11/4/2013
Scribes in the ED:
“I get what you are saying…”
Conflict of Interest and Bias
No financial relationships
Scribe Director at Academic County Hospital
Used a consultant to start our in-house scribe program
Eric Isaacs, MD, FACEP, FAAEM
Scribe Director
Attending Physician, San Francisco General Hospital and Trauma Center
Professor of Emergency Medicine, University of California, San Francisco
[email protected]
Objectives:
Describe the drive to develop scribe
programs in the emergency department
How many use an EMR?
Understand what scribes can and cannot do
Consider 3 models of scribe program
development and implementation
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How many stay late to document?
How many use scribes?
How did we get into this mess?
Bush and Obama Agree!
Bush 2004 State of the Union – “…By computerizing
health records, we can avoid dangerous medical
mistakes, reduce costs, and improve care.”
Obama 2008 “We will make sure that every doctor’s
office and hospital in this country is using cutting edge
technology and electronic medical records so that we
can cut red tape, prevent medical mistakes, and help
save billions of dollars each year.”
Penalties for not using EMR “meaningfully” by 2015
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Unintended consequences
Reality Check: After EMR
implementation
Rapid implementation
Less efficient
Go live together
Less time with patients
EDIS – frequently an afterthought
Patient Satisfaction
Productivity loss
Job Satisfaction
Compensation is productivity based
Physician retention
Chart accuracy/Medico-legal risks
Percent Time Spent per patient:
using EMR
Can we find a way to:
28% Direct patient contact
Improve patient satisfaction
44% Data entry
Better connections with patients
12% Reviewing tests and records
Increase RVU per hour
13% Case discussion
Improve efficiency
3% other
Go home sooner
Getter job satisfaction
Robert G Hill Jr. et al, 4000 clicks: a productivity analysis of electronic medical records
in a community hospital, American Journal of Emergency Medicine; article in press.
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There’s an “app” for that!
Why Scribes?
Imagine someone who:
Pulls up the old chart prior to your encounter
Documents the HPI/PMH/ROS/SH/Physical exam for you
Pulls up old ECG (and document it)
Pulls up X-rays for you
Tells you when labs or studies are back (and to acknowledge)
http://www.medicine.virginia.edu/clinical/departments/emergency-medicine/forundergraduatestudents/
Why Scribes?
Why Scribes?
Imagine someone who:
Imagine someone who:
Confirms you have enough elements and 10 ROS for level 5
Reminds you if a patient meets critical care (more than you
think)
Reminds you to check on serial observation patients
Allows you to actually look at the patient while you are
talking to them.
Takes care of your documentation while you are doing a
procedure or other task.
Specific areas of your charting deficiencies
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Why Scribes?
Scribes not right for you if…
Imagine someone who:
Excellent Documentation
Allows you to talk to the nurses, ancillary staff, or
consultants with greater attention while they are
documenting your chart or pulling up results.
Decreases your need to stay after to complete charts.
“Scrub” the charts in the morning
Patients seen and discharged quickly
Everyone going home on time
Group is stable
Making lots of money
EMR is easy to learn and use
Access to old records, labs, x-ray is simple
Why not scribes?
What can’t scribes do?
Initial outlay of $$
No independent interviewing/practice
Space and computers
Scheduling for partners not utilizing
Medicolegal risk
HR concerns
Place orders
The Joint Commission does not support scribes being
utilized to enter orders for physicians or practitioners due
to the additional risk added to the process.
ED Volume or payer mix
“Concern” about teaching and mentoring
www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=426&StandardsFAQChapterId=66
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What is a scribe?
Regulatory requirements
Unlicensed person hired to:
CMS E/M Guidelines:
Enter information into the electronic medical record (EMR)
MD, NP, or PA
The scribe does not and may not act independently but can
document the provider’s dictation and/or activities.
Scribes also assist
navigating the EMR
locating information such as test results and lab results.
support work flow and documentation for coding.
Every chart entry (by a scribe) needs to clearly indicate
that the scribe made the entry.
Scribes need to have their own log in – not a problem with
most EMR systems
The provider needs to attest or authenticate that the
scribe made the entry (can cover all the entries).
www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=426&StandardsFAQChapterId=66
CMS Guidelines
Examples of scribe charts
The Scribe’s Note Should also Include
• The name of the scribe and a legible signature
• The name of the physician providing the service
• The date the service was provided
• The name of the patient for whom the service was provided
Scribe: “I, Sue Perhelpful, am scribing for, and in the
presence of, Dr. Isaacs”
The Physician’s Note Should Indicate
Affirmation of that physician’s presence during the time
encounter was recorded
Verification that he/she reviewed the information
Verification of the accuracy of the information
Any additional information needed
http://www.ngsmedicare.com/wps/portal/ngsmedicare/!ut/p/c5/dY3LCoJAGIWfpRfw_H... 12/12/2011
Physician: “I, Dr. Isaacs, personally performed the
services described in this documentation, as scribed by
Sue Perhelpful in my presence, and it is both accurate
and complete. Any differences or additional
information is noted.”
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Who are the scribes?
Models of scribe programs
MEA model
In-house program from beginning to end
Burger King model
Pre-Health Care students
Last application period:
> 200 applications for 6 positions
Recruit, hire, orient, train, schedule
Evaluations with action plans, payroll
Turnover
Consultant to start in-house program
Outside Scribe provider
50%-100% admin fee
What do you need to start a
program?
What is the goal?
Interest from partner/director
Adapt to new EMR?
Identify what issue you are trying to address
Productivity?
Identify physician champion
Turnaround times?
Metrics for success
Documentation and coding?
Buy in from administration and nursing
Patient satisfaction and service?
Reimbursement?
Coding
Productivity
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Keys to success
Pitfalls
Motivated and engaged scribes
Splitting a scribe between two providers
Wiki to track physician preferences
Failed feedback
Train the physicians to use the scribes
Lack of physician engagement
Failure to actually read the chart
Engaged physicians (give feedback not just complain)
Conclusion
Resources
Use of scribes impacts:
ACEP Scribe FAQ
Quality of physician life
Reimbursement
Productivity
Efficiency
Scribes are not for every practice
If you are going to start a scribe program
Have the goal in mind
Get buy-in from physicians, nursing, administration
Persistence and engagement in program maintenance
www.acep.org/Content.aspx?id=85988
ACEP Focus On the Use of Scribes
http://www.acep.org/Continuing-Education-top-banner/Focus-On--The-Use-ofScribes-in-the-Emergency-Department/
Additional references available on request
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Questions?
[email protected]
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