See More Patients; Spend Less Time on Paperwork

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Practice Management Feature — August 2014

Tex Med. 2014;110(8):27-29. 

By Kara Nuzback

Many physicians say electronic health records (EHRs) have not made their lives any easier. Though the systems have the potential to improve accuracy and efficiency in a medical practice, EHRs often mean extra administrative work for physicians and less face time with patients.

But what if you no longer had to stare into a computer screen during a patient visit? What if you could scrap the extra hours spent documenting each visit and instead see one more patient? Some Texas physicians have turned these dream scenarios into reality.

They've hired medical scribes, who sit in during patient visits and document the exam in the EHR. Doctors says scribes make it possible for them to focus on the patient again.

"It gives you an opportunity to touch patients, to lay hands on them," said Texas Medical Association Trustee Douglas Curran, MD. "I'm doing what I did for 30 years."

A family physician with Lakeland Medical Associates in Athens, Dr. Curran says before he started using scribes three years ago, he took notes about patient visits throughout the day and completed EHR documentation after office hours, leaving him stressed and overworked. 

Once Dr. Curran hired a scribe, he says, he never looked back.

"I get done earlier, I see more patients, and my life is better," he said.

Dr. Curran's scribe, Deanna Mundy, a licensed vocational nurse (LVN), accompanies Dr. Curran during each patient visit, sits behind him in the examination room, and fills out each patient's EHR. At the end of the day, Dr. Curran needs only to check Ms. Mundy's work. During office hours, patients have his undivided attention.

"So much of the nonverbal stuff really helps you figure out what's going on with people," he said.

According to preliminary findings in TMA's February health information technology survey, 20 percent of members use scribes. Of those, about half train existing staff members to perform the task. 

Dr. Curran says when he first began using a scribe, he worried her presence would make patients uncomfortable, but he found the opposite to be true.

"They're just not intimidated at all," he said. 

Ms. Mundy says Dr. Curran's last scribe, who now works in the practice's insurance department, trained her for the job. Dr. Curran says patients still ask about his former scribe and her family, and when Ms. Mundy is out of the office, they want to know where she is.

"She's just a part of the team," he said.

Ms. Mundy is an LVN, but nearly any medical staff member can be trained as a scribe, and some medical students are opting to work as scribes while they finish school.

A Growing Need

As the 2015 meaningful use EHR incentive program deadline draws near, physicians are under pressure to adopt EHR systems or face a cut in Medicare payment rates. 

A 2013 study by the National Library of Medicine shows scribes improve productivity and patient care.

Four cardiologists from one clinic participated in the study and saw 59 percent more patients per hour with scribes present. Scribes allowed the cardiologists to see 81 additional patients in 65 clinical hours, generating $205,740 in additional revenue for the clinic.  

Alex Geesbreght, president of Fort Worth-based PhysAssist, a medical scribe staffing company, says as more practices adopt EHR technology, the demand for scribes increases. In the past few years, he says, "people started calling from all over." 

In 2008, Mr. Geesbreght says, PhysAssist had just two corporate employees and 35 scribes. Now, the company employs 130 people at its corporate office and has 1,500 scribes working in 21 states.

The staffing company owns I Am Scribe University in Fort Worth, where it trains scribes on medical terminology, EHR documentation, privacy laws, and professionalism. 

As a former medical liability attorney, Mr. Geesbreght says driving home the importance of following privacy laws, such as HIPAA, as well as Centers for Medicare & Medicaid Services (CMS) and Joint Commission regulations, is a top priority at the training center.

"The first day of Scribe U is devoted to professionalism and HIPAA compliance and training," he said. "We spend a lot of time on compliance."

 The facility contains a mock emergency department, developed by emergency room physicians, Mr. Geesbreght says. 

Houston Community College also offers scribe training. (See "Houston Scribe School.")

