Getting Started

Physicians and practice managers offer advice on how to incorporate scribes into your practice

After 6 weeks of using scribes, Dr. Brucker is slowly regaining lost time. He estimates that he will reach maximum efficiency within a few months, when the combination of two scribes and Penn's EMR system will allow him to restore the efficiency he once achieved with his pen, paper, voice recognition software and Dictaphone.

Dr. Brucker's experience is not unique. Several retina specialists have spoken of overcoming initial challenges when incorporating scribes into their routines. However, most say they will never return to conducting exams without these trusted assistants. Here is their advice on how to adjust and succeed with these new hires.

HELPING WITH EMR

The first major change for Dr. Brucker came in the summer of 2010, when his academic practice adopted an EMR system. The system, far from retina-friendly, is designed to meet the needs of the entire health care system at Penn.

“The EMR system requires a lot clicking,” he says. “It is not hard to use, but it's cumbersome and time-consuming.”

Dr. Brucker says he was seeing 45 to 50 patients a day before EMR slowed him down to 30 visits. “I was spending 10 minutes on the exam and 20 minutes on the record,” he recalls. “It was sheer insanity.”

The situation changed when Dr. Brucker began working with a scribe. Since then, his number of visits has climbed back to 40 and the quality of the exam experience has improved for him and his patients. He still uses his voice recognition software and Dictaphone to supplement the efforts of the scribe and data collection of the EMR system.

“When you have a scribe, you are free to examine the patient and speak your thoughts. Instead of expressing yourself in clicks, you can do it in phrases and sentences that are more descriptive and easier to record,” says Dr. Brucker. “The patient hears a more comprehensive assessment. Now all I have to say is order a photograph, a fluorescein or an OCT and walk out the door. The scribe can spend 3 to 5 minutes finishing up with the patient. Meanwhile, I move to the next room, where I can be up and running with another scribe, evaluating my next patient. Scribes can handle anything that requires documenting. You can go off and do a laser treatment or perform an injection while they do the paperwork and handle technical tasks.”

Dr. Brucker has only recently begun using two scribes—one in each exam room—as staff and resources has permitted. Since then, he has noticed even greater increases in efficiency. Once he gets up to speed with the two assistants, he expects to be able to see as many patients as he saw before the arrival of EMR.

When using only one scribe, he needs to start some exams by entering data. “With a second scribe, you walk in and everything is open—the old record, the results of the most recent tests,” he says. “If the scribe thinks photos are important, she will have them open. We have OIS imaging on one screen and digital images on another.

“Scribes pay for themselves in spades, in terms of allowing you to see additional patients. Our EMR system needs to be complete, including the follow-up visit. Scribes can do it all, if properly trained. They can take down the medication, set up the next visit, drop a note to a doctor and so on. I need to sign off on these things, but the scribe can actually do these tasks for me.”

INCREASING PRODUCTIVITY

Michael Harris, MD, a partner at Associated Retinal Consultants of Kenilworth, NJ, remembers feeling skeptical about scribes. He has been using them for 15 years, gradually doubling his average number of visits per hour, from four to eight.

“We were hesitant at first because we knew a scribe would mean hiring more staff and increasing our overhead,” says Dr. Harris. “But a consultant recommended going in this direction after analyzing our practice. What sold us was one comment: ‘How would you like to see more patients in less time, and leave more refreshed at the end of the day, feeling better about the care you have provided and making patients feel that they have received better care?' Who wouldn't want that? We bought into the concept, a little bit at a time. We incorporated more and more scribes, and it has been a complete winning formula for us.”

Dr. Harris says efficiency continued to increase with the introduction of EMR at his practice approximately 5 years ago. “We wanted to be able to view charts in any of our six offices without faxing and to visualize them from our homes if a patient called in with an emergency,” he says. “Now that we have made these changes, we would never go back.”

ONE SCRIBE AT A TIME

Introducing scribes gradually is the key to success. “It would not be wise to add multiple scribes at once,” says Hildy Abel, general manager of Vitreous Retina Macula Consultants of New York (VRMNY). Her practice has been phasing in scribes for nearly 2 years. “You are adding staff that will cost your practice money. Any practice, large or small, will pay extra salaries by adding scribes. However, in the long run it will increase the practice's efficiency and allow the doctors to see more patients.”

Abel recommends visiting a practice that uses scribes to observe how they function. In many settings, scribes roll up their sleeves for front-office tasks, perform telephone triage, prepare patients for injections, bring the medical bill to the front desk and do work-ups when they are not needed at the doctor's side.

