12/10/2013 Workshops: D8 & E8 The presenters have nothing to disclose Emergency Medicine Clinical Information Manager (Scribe) Program By Prince P. Raj, MHA and Rock Ferrigno, MD Wednesday December 11, 2013 09:30AM – 10:45AM 11:15AM – 12:30PM P2 Session Objectives To educate health systems, academic medical centers, and community hospitals about the benefits and challenges of implementing a Clinical Information Manager (Scribe) Program Topics include: • #1. Operational improvement • #2. Provider satisfaction • #3. Patient satisfaction • #4. Education • #5. Financial performance 1
12/10/2013 P3 Goals of the Scribe Program To facilitate and expedite Emergency Department (ED) patient flow by allowing providers to spend more time on direct patient care and education while concurrently producing more thorough and higher quality documentation P4 Scribe Program Presentation Format Scribe Program overview Goals #1. Operational improvement #2. Provider satisfaction #3. Patient satisfaction #4. Education #5. Financial performance Scribe Program overview and goals Q&A Case Study #1: Community Hospital (Bridgeport Hospital) Case Study #1 Q&A Case Study #2 Academic Medical Center: (RR UCLA Medical Center) Case Study #2 Q&A Funding the Scribe Program and tips for success Scribe Program final Q&A 2
12/10/2013 P5 What is a Scribe? An unlicensed member of the Emergency Medicine (EM) Team whose duty is to assist EM Providers (Physician or Mid-Level) with administrative duties during the course of their ED shift Duties include but are not limited to: • Charting • Assisting with navigation of the EHR and other IT Systems • Notifying providers when test results are available for review • Expediting consults and dispositions P6 What is a Clinical Information Manager? A Clinical Information Manager (CIM) is an experienced scribe with at least 1 year of Scribe experience CIMs • Are more knowledgeable about Emergency Medicine and ED patient flow • Are able to anticipate a provider’s needs • Understand what is needed to make a disposition and how to manage the expectations of providers, nurses, patients, and families • Have a better rapport with the EM Team/Family • Are able to assist with the training of new Scribes • Are more tech and EHR savvy: May assist with orientation of new providers 3
12/10/2013 P7 Unlicensed status of Scribes Scribes/CIMs perform their assigned duties under the direction of EM Providers Scribes/CIMs are not permitted to make independent decisions or translations while capturing or entering information into the health record beyond what is directed by the provider Scribes/CIMs are not permitted to participate in direct patient care (Hands-off) P8 Common Scribe documentation duties History of the patient’s present illness (HPI) Review-of-systems (ROS) Past, Family, and Social History Physical examination Laboratory, EKG and X-ray interpretations Progress notes Procedure notes Disposition Clinical impression After care instructions 4
12/10/2013 P9 Scribe / CIM training Paid Training is ~90 days: 3-4 weeks of didactic classroom training followed by 6-8 weeks of training on the ED Floor • Medical terminology • EHR and other IT systems • Medical shorthand • ED patient flow and throughput • Anatomy and Physiology • Admit, discharge, and transfer process • EM physician documentation • Patient / Provider satisfaction • EM billing and coding • Mock ED patient scenarios • EM documentation risk management • EM medical decision making P10 Who is the ideal Scribe candidate? Undergraduate degree (science preferred) with interest in pursuing further graduate medical or health education • Medical School • PA School • Nurses or nursing students with desire to pursue NP/APRN or above • MPH/MHA students interested in healthcare performance improvement • Experienced EMTs (2-3 years) Some prior healthcare experience (volunteering, shadowing, etc.) Minimum commitment of 2 years • Year 1: Scribe • Year 2: Clinical Information Manager (CIM) 5
12/10/2013 P11 What are the qualities of a great Scribe? Passionate about medicine and service to the community Excellent interpersonal and organizational skills Confident and self-motivated Ability to maintain equanimity in the face of resistance, indifference, and hostility Ability to work in a high-stress environment where teamwork, adaptability, multi-tasking, and attention to detail are imperative Willingness to work a flexible schedule that will include evenings, nights, weekends, and holidays P12 Scribe onboarding process Option #1: Medical Staff Option #2: Human Resources • Scribe job description • Background check and proof of eligibility to work in the United States • Occupational health screening including respiratory FIT testing • Hospital HIPAA and compliance training • Mandatory attendance of hospital orientation 6