For many physicians, especially those who've been in practice more than 10 years, scribes handle one aspect of practice that medical school did not train many doctors for: EHRs. But sometimes, Mr. Geesbreght says, physicians are hesitant to embrace change, and if they've already accepted the change to electronic recordkeeping, they likely don't want more change brought about by adding another staff member to the office.

"A scribe represents, at least initially, giving up more control," he said.

Once doctors see their colleagues going home on time, making more money by seeing more patients, achieving higher patient satisfaction scores, and reducing stress levels, physicians are more likely to give scribes a chance, Mr. Geesbreght says.

What's It Worth?

PhysAssist bills contracted physicians monthly and charges an hourly rate for each scribe. Mr. Geesbreght says the hourly rate runs between $20 and $23 per hour, depending on the size of the practice and its geographic location.

He says 85 percent of PhysAssist clients are independent groups, but the number of hospitals requesting scribe services is growing.

TMA Board of Trustees member Diana Fite, MD, is an emergency medicine specialist in Tomball who sees patients at Houston Methodist Willowbrook Hospital. She says in her group, each physician pays between $12 and $20 per hour for his or her own scribe, depending on the hours required and the scribe's experience.

"I work only nights, so I pay a little more for my scribe," she said. 

But time is money, and Dr. Fite says her scribe cuts one or two hours of paperwork from her schedule every day. 

"It's absolutely essential with EHRs," she said of using scribes.

Dr. Fite says she employs a scribe to help her meet CMS's meaningful use measures. 

"I wouldn't use a scribe otherwise. I've been in practice 34 years," she said. "The scribe saves us money now, but that's only because it has cost us so much money to switch over to EHRs."

Dr. Fite says she's gone through several scribes since she began using them about five years ago; some are medical students, while others work in the medical field, such as emergency medical technicians. 

It's important for patients to know a scribe is not a licensed professional. According to the federal Joint Commission, scribes may not act independently but may only document the dictation or activities of a physician. Read the Joint Commission's standards on scribes.  

Dr. Fite says she introduces her scribe to each patient, but the scribe does not interact with the patient. 

"I don't want the patient to think the scribe is a nurse and start asking him or her questions," she said.

TMA policy supports universal adoption of health information technology that supports physician workflow, increases practice efficiency, is safe for patients, and enhances quality of care.

Stuart Pickell, MD, an internist and pediatrician at Health-e-Care in Fort Worth, is a member of TMA's Ad Hoc Committee on Health Information Technology.

Dr. Pickell says he is competent with computers, but he wanted to see if a scribe would help his practice. A few months ago, two medical assistants at his practice began alternating scribe duties during patient visits.

He says no patient has complained about having a scribe in the exam room during an appointment. 

"The patients kind of forget they're there," he said. "For the most part, they blend in."

Dr. Pickell says having a scribe to enter patient history and other basic information into the EHR has allowed him to pick up on discrepancies in the patient's chart he otherwise might not have noticed, such as medication errors and missed screening tests. 

"These are things that sometimes fall through the cracks when you're focused only on the current problem and getting the data entered," he said. "Anything that makes it easier to see patients is a benefit as far as I'm concerned."

As for cost, Dr. Pickell said, "If you could see another patient or two a day, it'll more than pay for itself. And it does allow you to do that."

Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.


Houston Scribe School

Houston Community College (HCC) Medical Assistant Program Director Cyndee Lundgren says the high demand for medical scribes in the Houston area prompted the school to create a program to certify medical scribes.

HCC's Coleman College, located in the Texas Medical Center in Houston, is welcoming its first class for the new medical scribe certificate program this month.

She says the six-month, 17 credit-hour program will include teaching students medical terminology, anatomy and physiology, medical insurance, gathering data in EHRs, billing processes, and clinical scenarios for putting health information into an electronic health record.

The program also includes a practicum during which students visit a clinical site and spend 112 hours doing real-time scribing. At the end of the program, Ms. Lundgren says, students can apply for national certification through the American College of Medical Scribe Specialists. 

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