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Monday Feb 15, 2016

Discovering a Brave New World of Medical Scribing

Electronic health records. Just the term itself can unleash a torrent of feelings among physicians. We love them. We hate them. We depend on them, but we resent our dependence on them. We are told that they should help streamline our practices, but in reality they often slow us down.   

Our daily workflow rhythm is set by a cacophony of clicks on a mouse or keypad. I recall the time management challenges I faced during my second year of residency when we made the difficult transition from paper to electronic records. Beset by a new array of documentation requirements, my thought at that point was that this was a massive waste of time and had little to do with patient care. I wanted to be liberated from working on the computer so I could get back to the warm bodies that needed my attention.  

Tyla Buxbaum, R.N., documents a visit while I examine a patient. My practice's system of medical scribing has improved efficiency and documentation while reducing errors.

I remember joking back then that what I needed was a scribe. Little did I know that this would someday become a reality. Not only was I soon to learn about the benefits of having a medical scribe, but I was also about to discover that having this additional staff member would open a world of possibilities for productive workflow innovation and efficient practice management.

Enter the medical scribe
To my good fortune, I was hired by a hospital-owned practice that already had an established medical scribe program that allows for one scribe per physician, as long as we meet reasonable productivity requirements.

This staff member is in addition to the rooming nurse assigned to each physician. Funds for this program are dispensed out of the clinic's staff salary allotment based on the premise that physicians are more productive and do better documenting when they have a scribe. Hence, more patients can be seen and more work is captured in the notes, resulting in better reimbursement.

So, how does the rooming-and-scribing system work? My rooming nurse opens the chart and starts the note, and then she gets the patient from the waiting room, takes vitals, reconciles meds, narrows the focus of the visit, and obtains a brief history and review of systems. On my instruction, she may also order any preliminary tests or administer any needed vaccines. The rooming nurse also pulls into my note any labs, imaging, or reports to be reviewed with the patient during the encounter.

Meanwhile, I am working with my scribe on completing previous notes or preparing for the next encounter. If time allows, my scribe will often start the note for the next patient and help predict the agenda for the visit based on past notes or the reason for the visit we get from scheduling. Much ground can be covered this way before we even enter the room. Of course, I still have the option of bringing my laptop into the room to review the chart with the patient. An added bonus is I always have an assistant in the room to help me with procedures, and my scribe serves as a built-in chaperone, assuring that I am never alone with a patient and that I have someone who can corroborate everything that transpired during a patient encounter.  

Once the visit is complete, my scribe may follow me immediately or may stay to review instructions or complete other nursing tasks with the patient. Meanwhile, I am free to move on to charting or to seeing the next patient.

Taking it to the next level
So, here's where efficiency really picks up: cross training. I noticed there often was a disconnect between the agenda my rooming nurse and the patient had discussed and what became evident once my scribe and I entered the room. Naturally, this slowed things down. Although it was enormously helpful to have my scribe linger in the room to finalize things with the patient after I stepped out, I could easily get behind by waiting for her to be ready or by moving on without her there to document. To remedy this, I started cross training my rooming nurse as a scribe with the support of my clinic management. When I thought she was ready to take on the full responsibility of scribing, I began what I call the piggyback approach to rooming and scribing. This approach works because my scribe is also a nurse, but it would work about as well if she was a medical assistant.

The piggyback system is simple: The cross-trained nurse/scribe starts the note, rooms the patient, and stays in the room from beginning to end, scribing all the while and providing any nursing services as needed. By doing this, the nurse/scribe is better able to help keep the visit focused in a way that addresses the patient’s agenda while also meeting my own. I find that documentation is more seamless, and more work actually gets done because the nurse who rooms the patient feels no pressure to rush out and move on to the next patient. This results in better agenda-setting, more accurate medication reconciliation and renewal, and more complete history and health maintenance updating.

An added bonus is that patients never wait in the room alone, so they may have the perception of shorter wait times or at least feel attended to while waiting for the physician. By the time I get in the room, much of the history of present illness has been written, the patient has had many questions answered by the nurse, medication issues have been addressed, any in-clinic labs/imaging have been obtained, required vaccines have been given, and often mammograms or colonoscopies have been ordered along with any other health maintenance updates.

My nurses tell me they love this method because they feel more ownership of the visits, are less tired because they are seeing half the patients, and feel less stressed overall. All this amounts to more patient and staff satisfaction, increased efficiency, fewer errors, and better documentation.  

The only downsides I have seen to the piggyback method are the tendency to lose the sense of urgency to move on to the next patient and the bind you get in if one of your nurse/scribes is unable to work. The first is easily remedied by a team huddle and the second requires a shift back to the old way of rooming and scribing until more than one nurse/scribe is available.

The conclusion: Scribes increase practice efficiency, especially when employed in tandem using the piggyback method.

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri. A version of this post originally appeared in January-March issue of Missouri Family Physician(issuu.com).

Posted at 11:21AM Feb 15, 2016 by Kurt Bravata, M.D.

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