11/4/2013 Conflict of Interest and Bias Scribes in the ED: � No financial relationships “I get what you are saying…” � Scribe Director at Academic County Hospital � Used a consultant to start our in-house scribe program Eric Isaacs, MD, FACEP , FAAEM Scribe Director Attending Physician, San Francisco General Hospital and Trauma Center Professor of Emergency Medicine, University of California, San Francisco Eric.Isaacs@emergency.ucsf.edu Objectives: How many use an EMR? � Describe the drive to develop scribe programs in the emergency department � Understand what scribes can and cannot do � Consider 3 models of scribe program development and implementation 1
11/4/2013 How many stay late to document? How many use scribes? How did we get into this mess? Bush and Obama Agree! � Bush 2004 State of the Union – “…By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” � Obama 2008 “We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year.” � Penalties for not using EMR “meaningfully” by 2015 2
11/4/2013 Reality Check: After EMR Unintended consequences implementation � Rapid implementation � Less efficient � Go live together � Less time with patients � EDIS – frequently an afterthought � Patient Satisfaction � Productivity loss � Job Satisfaction � Compensation is productivity based � Physician retention � Chart accuracy/Medico-legal risks Percent Time Spent per patient: using EMR Can we find a way to: � 28% Direct patient contact � Improve patient satisfaction � 44% Data entry � Better connections with patients � 12% Reviewing tests and records � Increase RVU per hour � 13% Case discussion � Improve efficiency � 3% other � Go home sooner � Getter job satisfaction � Robert G Hill Jr. et al, 4000 clicks: a productivity analysis of electronic medical records in a community hospital, American Journal of Emergency Medicine; article in press. 3
11/4/2013 There’s an “app” for that! Why Scribes? � Imagine someone who: � Pulls up the old chart prior to your encounter � Documents the HPI/PMH/ROS/SH/Physical exam for you � Pulls up old ECG (and document it) � Pulls up X-rays for you � Tells you when labs or studies are back (and to acknowledge) http://www.medicine.virginia.edu/clinical/departments/emergency-medicine/forundergraduatestudents/ Why Scribes? Why Scribes? � Imagine someone who: � Imagine someone who: � Confirms you have enough elements and 10 ROS for level 5 � Allows you to actually look at the patient while you are talking to them. � Reminds you if a patient meets critical care (more than you think) � Takes care of your documentation while you are doing a procedure or other task. � Reminds you to check on serial observation patients � Specific areas of your charting deficiencies 4
11/4/2013 Why Scribes? Scribes not right for you if… � Imagine someone who: � Excellent Documentation � Allows you to talk to the nurses, ancillary staff, or � Patients seen and discharged quickly consultants with greater attention while they are documenting your chart or pulling up results. � Everyone going home on time � Decreases your need to stay after to complete charts. � Group is stable � Making lots of money � “Scrub” the charts in the morning � EMR is easy to learn and use � Access to old records, labs, x-ray is simple Why not scribes? What can’t scribes do? � Initial outlay of $$ � No independent interviewing/practice � Space and computers � Place orders � The Joint Commission does not support scribes being � Scheduling for partners not utilizing utilized to enter orders for physicians or practitioners due � Medicolegal risk to the additional risk added to the process. � HR concerns � ED Volume or payer mix � “Concern” about teaching and mentoring www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=426&StandardsFAQChapterId=66 5
11/4/2013 What is a scribe? Regulatory requirements � Unlicensed person hired to: � CMS E/M Guidelines: � Enter information into the electronic medical record (EMR) � Every chart entry (by a scribe) needs to clearly indicate � MD, NP , or PA that the scribe made the entry. � Scribes need to have their own log in – not a problem with � The scribe does not and may not act independently but can most EMR systems document the provider’s dictation and/or activities. � The provider needs to attest or authenticate that the � Scribes also assist scribe made the entry (can cover all the entries). � navigating the EMR locating information such as test results and lab results. � � support work flow and documentation for coding. www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=426&StandardsFAQChapterId=66 CMS Guidelines Examples of scribe charts � The Scribe’s Note Should also Include � Scribe: “I, Sue Perhelpful, am scribing for, and in the � • The name of the scribe and a legible signature presence of, Dr. Isaacs” • The name of the physician providing the service • The date the service was provided • The name of the patient for whom the service was provided � The Physician’s Note Should Indicate � Affirmation of that physician’s presence during the time � Physician: “I, Dr. Isaacs, personally performed the encounter was recorded services described in this documentation, as scribed by � Verification that he/she reviewed the information Sue Perhelpful in my presence, and it is both accurate � Verification of the accuracy of the information and complete. Any differences or additional � Any additional information needed information is noted.” http://www.ngsmedicare.com/wps/portal/ngsmedicare/!ut/p/c5/dY3LCoJAGIWfpRfw_H... 12/12/2011 6
11/4/2013 Who are the scribes? Models of scribe programs � MEA model � In-house program from beginning to end � Recruit, hire, orient, train, schedule � Burger King model � Evaluations with action plans, payroll � Turnover � Pre-Health Care students � Last application period: � Consultant to start in-house program � > 200 applications for 6 positions � Outside Scribe provider � 50%-100% admin fee What do you need to start a program? What is the goal? � Interest from partner/director � Adapt to new EMR? � Identify what issue you are trying to address � Productivity? � Identify physician champion � Turnaround times? � Metrics for success � Documentation and coding? � Buy in from administration and nursing � Patient satisfaction and service? � Reimbursement? � Coding � Productivity 7
11/4/2013 Keys to success Pitfalls � Motivated and engaged scribes � Splitting a scribe between two providers � Wiki to track physician preferences � Failed feedback � Train the physicians to use the scribes � Lack of physician engagement � Failure to actually read the chart � Engaged physicians (give feedback not just complain) Conclusion Resources � Use of scribes impacts: � ACEP Scribe FAQ � Quality of physician life � www.acep.org/Content.aspx?id=85988 � Reimbursement � Productivity � ACEP Focus On the Use of Scribes � Efficiency � http://www.acep.org/Continuing-Education-top-banner/Focus-On--The-Use-of- Scribes-in-the-Emergency-Department/ � Scribes are not for every practice � If you are going to start a scribe program � Additional references available on request � Have the goal in mind � Get buy-in from physicians, nursing, administration � Persistence and engagement in program maintenance 8
11/4/2013 Questions? � Eric.Isaacs@emergency.ucsf.edu 9
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