Dr. Freund, a partner at VRMNY, says he was the second physician to start using a scribe at the practice that Abel manages.

“I was reluctant at first,” he admits. “When you have been doing something a certain way for 15 years, the fear of the unknown is significant. Also, if you are used to being on your own with your patient, the idea of someone sitting or standing next to you seems intrusive. I wondered how this person could possibly understand the intricacies of fundus drawings and what I was observing.”

One of his partners strongly recommended the use of scribes, based on a positive experience at another practice. Eventually, Dr. Freund was won over by the results, as well as by the realization that a scribe could strengthen his approach to documentation, an area that needed improvement.

With a scribe by his side, Dr. Freund sees up to 25% more patients a day. “But that isn't why I use a scribe,” he says. “We don't have EMR, which means I would need to spend my time looking into the chart instead of into the patient's eyes to improve the quality of the visit. To protect against audits today, a lot of tedious documentation is required.”

TAKING IT SLOW

Other physicians are introducing scribes to their practices gradually. Dr. Pieramici says he has added two new positions to his staff during the past year. His six-physician practice in California has eight offices, each used by one physician at a time. At this point, he is using scribes for about 40% of his visits.

“We are still using technicians to scribe and we need them to multi-task,” he says. “I work out of two or three rooms and have additional rooms for laser treatments, screenings and injections. We are constantly rotating staff among these rooms. When I go into a room to start an exam, someone is finishing up with the patient I have left behind in another room. I need at least two to three techs for each office. In effect, our staffing needs have gone up 25%.”

Dr. Benz says his Houston practice maintains a one-to-one ratio of physicians to scribes. “If a person who is scribing for me is answering a phone call or providing education to a patient, I am still capable of scribing for myself,” he says. “If I had another scribe, that would be great. But I don't know if the added cost would be worth it.”

AFFORDABILITY

Because reimbursements have decreased and the amount of work per patient has increased, the higher number of visits made possible by scribes has not necessarily been mirrored by income growth. (See “The Increasing Need for Scribes.”) Rather than solely increase practice opportunities, scribes may simply help meet the complexity of today's patient demand.

Dr. Bennett, who has conducted minute-by-minute studies of patient visits in search of ways to improve the patient experience, says he can't quantify the full impact of scribes on practice management. A partner at the Retina Institute of Hawaii, with offices in Honolulu and six other locations, he uses three scribes while rotating among three exam rooms throughout his clinic day. Dr. Bennett says these assistants manage about 80% of the burdensome and often redundant paperwork and tasks associated with the increased number of injections he administers.

“Besides taking care of the paperwork and consent forms, they can help in many ways before I enter the room,” he says. “They can sterilize the area around the eye, make sure it remains sterile, administer numbing drops, review signs and symptoms of infection with the patient and discuss new eye drops or a surgical procedure. To summarize, they are essential to our practice.” RP

A Case Against Scribes

Abdhish R. Bhavsar, MD, who practices in Minneapolis, Minn., does not plan to hire scribes anytime soon—if ever. “Scribes would add extra staff and I don't need them to be more efficient,” he says. “The notes I write and the drawings I make constitute the definitive record of my patient—medically and legally. If a scribe is writing information on my behalf in the chart, I have basically granted him the ability to be the main documenting person for my retinal exam. Either I have to trust that he has documented exactly what I have said or I have to review it myself to be sure. Both are sub-optimal choices for me.” Dr Bhavsar uses his own shorthand to record his exam findings. He has also created a decoding document to make his charts clear in the event of an audit. Below are some of his symbols and translations: AMD = age-related macular degeneration D = drusen D/B = dot/blot retinal hemorrhage DME = diabetic macular edema SRF = subretinal fluid SRH = subretinal hemorrhage SRE = subretinal exudates R = peripheral reticular degeneration P = Pavingstone degeneration (when noted in the peripheral retina section of the form) P = posterior vitreous detachment (when noted in the vitreous section of the form) S = vitreous strands A = asteroid hyalosis (when noted in the vitreous section of the form) Dr. Bhavsar says his exam records are streamlined, featuring short phrases. “It's much easier to read my own handwriting than someone else's, and this even works better when I'm typing into the EMR system at the hospital,” he says. “I look up at the patient, then down to write. When a patient returns, I can scan my notes, look at my own drawings and I can tell in an instant what I need to know.”