12/10/2013 P13 Scribe onboarding (continued) Create an administrative policy on the use of scribes • Must be compliant with CMS and Joint Commission rules and regulations • Scribe signature and provider attestation must be included Ensure Scribes have the appropriate IT system access and equipment required to perform their job duties • Disable order entry and prescription writing • Provide individual login credentials specific to the Scribe role • Do not share computers or take computers away from other ED Staff P14 Goals of the Scribe Program To facilitate and expedite Emergency Department (ED) patient flow by allowing providers to spend more time on direct patient care and education while concurrently producing more thorough and higher quality documentation Topics include: • #1. Operational improvement • #2. Provider satisfaction • #3. Patient satisfaction • #4. Education • #5. Financial performance 7
12/10/2013 P15 Goal #1: Operational Improvement • Improve overall ED throughput on the front end and during the discharge process • Reduce door to doctor time (initial waiting time) • Reduce evaluation to disposition time (subsequent waiting time) • Expedite dispositions by notifying providers about the availability of test results required to make a disposition and assisting with aftercare instructions as needed • Reduce overall ED length of stay • Increase the ED’s capacity to care for additional patients in a more timely manner • Reduce Left Without Being Seen (LWBS) Rate P16 Goal #2 and #3: Provider and Patient Satisfaction Provider Patient • • Provider is able to • Shorter door to provider time and Personal assistant available to help with charting and to navigate several sit, listen, make eye treatment area to provider time different computer systems contact, and put the (decreased waiting time and focus where it ED length of stay) • Ability to see more patients per shift belongs: and go home on time on the patient • • More time to speak • Assist patient with non-clinical Reminder for labs and other test results with patient, family, needs (blankets, pillows, ice PCP, consultants, and chips, guiding family to the • Assistance in expediting dispositions nursing staff cafeteria) and arranging consults • • More time for • Improved aftercare instructions Consultants, admitting physicians and PCPs will benefit from improved patient education Consider : Arranging follow-up real-time ED physician charting clinic appointments directly from the ED 8
12/10/2013 P17 Goal #4: Education Scribe / CIM Resident / MLP Attending • • Administrative burden is • Scribes may assist in orienting Firsthand exposure to clinical setting and practical applications of reduced leaving more time new providers to the ED, the EHR medicine in dynamic ED Setting to see additional patients, and other IT Systems for teaching by Attending, • • Attendings may learn EHR tips, Mastering medical terminology, for patient education and acronyms, abbreviations, and for performing procedures tricks, and shortcuts from Scribes shorthand at an early career stage to further optimize their workflow • • Teaching Scribes medicine • Decreased administrative burden Ability to learn from and work side by side with some of the most improves their ability to leaves more time for teaching talented EM Providers teach other residents and residents/students/Scribes/nurses • students and for patient education Adoption of excellent clinical • Scribes may have helpful documentation techniques documentation/coding tips • • Improve competitiveness in • Provides an outlet for teaching in 2 year commitment gives them time to decide if graduate medical NRMP Residency Match the community hospital setting education is the right fit for them P18 Goal #5 Financial Performance • Improved quality of charting leads to better revenue capture for both the professional side (provider) and the facility side (hospital) • Missed or under-documented procedures may be rectified in real-time • Facilitated chart completion improves turnaround time for billing/coding • Enhanced throughput improves the ED’s capacity to care for more patients • Assist hospital or health system with Core Measure Compliance, meeting Meaningful Use Criteria, EHR migration/transition, and other PI initiatives • Improved patient satisfaction scores for Value Based Purchasing • New Program Development: Example Limited ED Bedside Ultrasound Program 9
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