Describing Scribes: Improving Efficiency and Satisfaction in the ED

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Most EM residents and medical students interested in EM have seen or heard about medical scribes. Very few have had the opportunity to work side by side with one during their training. Like many things outside of clinical care, we receive little education, if any, on how to work with (or around!) medical scribes. With some foundational knowledge, you can decide if in the future partnering with a scribe will benefit your practice.

Why Are Scribes Becoming Common in EM?

The majority of medical students have volunteered their time shadowing a practicing physician. These clinical experiences are used to both validate the students’ interest in medicine and show admissions committees they have had adequate exposure to medicine to make an informed choice about their career path. Whether these volunteer experiences provide adequate exposure can be debated. In an ideal world, these future colleagues would be able to watch as we care for patients, face the daily challenges intrinsic to clinical practice, as well as make the life-and-death decisions that are fundamental to emergency medicine.

We have all dealt with the inherent complexities associated with using electronic medical records (EMRs) in the emergency department. With federal incentives for early adoption at stake, many health care institutions dove into EMRs in the mid-2000s. Faced with the dilemma of now having to treat a computer in addition to patients, emergency physicians added a new member to their team – the medical scribe. At the time, the main goal of a scribe was to help the physician more efficiently document in the new electronic systems.

Who Are Medical Scribes?

Undergraduate students from pre-medical programs made up the majority of employees in most of the early scribe groups. In contrast to short-term, volunteer shadowing experiences, medical scribes work closely with either an individual physician or a core group of physicians for an extended period of time. As a scribe, future medical students have what is considered by many to be a more valuable opportunity to experience one-on-one patient encounters firsthand. Previously short-lived encounters are now daily, full-time, paid, and possibly benefit-earning employment opportunities.

Today, although a significant number of scribes aspire to attend medical school, the field draws candidates from several other pre-health care programs, including EMT, RN, PA, and CNP. New college graduates have been drawn to the field as well, filling their “gap” year before applying to these professional schools. More recently, programs have seen a small percentage of applicants who are looking at full-time careers as medical scribes. Programs must contend with a significant attrition rate on an annual basis. This becomes a naturally replenishing cycle, as scribes “graduate” and new employees look forward to the same advancement.

What Qualifies a Scribe for Work in the ED?

This is a complicated question. First, it is important to recognize that scribes are not allowed to take part in patient care. According to the Joint Commission, a medical scribe is an unlicensed person hired to record information in the EMR under the direction of a physician or licensed practitioner.1 Scribes cannot independently translate information or make decisions while gathering and recording information in the patient’s chart. Realistically, medical scribes should not have direct contact with the patient or enter information into the chart that is not readily available through direct observation of the patient encounter with the provider or through direct dictation.

Various stakeholders perform medical scribe training: individual providers, specific institutions, scribe companies, and scribe certification programs. Irrespective of where training occurs, it typically includes standards of professionalism, EMR basics, medical terminology, and an introduction to the common documentation templates used in the ED.

Independent, self-sufficient scribe programs perform training that is provider or institution specific. The recruiting, hiring, and training in this model is labor-intensive with significant up-front costs. Scribe companies generally perform training in order to supply a stable workforce to a clinical partner (an affiliated ED or health care system). In general, these companies also have fee-based programs that lease scribes to non-affiliated EDs. This model requires very few resources to bring scribes into an ED, but is more expensive than independent programs. Recently, scribe certification programs through technical schools, community colleges, and online sources have become available to candidates. However, unless the scribe is considering long-term employment in the field and has been unable to locate employment, tuition costs may be an unnecessary expense.

What Is a Scribe’s Role in the ED?

The primary role of a scribe in the ED is to allow providers to be more effective. This manifests as improvements in patient-centered care, patient flow, efficient documentation, and provider satisfaction.

Despite the chaotic environment, patients are at the center of every ED visit. Emergency physicians strive to rapidly establish rapport with patients while quickly gathering historical and exam findings that will lead to the diagnosis and appropriate treatment. Medical scribes join the emergency physician in the patient room and document the information that is gathered during the interview. During the exam, the physician conveys findings for the scribe to record in real-time. A provider who has experience working with a scribe is able to “announce” these findings in a manner that keeps the patient engaged and informed, while alleviating fear about abnormal findings.

The constant flow of information during the encounter positions the physician to move into the assessment and plan phase of an ED visit in front of the patient. There has been some data to support improved patient satisfaction with this style of communication. The physician is able to talk through the anticipated plan with the patient while the scribe records the details in the EMR.

Emergency physicians are under constant pressure to oversee their busy departments while attempting to maintain continued patient flow. Tasks begin to grow at the beginning of each shift, and each adds to the complexity of an individual patient’s visit and ultimately decreases the provider’s efficiency to resolve any one specific item. This inherent inefficiency increases the risk of error. The average emergency physician spends approximately one-third of his/her shift documenting in an EMR. This does not include navigating through the record as a “chart biopsy.” An experienced medical scribe can pull relevant information from the chart to be scrutinized, thus freeing the physician to focus on the patient or other tasks. Medical scribes are able to further improve patient flow by entering discharge and follow up information, completing work or school forms, and pulling diagnosis-specific patient information under the direction of the provider.

