it. Because we find that clinicians that do take the time, they do download it, they do start using it in earnest for a couple of weeks, they never wind up putting it down again.

Our challenge is how do you build that trust with them? How do you get other clinicians to voice how valuable this has been to them and to their patients? Then, how do you encourage those that continue the adoption within the organization? From a pure technology play, the EHRs have made this very easy. Our app is simple to download. We have integration with many of the EHR partners in the room. It’s, from a technical perspective, very, very simple. We can stand somebody up in a day, and clinicians can be using it the next day. That was the goal. Clinicians have a lot on their plate. Don’t give them a whole lot more to learn.

On Android devices, for instance, we replace the Google keyboard with ours, so they don’t really have a major user interface change. In the EHRs, they embed it right in the EHR, so it’s even easier to use. We really want to make it easy for that clinician to use, not a lot to learn. It’s medically infused, so it is highly accurate out of the box. There’s a bunch of shortcuts to be able to do common words, phrases, sentences, paragraphs that the clinicians are documenting on each and every visit.

We try to build things in there that are going to, again, speed up the process, and give that clinician more time back. Usually, they spend that time with the patient and family, which is exactly what we want. It improves that relationship and that connection with the family, and patient as well.

HSPN: Are there any frequently asked questions that you hear from your clients that maybe we haven’t covered here that it might be good to address in case our audience shares those questions?

Banks: Oftentimes we get the question that you asked about what is the ROI associated with this? What’s the average adoption that we have with clinicians? They often will ask about HIPAA privacy and security as well. It’s a primary concern. If you’re not compliant with HIPAA, you’re out of business. Obviously, that’s number one. Ours is a HIPAA-compliant solution. We go through all the BAA processes with our provider organizations.

We have SOC 2 readiness, which I don’t think there’s too many technical people in the room. Probably means something to somebody, but we go through the highest levels of security to ensure compliance. That is often a question that we get asked.

When we work with providers, we get almost every clinician saying, “Yes, this is really good. We get a lot of good feedback.” IT goes, “Yes, this is really good. Then the CFO enters the room, and they’re just like, “What’s my hard ROI?” That’s where the true work begins. That’s where most of our questions come from is from that economic or financial stakeholder within the organization.

nVoq Incorporated provides a HIPAA and PCI-DSS compliant, cloud-based speech recognition platform supporting a wide variety of healthcare delivery scenarios including post-acute care with an emphasis on home health care and hospice. To learn more visit: www.nvoq.com.

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