Scribes To the Rescue

Why EMRs will make them only more indispensable in the practice.

BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR

In the realm of ophthalmic personnel, scribes have made great strides over the last 20 or so years. Janna Mullaney, chief operations officer of Katzen Eye Group of Baltimore and a consultant, estimates that when she began as a scribe in 1986, about half of all eye-care practices employed scribes. Now she would put that figure at 80% — and she expects them to become more prevalent in the coming years. Why? Well, there are the usual suspects of shrinking reimbursements and increased Medicare scrutiny, but the adoption of EMRs is also a major contributor.

Yes, hiring a scribe would mean another salary to pay, on top of EMR’s steep price tag. But the ability of a scribe to boost productivity is already widely known. Proponents point to the scribe’s multitude of advantages. She allows the doctor to be more hands-on with the patient. She makes records more legible, largely eliminating the bugaboo of poor physician handwriting. She enables a popular doctor to see more patients, and keeps the doctor on track during an examination. She can even write prescriptions.

Elaine Heffernan, CMPE, CPC, administrator at an eye-care practice that uses paper charts, believes that scribes are well worth the cost, helping the practice maintain quality patient care while keeping ahead of decreasing revenue. So there’s already an excellent case for hiring a scribe. The changes coming to medicine, particularly those associated with EMRs, however, are about to make that case even stronger.

Solving EMR’s Little Problems

A scribe can also play a crucial role in helping a practice avoid the pitfalls EMRs often bring. Shocking in light of much of the advertising around them, yes, but some practices that have adopted electronic medical records report they are not an unadulterated boon. Like everything else, they bring some drawbacks, the most significant of which may be a decreased focus on the patient, as the computer requires the physician’s attention. Another is the precious exam time spent waiting for the EMR to upload charts and photos — costly even on days when the server is not slow. In both cases, however, a scribe enables the physician to keep her or his focus where it belongs.

Of Face Time and Uploads

Given that one benefit of EMR is that it eliminates the ancient problem of physician’s indecipherable handwriting, isn’t it less likely that practices would need scribes once they have taken the electronics record plunge? Not at all, says Cathi Lyons, administrator at Gordon-Weiss-Schanzlin Vision Institute, San Diego and member of the American Society of Ophthalmic Administrators (ASOA). She says that scribes will become more prevalent as EMR does. “The one thing we don’t want to do is take our doctor’s focus away from the patient,” she says. “And when they are banging on the keyboard and filling out all those things they need to, they’re looking at the computer and not at the patient.”

Ms. Mullaney agrees that “the face-time fear factor” will lead more practices to employ scribes. Whereas doctors had become proficient at writing in paper charts without looking down, she notes that there is no way to get around the fact that computers, even tablets and laptops, require the doctor to look at them instead of the patient. “So they start to realize the benefit of a scribe,” she says.

Despite the celebrated timesavings from EMR — no more lost charts, or contacting a satellite office for information, etc. — EMR itself can be time-consuming in its own right. As Hugh Glatts, CA, director of operations at Mittleman Eye Center, West Palm Beach, Fla., and ASOA member points out, you can’t just flip open an EMR chart like you can a paper chart. The physician could waste valuable time logging in and opening and loading electronic documents or updating them. A scribe, he notes, can have the patient record on the system, the patient plan in place and the patient worked up with the relevant facts documented in the record when the doctor enters the exam room.

A Question of Margin

Of course, with Medicare cuts looming and the fallout from the unwinding health-care reform law, as well as the costs of EMR implementation, many practices are understandably leery of adding another salary to the bottom line. Yet the “pro-scribe faction” is adamant that they increase a practice’s profitability.

In the course of Ms. Mullaney’s consulting with other practices, she has found that a scribe can add up to two patients per session per day. “That’s enough to more than pay for a scribe,” she says. Additionally, she points out that having a scribe typically results in more accurate coding. “And you miss less,” she says. “You don’t miss that bandage contact lens, you don’t miss those punctal plugs, and you don’t miss that external photo.”

Ms. Heffernan agrees that scribes can bring more accuracy to a practice’s coding and compliance. At her practice, which has not yet converted to EMR, scribes record the billing codes for each visit on a special sheet and in the patient’s chart. “We audit our charts and charges daily,” she explains. “So we go back the next day to make sure that everything is matching. The scribe is also entering the codes, the diagnoses, linking the appropriate diagnoses and tests, etc., on the charge slip.”

All Face Time Now

What’s more, the increased one-on-one time doctors have with their patients enables them to discuss ancillary services such as oculoplastics or LASIK, Ms. Mullaney points out. “Because it’s all face time now.”

The principal doctor at Mr. Glatts’ office sees 80 to 90 patients a day. “The only way for a doctor to see that many patients is to have a scribe in the room,” he says. In fact, that principal doctor has not one, but two scribes to help him successfully meet the challenge of seeing that number of patients each day, Mr. Glatts notes: One in the room with him and the patient currently being seen, and the second in the another room getting the next patient ready for the doctor.

The other six physicians in the practice are each assigned one scribe. “When their schedule gets to a certain level, then they’d be considered for another,” Mr. Glatts explains. “There’s truly no way that a doctor is going to get through a busy day without having somebody in the room to make all of this happen with him. It’s just impossible.”

How do you know when a scribe’s advantages outweigh the costs in salary and benefits? It’s a question of volume, according to Mr. Glatts. Doctors who see, say, 40 to 50 patients a day need a scribe, he maintains, to provide quality patient care while keeping on schedule. At some point north of 50 patients is when having two scribes for that doctor makes sense, he says. A new doctor at his practice who sees less than 40 patients a day does not use a scribe.

Making It Work in Your Practice

Just as important as a scribe’s facility with computers and familiarity with ophthalmic terms is the rapport between her and the doctor. For the partnership to succeed, a relationship must be nurtured. “You have a language together,” Ms. Mullaney explains. “When I was a scribe, I would know which eye my doctor did first in a gonisocopy, so I would know without having to look up that he was doing the left eye.”

Mr. Glatts agrees that familiarity is essential. Knowing the doctor’s routines saves time because the scribe knows the “basic plans and the speech and documentation that he is going to give the patient, depending on what their condition is. A really good scribe is always going to be one step ahead of the doctor,” he says.

Because being in sync is critical to achieving high productivity, rotating scribes is not the typical practice. “Another scribe, or a less experienced scribe, is not going to do exactly what the doctor is going to do,” Mr. Glatts explains.

Ms. Heffernan agrees. “Their regular scribes are like an old shoe; you wear it enough and it’s molded just to the way you want it.”

A Matter of Faith

A key element of nurturing the physician-scribe relationship requires the physician to put some faith in the new assistant. Ms. Mullaney says that scribes are underutilized because some physicians, especially younger ones who are more tech savvy, believe it’s just easier to do it all themselves.

“They want to move the scribes out of their way and sit down and write out their own paragraphs or their own plans, because they don’t have enough faith that the scribe can get their words down the way they want,” she says.

Ms. Lyons reports that two younger doctors at her practice decline to use a scribe. Instead, they walk the patient out, then immediately fill in their charts. When the practice goes live with their EMR, she expects that these doctors will use a handheld device to continue doing it all themselves.

Ms. Mullaney tells such scribe-wary physicians that it is better to say out loud what they want the scribe to learn rather than typing it in themselves, because people learn — the terms and how to spell them, the phrasing — when they write things down. The understanding the scribe thus obtains about the way a physician practices, and the personalities of the various patients, pays big dividends, according to Ms. Mullaney. The scribe can become the physician’s right hand, taking patient phone calls and delivering test results. “You were in the room when the patient was being examined, so you know what the doctor said and you know the patient’s personality,” she says. And because the patient knows the scribe, too, he or she is more likely to accept the scribe’s answer rather than insisting on speaking with the doctor.

It is this ability to reduce some of the physician’s burden — “spreading out the knowledge base and the responsibility to someone who can handle that portion of the examination,” as Mr. Glatts puts it — that makes scribes so essential with the coming of EMRs. “If you see a lot of patients and you want to make a living in health care, you need a lot of support staff,” he says — “with electronic records, especially.” OM