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Implementing a Scribe Program – Setting up for Success

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Implementing a Scribe Program – Setting up for Success Implementing a Scribe Program – Setting up for Success Exploratory Paper Samantha Beatty, FACMPE August 24, 2016 This paper is being submitted in partial fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives American College of Medical Practice Executives Professional Paper Exploratory Paper Implementing a Scribe Program – Setting up for Success The increasing use of electronic medical records (EMR) during the clinical encounter brings not only benefits but also barriers that may affect the doctor-patient relationship and increase the work burden of the physician (Koshy, S., Feustel, P. J., Hong, M., & Kogan, B. A., 2010). The adoption of EMR is becoming a widespread reality and may bring benefits including more efficient and effective patient encounters, better continuity of care between specialties, and improvement in data quality, readability, availability and information exchange. An EMR can also increase the opportunity to improve healthcare through better adherence to protocol guidelines, decreased medical errors, and improved data monitoring and aggregation (Shachak, A., & Reis, S., 2009). However, as clinicians and patients are increasingly experiencing the computer as a barrier during the clinical visit, groups are beginning to look at a variety of solutions to improve the clinician-patient relationship; leaving clinicians free to focus on establishing better rapport and communication with patients. One solution medical practices are exploring is the use of medical scribes. This paper is based on a literature search, personal experience, and several interviews of other practice leaders, with the goals of reviewing the evolution of scribes in the medical practice setting and determining how to implement a scribe program and set it up for success. While this paper primarily focuses on the keys steps to implementing medical scribes, it also explores several scribe personnel options including pre-med students, medical assistants, and virtual scribes. A review of the pros and cons to consider when determining whether to employ scribes or contract with an independent scribe company is also included. The target audience is practice administrators and physician owners who are considering medical scribes as a possible solution to 2 increase clinician productivity, satisfaction, revenue, and patient satisfaction while decreasing documentation time. History of Scribes – Emergency Departments Based on literature review, the first documented use of medical scribes occurred in 1975 in the Emergency Department (ED) at St. Mary’s Hospital in Reno, Nevada. According to Allred and Ewer (1983), the hospital ED was experiencing an increase in patient volume as well as the number of patient records that were being completed later in the shift. By implementing scribes, they stated, “In five years, it has proven to be a cost-effective means of providing a prompt, accurate medical record.” In this early study, Allred and Ewer (1983) described the non-nurse scribe as someone with a “knowledge of basic medical terminology and anatomy and good penmanship” and they found “pre-medical and pre-nursing students especially well motivated.” As time progressed, other hospital ED’s began evaluating and using a scribe solution, although in most cases, the primary reason stated for implementation had to do with increasing throughput. Very few of these hospitals performed documented studies or outcomes, which limits the research and evidence around the effectiveness of scribes. One specific assessment took place more recently in the Department of Emergency Medicine at a University of Florida Health hospital. This assessment aimed to improve both throughput and clinician satisfaction by implementing scribes and set very clear outcome measures to evaluate their success. In this research article, Allen, Banapoor, Weeks, and Payton (2014) were able to demonstrate that “through evaluation of pre-scribe and post-scribe implementation, the post-scribe time period reflects many throughput improvements not present before scribes began.” They also demonstrated, “100% of clinicians indicating scribes were a valuable addition to the department and 90% of clinicians stating scribes increased their workplace satisfaction and quality of life. (See Appendix A: Throughput Measures Assessed and Clinician Survey Questions from (Allen et al., 2014) to see the throughput measures and a list of survey questions they used for evaluation.) 3 Outpatient Medical Practices: Definition of a Scribe and Types of Personnel The movement to using scribes in outpatient medical practices is first documented in 2010, and has increased dramatically over the last several years. According to The Joint Commission, a scribe is an unlicensed person hired to enter information into the EMR or chart at the direction of a clinician (physician or practitioner). It is important to note that The Joint Commission’s stand is that the scribe does not and may not act independently but can document the previously determined clinician’s dictation and/or activities (Shultz, C. G., & Holmstrom, H. L., 2015). Typical activities of a scribe include chart preparation, pulling forward relevant information or data from previous visits, collaborating with and cueing the clinician during the patient encounter, taking dictation, editing notes, and order entry for clinician review and signature. According to a personal interview with a multi-specialty practice’s medical director, “One of the greatest benefits of having a scribe, is the detailed visit summary that patients receive at the end of their visit. All of the key points from the encounter are noted, as well as any changes to medications, and instructions for them to follow. They also have easy reference to any orders or referrals generated during the visit (Sparling, 2015).” There are different types of personnel utilized as scribes in the outpatient setting. Options include medical or nursing students, medical assistants (MA), registered or licensed- practical nurses (RN or LPN), and those without clinical training that are administrative personnel trained specifically in the skills and function of a scribe, such as transcriptionists. In the majority of the documented research and personal interviews conducted over this past year, the two primary types of personnel functioning as scribes are medical students and MAs. 4 Medical Scribes Medical scribes can be hired as direct employees of a medical practice, or contractually hired through an independent scribe company. Those hired through a contract with an independent company are most often pre-med or medical students who are able to work with a clinician for an average of one to two years. They come to the practice with training around the medical scribe role, general medical terminology, and strong typing and documentation skills. In some instances, they may already have EMR specific training. Scribes in the outpatient medical practice require focused recruitment and selection, and customized training materials specific to a practice’s specialty and individual clinician. According to Hiller (2016), “The partnership with an independent company can ease the burden on the practice to recruit and train medical scribes, as well as developing a transition plan when scribe turnover occurs.” For practices that choose to hire and train their own pre-med or medical students as scribes, there are several important factors to consider. One factor is understanding the length of time a scribe can commit to working with a clinician. Having a defined period of time and setting appropriate expectations up front can set the scribe and clinician up for success. Second, the need for documented training processes as well as clinician preferences and workflows is critically important. When there is scribe turnover, having everything documented makes the transition period smoother from one scribe to the next. The third factor is to ensure the practice evaluates the appropriate salary range for the medical scribe so they are competitive with salaries offered by independent scribe companies. One multi-specialty practice’s director stated, “Turnover and competitive market salaries were our biggest challenges. The clinicians have become very reliant on their scribe, and describe the day as painful when the scribe is not there. Having a pool of scribes to draw from is a strategy we are considering, but we need to be willing to pay a higher salary than is currently offered to make this possible (Shields, 2015).” 5 In a recent text poll by the Medical Group Management Association (MGMA), called MGMA Stat, members were asked to answer the question, “Does your group employ scribes or rely on external scribe resources?” Twenty-five percent of respondents selected “employ” compared with just over ten percent responding “external” and sixty-five percent responding with either “no scribes, not applicable, or not sure.” This data suggests that there is more collective experience with employing scribes in a medical practice, however, there is still much to be learned from both models. Medical Assistants as Scribes Hiring a medical assistant (MA) as a scribe is another possible personnel option. While no evidence of published research in this particular area was found, in roundtable discussions of practice administrators with this model of scribe staffing, there were several consistent themes. Situations where the MA was successful included a highly motivated MA and clinician team, where both
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