Even junior residents recognize the pressure to be accurate and compliant with documentation guidelines. Documentation requirements are constantly changing, and the ever-present software “upgrades” that alter familiar workflows can inhibit efficient documentation. When these EMR issues are combined with an expectation to treat two or more patients per hour, the ability to efficiently document at the time of visit is unrealistic. Many emergency physicians in busy centers need to stay several hours after seeing the last patient to complete their medical records. There is growing data to support that scribes not only decrease the amount of time physicians spend documenting a patient encounter, but that the documentation quality is improved. This translates into providers spending more time with patients and less time during and after a shift doing charts.

It is no secret that the practice of emergency medicine is fast-paced, requiring minute-to-minute life and death decisions with limited information. Scribes will not change the fundamental pressures we face on a daily basis, but they do provide support with many of the administrative and clerical tasks that add stress. Several studies support marked improvements in provider satisfaction after the addition of medical scribes, and there is growing data to suggest this is maintained even with slight increases in patient volumes.2-5

How Can I Make the Most of the Provider/Scribe Relationship?

  1. Follow the rules.
    Recognize the limitations of the provider/scribe team. The Joint Commission is cognizant of this partnership. They are aware of the benefits to patients and providers, but they look closely for any evidence of abuse. Particular concerns focus on the scribe documenting under the provider’s login, failure to document the required statement attesting to the use of a scribe, evidence of the scribe performing clinical duties, and any indication that the scribe is entering orders for the provider.

Scribe documentation should outline who performed the service and who documented the service. Notes should include the name, title, and signature of the person entering the information in the medical record; attestations are required by both the scribe and provider. The suggested attestation statements according to ACEP are:6

  • Scribe: I personally scribed for (name), MD/PA/CNP on (date and time). Electronically signed by scribe (name) on (date and time).
  • Practitioner: Portions of this note were transcribed by scribe (name). I, Dr. (name) personally performed the history, physical exam, and medical decision making; and confirmed the accuracy of the information in the transcribed note. Authenticated and electronically signed by Dr. (name) on (date and time).
  1. Set expectations with your scribe.
    Whether you hire your own scribe or work with a pool of scribes, it is crucial to set them up for success. The reality is that no matter how much training a scribe has, we are expecting him/her to understand a patient encounter as a provider would. In many respects, an experienced scribe will understand medicine at the level of a highly functioning fourth-year medical student or a good intern. Understanding a decision or recognizing the shades of gray that influence an experienced physician’s decisions are not clear to even a seasoned scribe. Take the time to outline your preferences, documentation style, how often you document serial reassessments, how you document your review and interpretation of diagnostics, procedures, and contact with consultants.
  2. Act natural.
    After residency, most of us are used to seeing patients independently. It may feel unusual to have another person in the room other than the patient and his/her family. Just proceed as normal. When you introduce yourself, introduce the scribe as part of your team. You may want to let patients know that your scribe will help you spend more time with them during the ED visit by freeing you from paperwork. Take the opportunity to refocus your efforts on the patient; remember, scribes are there to help manage the data, empowering you to concentrate on the patient.
  3. Think out loud.
    As you progress through the visit, use the scribe as a way to kill two birds with one stone. Feel free to talk the patient through your differential diagnosis, then your assessment and your plan. The more you verbalize, the more the scribe can document in the EMR, and often you can walk out of the room with the vast majority of your encounter already documented.

While you are talking with the patient, use the scribe as a resource for other information. Ask him/her to pull up various images (x-rays, ECG, etc.). Most mobile computers in the ED have this capability. Patients appreciate seeing their broken bones, but many like to see their normal images as well – scribes can do this easily for you.

  1. Allow your scribe to be an extension of you.
    This is a benefit that often goes overlooked until you work with a scribe. While you are wrapping up with a patient, checking on a new arrival, or fielding a call from a consultant, you are not available to the ED staff. During these times, scribes can often act an intermediary between you and the rest of the team. Scribes are able to pass along simple messages, convey to nurses the plan you discussed with a patient, or simply let people know you went to grab a cup of coffee. The scribe typically wears multiple hats.

Ultimately, the medical scribe can be a significant asset to emergency physicians. These extremely capable and interested individuals allow us to focus on the patient and are associated with substantially improved provider satisfaction. More complete and timely documentation has the potential to improve your efficiency and your productivity. As you become comfortable with the process, you will feel the weight of documentation lifted from your shoulders. In many cases, your documentation will more accurately reflect the time and effort you spend with a patient. This can easily translate into improved billing and coding.

Although medical transcriptionists have been a part of medicine for decades, medical scribes are relatively new to health care. With the growing burden of documentation, constantly changing regulations, and complicated EMRs, medical scribes can now be found in a variety of settings. Scribes are in the ED, but are becoming more common in both the outpatient and inpatient settings as well. Hopefully, the group you join has come to appreciate the value of medical scribes, and you will be able to reap the benefits of more time with patients and less onerous documentation.

References

  1. http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=426&StandardsFAQChapterId=66. Accessed May 3, 2015.
  2. Allred RJ, Ewer S. Improved emergency department patient flow: five years of experience with a scribe system. Ann Emerg Med. 1983;12(3):162–163.
  3. Scheck A. The next big thing: medical scribes : Scribes push emergency medicine closer to adoption of electronic medical records. Emerg Med News. 2009;31(2):13–16.
  4. Arya R, Salovich DM, Ohman-Strickland P, Merlin MA. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17(5):490–494.
  5. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406.
  6. http://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Scribe-FAQ. Accessed May 3, 2015.
Marc Martel, MD

Marc Martel, MD

Hennepin County Medical Center, Associate Professor, Department of Emergency Medicine, University of Minnesota
Marc Martel, MD

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