Expanded scribe role boosts staff morale
'Another set of eyes and ears' for ED physicians
A growing number of EDs are using physician scribes to help with histories and physical exams, but Joe Danna, MD, FACEP, has been using scribes for much, much more, and he says it's made a world of difference when it comes to staff morale.
"I can tell you that in 28 years of ED practice management, I have never seen anything positively impact our practice more than scribes functioning in an expanded role," says Danna, who is president of Kankakee, IL-based ESST (E2 Scribe and Template), which employs the expanded scribe model and specifically designed tools to enhance ED practice.
Kate Ketterhagen, PA-C, who coordinates the scribe programs at Provina Kankakee St. Mary's Hospital and Genesis Allini Quad Cities, both in Illinois, is equally enthusiastic about this approach. "Once we introduce the program into an ED, the physicians and nurses get spoiled," she says. "The common response is that they would not want to practice without them."
These scribes do not simply document the history and the physical exam, but the entire record of ongoing patient care: assessment, diagnostics, procedures, and re-examinations, Danna says. He designed the program to address what he considers one of the biggest physician dissatisfiers: having increasingly less time to spend with patients. The typical ED physician now spends about 34% of their time with patients [without scribes], he says, "And if you add EMR [electronic medical record], it goes to the mid-20s, based on the best information we have."
"The [EMR] systems work well enough for docs who sit down with the chart after their work is done and finish it in one sitting as would a family doc seeing a patient on the floor," Danna explains. "However, a typical emergency physician would commonly have several chart encounters per patient and could easily have a dozen or more on an ill patient, while managing a dozen or more patients at a time."
It's simply easier to grab the chart, make a brief note or have the scribe do it, and move on, than it is to find the patient's chart on the EMR, locate the template, find the right field and enter the data or type the comment, he says. "And this, of course, does not include computer physician order entry, or to find, compare, and record EKGs, and printing off discharge instructions and scripts," Danna says.
He says the other 60%-70% of the time a physician spends is divided as follows: documentation, 35%; case management discussions, 15%; and clinical information management, 15%. The only tasks a doctor has to do are direct patient contact time and case management, Danna adds, so if someone else handled the other tasks, the time available to spend in direct patient care leaps to 60%. "This makes an obvious difference in comfort, and addresses the innate angst I recognized nine years ago: anxiety and tension that really distract from the joy of our practice," he says.
Danna says scribes can be trained successfully in critical thinking "and become another set of eyes and ears in how doctors organize and prioritize their works, and that's huge," he observes.
Ketterhagen says, "I see it all the time. On multiple occasions, the prompting and reminding is probably the most valuable service the scribes provide, besides eliminating the documentation load.
Danna adds: "For example, let's say I'm in a room examining a child with belly pain. In the middle of examining the toddler, I end up getting called out of the room and pulled into a trauma room. The next thing you know I'm in another trauma room, where a patient is in respiratory extremis."
While he is distracted by those critical cases, the scribe keeps the original patient in mind. The documentation priorities are maintained by the scribe, while the physician is able to focus on the clinical priorities for the many patients under his/her care at the time. "He will say to me, 'Were you done with that kid? Do you want labs done again?'" Danna points out. In short, the scribes help drive the workflow for the entire patient encounter. Because the scribes concept has been around for a while, there is a significant amount of research on where they have succeeded and where they have failed, he says.
"Many times they fail because they're given a very limited role," Danna notes. "The real value to a scribe is when they become actively involved in managing the reams of clinical information, transcription, and prioritization."
Danna does not yet have hard data on staff satisfaction, but he is collecting them. "Still, we know conclusively, beyond the shadow of a doubt, that the two are related," he says. "One of our doctors had to leave for a job on the coast and called virtually in tears because he did not want to lose his scribe."
Templates help organize care The expanded scribe model employed by Kankakee, IL-based ESST (E2 Scribe and Template), which entails managing "reams" of clinical information, transcription, and prioritization, requires specialized tools to help maintain a systematic approach, explains Joe Danna, MD, FACEP, president of the company. "In order for the scribes to understand how physicians work, interpret, and document history, it's best to use a template that has been designed for that purpose," he explains. For the physical exam, for example, the templates present an organized approach that is system-focused or structured for a multisystem complaint. "When you walk into the room, you might think you have a simple ankle sprain, until the patient tells you they got dizzy and fell down the stairs," Danna explains. "The templates teach the scribes how to listen to and anticipate how the history will go and interpret it so they can document appropriately." The basic structure of each template is population-based, not symptom-based. In other words, there will be an adult template and a pediatric template. "So, for example, you would either find the term "ear tug" or "ear ache," depending on the patient," Danna says. [A copy of one of the templates is available.] |
Scribes receive extensive training The physician scribes recruited by Kankakee, IL-based ESST (E2 Scribe and Template) have a much more expanded role than the typical scribe, and because of that, require extensive training, says Kate Ketterhagen, PA-C, who coordinates the scribe programs at Provina Kankakee St. Mary's Hospital and Genesis Allini Quad Cities, both in Illinois. "Our training program lasts four or five days, eight or nine hours a day, plus an orientation period where they work with an experienced scribe," she explains. "They teach histories and physicals; how to listen to the physician, document and comprehend what they say; and critical components." There also is a lab and diagnostics session so the scribes can gain a good general understanding of results, a lengthy session on critical thinking, an introduction to the demands of the ED, understanding what the ED doctor deals with and processes they use, patient flow management, and clinical information management. "There's also a lecture on documentation and coding, what needs be on the chart, and why," Ketterhagen adds. The scribes are recruited primarily from other health care-related fields, such as EMTs and paramedics, respiratory therapists, and medical students. You don't need a large budget to start such a program, says Joe Danna, MD, FACEP, president of the company. "Their salary ranges from about $15 per hour to $20 for the most experienced," he says. This salary is not a tough sell, he adds, because administrators realize they end up filling a significant number of gaps. "There are times when nurses can't do certain tasks that scribes can do, such as making phone calls, tracking down labs, getting key results, or simply kicking the system in the butt," Danna explains. Ketterhagen says, "They also provide accessibility to the physician's thinking. When the doc has his face in the chart, the scribe is available to discuss case management in detail — what the plan is for this patient." |
Scribes improve compliance with core measures The physician scribe, when given an expanded role, is an important asset when it comes to monitoring compliance with core measure guidelines and time-sensitive events, says Joe Danna, MD, FACEP, president of Kankakee, IL-based ESST (E2 Scribe and Template), which employs the expanded scribe model and specifically designed tools to enhance ED practice. "For patients with sepsis, pneumonia, STEMI [ST-elevation myocardial infarction], Stroke Alerts, Trauma Alerts, and so forth, the physician scribe will help to track all of the components and time-sensitive tasks that accompany those events," he says. "The scribe will also help facilitate the responsiveness of ancillary departments in cooperation with the ED to ensure that our goals are met." |
