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August 2018

Efficiency Experts
By Selena Chavis
For The Record
Vol. 30 No. 7 P. 20

Providers increasingly look to scribes to improve workflows, patient outcomes, and the bottom line.

While the use of scribes in health care settings is not a new concept, the industry is witnessing an unprecedented growth of workflow models featuring these professionals.

In 2008, there were 500 licensed scribes nationally, according to Kristin Hagen, CMSS, CPHIMS, executive director of the American College of Medical Scribe Specialists (ACMSS). Today, there are 23,000 medical scribes working in more than 2,300 medical facilities nationwide, with the number of scribes expected to reach 100,000 by 2020.

Fabio Giraldo, southeast regional president with Scribe America, says scribes are the "human glue that helps providers and hospital systems bridge gaps in processes" amid heightened administrative requirements introduced by EMRs and evolving national quality initiatives.

"As doctors see their patients, they have quite a task of documenting these encounters in EMRs in real time," Giraldo explains. "The EMR bogs providers down with low-level clerical tasks that don't require an MD to perform. I've yet to ever meet a provider who said, 'I went to medical school to become a data entry clerk.'"

Increased use of scribes comes at a time when primary care is in crisis, according to Peter Anderson, MD, founder and president of Team Care Medicine. "Because primary care is in crisis, all health care systems are in crisis for expense, for quality, and for satisfaction," he says, pointing out that an aging population with more chronic illness coupled with growing demands placed on physician workflows equates to limited access. "Patients need more time and attention. … They can't get in to see the doctors they know and trust."

Scribes improve workflows and access by serving as clinical assistants who establish a dialogue with providers throughout the patient encounter, leading to the efficient creation of a complete medical record, whether that record is paper or electronic, Hagen says.

The ACMSS aims to advance the education, proficiency, and professional standing of these professionals through the Certified Medical Scribe Specialist (CMSS) designation, which complies with requirements found in the 2015 EHR Incentive Program Final Rule (now known as the Promoting Interoperability program).

"The primary function of the CMSS is to create and maintain the patient's medical record under the supervision of an attending physician," Hagan says. "Several studies have shown the practice efficiencies that CMSS personnel provide through and beyond documentation. Using CMSS personnel can help alleviate some sources of physician dissatisfaction we are seeing in our health care system today and keep us on the right track toward the patient-centric, precision medicine path for health care, creating breakthroughs."

Top of License
Giraldo defines scribes as efficiency experts who gather and manage critical patient data for providers. The transference of these administrative duties allows physicians—an expensive resource—to operate top of license, enabling higher patient throughput and improving patient-provider interaction.

In a busy emergency department (ED), for example, a scribe will typically shadow a physician as he or she makes rounds to see patients, documenting all that is happening. Throughout the day, the scribe monitors test results, cueing up the provider as needed.

"We've seen an increase in the amount of access to the provider, where the provider may have been able to see only two patients an hour, with use of a scribe, they are able to increase that to 2.5 or three patients an hour, allowing for a reduction in wait times in the ED and expediting that level of quality of care," Giraldo says.

Hagen says scribes can help ease the burdensome amount of documentation that must be entered into a myriad of systems. "Within each hospital, there are additional frequent changes to what needs to get documented and how," she says. "There is so much constant change and mounting documentation responsibility levied on the medical provider that the traditional paradigm of the medical provider who performs his or her own unassisted documentation or dictates into a recorder has proven to be uneconomical, inefficient, and unsustainable."

While scribes are a great resource for physicians, Peter Reilly, president and CEO of the American Healthcare Documentation Professionals Group, points out that they do have restrictions. "As far as documenting each patient encounter, like a transcriptionist, a medical scribe is an unlicensed professional who is allowed to enter into the EHR only that which the licensed professional instructs them to enter," he says. "The licensed professional is still responsible and required to sign off on any information entered by the scribe."

Expanding Roles
Giraldo says the responsibilities of scribes are evolving as value-based care and risk-sharing arrangements take shape. For example, more scribes are being used to help gather and manage data for population health and other quality initiatives.

Anderson notes that his organization expanded the concept of the scribe in the mid-2000s to encompass a Team Care Assistant (TCA), who not only increases efficiencies but also helps physicians advance quality and elevate patient experience. This approach entails six steps to provider-patient interaction, starting with standardized data collection based on the symptoms. For instance, he points out that if a patient presents with a cough, there are typically eight to 10 questions that a physician will ask to narrow the scope of the issue.

Once the questions are answered and the physician enters the room, the TCA will verbally present the information to the provider in front of the patient. Anderson says this process alone has been a game-changer for the patient-provider relationship in that patients feel they have been heard and are part of care planning.

Once presented, the traditional documentation processes employed by the scribe come into play and then extended to the fourth step, which entails follow-through and ordering of the physician's prescribed treatment plan. The parameters of what is allowed in this fourth step will vary by state, Anderson points out.

The fifth and sixth steps, which address closing and controlling the patient visit, speak directly to efficiencies. By allowing the TCA to close the visit, physicians are often able to circumvent getting sidetracked with conversations that are irrelevant to their patient-care tasks—distractions that can easily add five to 10 minutes to any patient encounter, Anderson says.

In terms of controlling the visit, TCAs act as the liaison between the patient and the physician when additional care requests are made outside of the presenting problem.

This model's effectiveness was demonstrated in a pilot program conducted at Greenville Health System, a large not-for-profit network in South Carolina. Efficiencies achieved through the TCA workflows allowed the health care system to increase visits per day by 29%, relative value units by 38%, and physician gross revenue by $180,000 per year.

In line with trends to elevate the role of scribes, Hagen says that the scope of the CMSS credential was officially expanded in early 2017 to prepare for the Medicare Access and CHIP Reauthorization Act (MACRA). CMSS personnel now use an evidence-based integrative medicine model of care to expand upon their current clinical assisting duties, while allowing for individualized treatment regimen, education, and supplementation to advance medical specialties.

"The CMSS is cross-trained in many functions that help improve efficiencies and the quality of patient care in the organization," Hagen says. "The new curriculum standards also equip them with a focus on wellness, prevention, integrative care, and complementary and alternative medicine."

Examples of nonclinical tasks CMSS personnel can perform include the following:

• preparing and maintaining medical records and assembling patient chart materials and paperwork;

• assisting physicians in using the EMR and researching information in the EMR;

• filling out insurance-related forms;

• serving as a liaison between patients and physicians; and

• entering information into the EMR.

Examples of clinical tasks CMSS personnel can perform as directed by the physician include the following:

• assisting the physician during exams and procedures;

• setting up procedure trays;

• preparing patients for examination;

• explaining treatment procedures to patients and reviewing physician instructions;

• obtaining vital signs;

• authorizing prescription changes;

• entering pended computerized physician order entry, including medication, diagnostic, and laboratory orders;

• collecting and preparing laboratory specimens;

• performing basic diagnostic tests; and

• educating integrative/functional nutritional components for patient care improvement.

Best Practices for Implementation
Reilly says organizations have two options when introducing scribes into practice: build or buy. "These [choices] are characterized by individuals and organizations who are interested in building their own team of medical scribes vs those individuals and organizations who are inclined to buy the services of one of a variety of scribe management companies," he says.

Organizations engaged in the "build" option focus on developing a stable, long-term scribe solution by leveraging new or existing allied health professionals, including medical assistants, medical transcriptionists, licensed vocational nurses, and technicians. "These [professionals] are loyal to their organization, already contributing to its success and committed to the organization for the long term," Reilly says. "This is vastly different than those individuals or organizations looking to buy the scribe services via a scribe management company."

In the case of the "buy" category, Reilly says scribe management companies must charge their clients significantly more than what they pay their scribes to provide their services. "To do this, the scribe management companies have zeroed in on the use of premed students," he says, pointing out that these students are typically willing to work for minimum wage to $12 per hour. Third-party scribe organizations can then upcharge to $20 to $30 per hour.

"From the hospital's perspective, their decision is between paying a scribe management company $20 to $30 per hour or paying an existing or new scribe $14 to $18 per hour," he says. "The key to implementing a long-term scribe strategy includes determining upfront which of these two options is best for the organization."

Giraldo advises organizations to avoid altering clinician workflows by conducting workflow mapping upfront before integrating scribes into daily clinical processes. "No two doctors work the same way; no two hospitals work the same way. There is no cookie-cutter approach … and it's difficult for providers to change their workflow," he says.

In addition to workflow mapping, Hagen says provider organizations must identify current and future needs based on potential increases in patient volume and assess which areas of clinical and nonclinical practice can best utilize CMSS-assistive skills. Once this is determined, scribe strategies can be extended to improve care quality, workflow design, and patient/clinician/staff satisfaction, while also meeting national regulatory objectives such as HIPAA and MACRA compliance.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.


Peter Reilly, president and CEO with the American Healthcare Documentation Professionals Group, says organizations take different paths when going the scribe route depending on whether they use premise-based or virtual scribes.

For premise-based medical scribes, one scenario entails a scribe shadowing a physician throughout the day. For example, the scribe enters the patient room along with the physician and observes the interaction with the patient as unobtrusively as possible. The scribe efficiently captures the pertinent facts of the encounter by documenting into the proper sections of the note or chart.

After leaving the exam room, the scribe clarifies any uncertainties with the physician. A scribe may keep track of lab work when results are ready and document these findings into the chart if it is not already autopopulated. Any pertinent findings are conveyed directly to the physician. When the scribe believes the note is complete, it's turned over to the physician to review, revise if needed, and sign off.

Another premise-based scenario is characterized by a team approach to patient care between medical assistant scribes and physicians. In this case, the scribe greets patients in the waiting room, brings them to the exam room, and completes an initial interview, documenting the reason for the visit as well as vital signs. Often, scribes can document the Review of Systems at this time via a patient-completed questionnaire or through a series of verbal questions.

Once the physician enters the patient room, scribes observe the patient-provider interaction. The remainder of the encounter follows a similar path to the other "shadowing" scenario, with the additional responsibility of finalizing visits by making patient appointments and printing discharge paperwork.

The use of virtual scribes typically takes two forms, Reilly says. In the first, scribes conduct documentation-related activities from a prerecorded patient visit for which the provider has obtained permission. In a "voice recording only" setting, the physician is aware that the scribe documenting in the chart will not have a visual and may need a description of findings such as location of pain or wound as well as the patient's response to certain stimuli if no sound is audible. Following the patient visit, the virtual scribe documents accordingly into the patient's chart within the EHR system.

Virtual scribes can also document in real time via a direct communication tool that links them to the patient visit. Scribes can see and hear the visit as if they were there in the room, enabling real-time interaction. This workflow allows physicians to ask questions such as "When was the patient's last visit?" which the scribe can answer following a quick scan of the chart.

— SC