Beyond Scribes: A Better Idea on the Horizon (2010)

ImageA lot of chatter is going on within our specialty about the use of scribes, but a better idea is on the horizon. Small wonder: Physician productivity is down across the country (VHA Database, August 2009), and the documentation burden keeps growing. ACEP's Quality and Performance Committee has seen more than 140 suggested “quality measures” proposed for our practice. Imagine trying to comply and document that number of parameters! Emergency physicians want more than a clerical assistant to do documentation. Most EDs are fraught with operations that are clumsy, redundant, and inefficient, and they often require the most highly trained and skilled person on the health care team (the physician) to chase data. “Where is the urinalysis?” “Why is that CT not back?” “Has anyone seen that EKG?” Physician productivity would increase if they could offload not only documentation tasks but that data-chasing and coordination of the ED workup and care plan. Interestingly, the difficulties associated with implementing an electronic health record can lead departments to discover this newest addition to the health care team. Sometimes dubbed the PAL, the physician assistant liaison or personal assistant liaison helps run interference for the physician in documentation, data retrieval, and care coordination. The leadership at Parkview Medical Center in Pueblo, CO, was convinced it could increase patient safety by implementing electronic medical records, and particularly improve turnaround time for patient records. They went live in 2004 with a high-tech EMR that included desktops and portable laptops, and all charting had to be done on the computerized system. What followed was a surprise. Efficiency suffered, patient satisfaction fell, and walkaways (which had been remarkably low) rose to 2.5 percent. Why? The physicians were spending so much time interacting with the computer system that overall patient flow and processes suffered. Even worse, the EMR was so cumbersome that physician productivity had fallen to an unsustainable 0.5 patients an hour! Rather than throw out the EMR system, they implemented their physician assistant liaison program. While they initially tried using emergency medical technicians and paramedics, they subsequently established a program with local colleges to use second- and third-year nursing school interns. These PALs follow physicians around doing documentation, order entry, and data retrieval. The PAL maximizes the efficiency of the physician, freeing him for clinical tasks. With the help of the PAL program, physicians are seeing a respectable 2.5 patients per hour, and ED patients are being seen 15 minutes faster. In addition, because the scribe pool draws from students at the nearby nursing school, this program has proven to be a built-in recruitment vehicle for hiring ED nurses! (Urgent Matters 2006;3[4]; http://urgentmatters.org/346834/318749/328750/318752.) Similarly, Mahmood Vahedian, MD, an emergency physician with the Banner Health System in Arizona, wanted to improve working conditions for the physicians in his group. Struggling under staggering clerical duties during each shift, physician satisfaction was at an all-time low. Dr. Vahedian, who worked as a scribe before medical school, had an insider's view of the work. Beginning with five scribes, he launched a training program. Scribes are paid by the 35-member physician group. He had some groundwork to lay because the job description, credentialing, and security issues had to be worked out from scratch. According to data from professional scribe companies, the majority of homegrown scribe programs fail. This is likely due to lack of experience with job description and credentialing issues as well as inadequate training. Since Dr. Vahedian had experience as a scribe, he was able to incorporate the necessary elements in launching his program. One clever strategy he used was to partner the scribes in-training with the most productive physicians in his group. As most readers will intuitively understand, all emergency departments have process idiosyncrasies, and experienced, efficient physicians learn the workarounds and techniques to get workups done expeditiously. This is one way homegrown programs may outperform the outsourced programs. In turn, these “super scribes” (who really function as physician assistant liaisons) expose each physician in the group to the tricks of the trade they have learned from the most efficient physicians. It becomes an iterative process with benefits all around. Dr. Vahedian tries to partner the same scribe with the same physician as much as possible in the schedule so the scribe learns the style and nuances of how that physician practices and documents. Over time the efficiency grows as the scribe and physician work as a team. Though no physician has been required to use the scribe program, over time the group has unanimously requested scribe services, and even the physician assistants working in the fast track want to use them. His program now has 40 trained scribes, and he fills their ranks with pre-med or pre-nursing students. Many are looking for hospital experience to put on their professional school applications, and he offers them great front-line experience for which they are paid a small hourly wage. The program now populates itself by referrals from other scribes, and turnover is low but expected as the students advance their education and careers. Each scribe currently works fewer than a thousand hours a year, which allows the physician group to pay the hourly wage but not provide benefits. Since its earliest days, Dr. Vahedian's program demonstrated an increase of $28 per chart through better documentation, along with physician and patient satisfaction gains. One physician who was slated to retire asked to stay on because he finds the work environment so much less frustrating. Physicians are freed up to spend time with patients and families, and the frenetic game of chasing data and paper has been mitigated. For more information on how he did it, email Dr. Vahedian at [email protected]Figure: Dr. Welch is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing.