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Monday, March 24, 2014

The case for EHR scribes?

Ran across an interesting Medscape paper.
Hate Dealing With an EHR? Use a Scribe and Profits Increase
Neil Chesanow, February 27, 2014

Like many doctors, you may have resigned yourself to life with an electronic health record (EHR): the torturous clicking, the precious minutes ticking away, the patients squirming in their seats as you squint at the screen, and the hour or two it takes you at the end of each day to catch up on your charts.

It doesn't need to be this way.

A growing number of doctors are saying, "Enough!" They are hiring medical scribes to enter notes, test results, and other data into the software while the doctors devote their full attention to their patients. When the visit is done, so is the patient chart, ready for doctor review.

Patients love it. When scribes are used, patient satisfaction scores increase, often dramatically, studies show. Doctors love it too. Documentation is so thorough that a higher-level Current Procedural Terminology (CPT) code is often earned. The scribe suggests which codes to use, sends electronic prescriptions to the patient's pharmacy on the doctor's behalf, and generates referral letters to specialists.

Between patients, the doctor reviews the scribe's work in the EHR and does whatever tweaking is necessary. A few moments and it's done.

Asfer Shariff, MD, an ENT surgeon in Toledo, Ohio, as well as Founder and Chief Medical Officer of a scribe service called Physicians Angels, says he is now able to review 15-20 scribe-produced charts in as many minutes in his practice. Without a scribe, he was spending up to 2 hours at the end of each day updating charts in the EHR. "I got my family back," he says.

Physicians who work with scribes see, on average, one additional patient an hour, experts maintain. Despite this greater productivity, at the end of the day, all the charts are done. This is true even for high-volume specialists who may generate 50-75 charts per day. The doctors are free to go home at 5 or 6 PM.

Scribe Boom Sparked by Dissatisfied EHR Users
That doctors are seeking help with their patient records isn't a new phenomenon. Transcription services have been around since the 1960s. In the 1990s, a few doctors hired stenographers to follow them from exam room to exam room, taking dictation and later typing up a transcript of what was said to file in paper charts. They were known as scribes. But the idea never caught on...

"Research shows a physician using an EHR sees, on average, 11.2 patients fewer per week -- a potential revenue loss of up to $3800 per month -- than before adoption of an EHR," Toth says.

EHRs also cost a bundle in inefficient use of physician time.

"A doctor's cost runs up to $4 a minute or $240 an hour," Shariff observes. "Would you pay $240 an hour to have someone type and click information into an electronic medical record? Would you take your most expensive employees and make them data entry staff? That's what has been happening."...

What Is a Medical Scribe?
The Joint Commission defines a medical scribe as an unlicensed individual hired to enter information into the EHR or chart at the direction of a physician or licensed independent practitioner. Physician practices, hospitals, emergency departments (EDs), long-term care facilities, long-term acute care hospitals, public health clinics, and ambulatory care centers all use scribes. Scribes can be employed by a healthcare organization, physician, or licensed independent practitioner. They can also be subcontracted from a scribe service...

"A medical assistant or nurse takes the patient's weight and vital signs and accompanies the patient to an exam room," Toth explains. "The scribe accompanies the physician when he or she enters the exam room and records the history, examination, treatment plan, and other clinical data in real time, while the physician interacts with the patient.

"The scribe does additional typing and other documentation while the physician moves on to the next room," she continues. "At the end of the clinic session, the physician reviews the documentation and makes any corrections to the scribe's documentation and signs off."
"Scribing is not merely listening to a doctor dictate a note and typing it into the EHR," adds Shariff. "It is interpreting the physician-patient interaction and converting it into a concise document with relevant information, then doing appropriate coding to send to the coders/billers, while also creating the letter to the referring physician and doing all the associated tasks."

"The physician-scribe relationship goes beyond transcription," Toth agrees. "For example, scribes remind physicians of treatment plans and other recommendations from previous visit notes and provide a check-and-balance system to ensure visit documentation requirements are met, test results are received, and prescriptions are refilled."

Scribes aren't licensed coders or otherwise licensed, but they do receive from 3 weeks to 3 months of training, depending on the vendor, during which they learn, among other things, clinical terminology and common CPT codes for the specialties for which they are being groomed as well as compliance with Health Insurance Portability and Accountability Act (HIPAA) patient privacy mandates...

"Patients love this," he says. "Even though it's just bread-and-butter medicine, the physicians sound smarter, and patients love the physician's display of intellect. As a result, we've seen patient satisfaction scores go dramatically up."
How dramatically?

"We've had orthopedic surgeons consistently in the 20th percentile in patient satisfaction over 20 years of practice who suddenly leap to the 85th percentile because they do a narrative physical exam while working with a scribe," Murphy says. "Patients like that interaction, the doctors are happier, and they are able to focus on the patients even more."
Physician satisfaction scores, if anything, are even higher.

"It's amazing when you see the difference between a dictated note and one that's generated by a computer," marvels William A. Rivell, MD, a family physician in North Augusta, South Carolina, who began using a scribe for the first time last September. "Even if you're using the templates, it just sounds terrible; whereas I can just tell the scribe what's going on, and it comes out much more fluid."

"Scribes create comprehensive, nuanced documentation that might improve reimbursement by allowing a physician to bill a higher level evaluation and management (E&M) code than he or she would have without this level of documentation," Toth explains. "Many physicians gain a sense of security, knowing that their documentation was completed thoroughly and according to regulations and guidelines."

Ironically, this more comprehensive, nuanced documentation results from spending more time with patients and less time with the EHR...
It's a fairly lengthy, extensively documented paper. It's free, but is firewalled via (the also free) registration.

It seems to me that there is a huge untapped resource out there for EHR scribe deployment. Medical students. it could be (and perhaps should be) part of the curriculum.

"Internships," in the broader business sense.

Liability concerns could be mitigated via some sort of standardized competency testing. Maybe lay that off onto the vendors as part if their ONC certifications. Back during the 2005-2007 DOQ-IT era my company (HealthInsight) sent me to eClinicalWorks HQ for four days of computer-based classroom/hands-on training, the culmination of which was having to do an entire patient chart, soup to nuts, all the way from intake demographics through FH, SH, PMH, Active Rx, Active probs, HPI, CC, ROS, etc, and a full SOAP, and finally coding for dropping the bill, all under time pressure.

I recall making one readily resolved coding error. Four days of group training.

This is doable.

What do you think?

Med schools add EHR training to the curricula
Training reflects hope that young doctors will embrace EHRs in medical settings
11:29 AM - March 25, 2014

Some medical schools are incorporating training on electronic health records (EHRs) into their curricula because exposure to the IT systems is increasingly considered a crucial element of the medical education experience, Politico Pro reports.

The move reflects the medical schools' hope that young, technology-savvy doctors will help integrate EHRs into medical settings. Medical educators note that doctors-in-training do not appear to struggle with EHRs like some of their older colleagues do.

Already, most medical schools include some EHR requirement, and more institutions are expected to follow suit, especially given the growing national investment in health IT. The training can take many forms, including tutorials at the beginning of students' first year, units during pre-clinical courses, and components of patient simulations...

OK, how about scribe duty as a curricular component?

More to come...


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  2. Very kind of you. Thanks. -BG