Pulse
Wingmen in the ED
Medical scribes have found a niche in hospital emergency departments. There, these skilled transcriptionists attend to the electronic health record while physicians tend to patients.
By J. Trout Lowen
Christopher Obetz pulls back the curtain and steps into exam room 11 in Abbott Northwestern Hospital’s emergency department. Inside, a young woman lies on the bed fully clothed; the clear plastic brace encircling her neck is the only obvious indicator that something is wrong. Her chart says she has had a seizure and hit her head.
“Hi, I’m Dr. Obetz, one of the emergency physicians here. I’ll be helping you. And this is Ann, my scribe. What brings you to the emergency room today?”
The woman explains that the last thing she remembers was being on the phone. “Then I just woke up on the floor.”
As the patient talks, Ann Konrardy begins to type on a laptop computer that sits on a desk she has wheeled into the room and tucked discretely into a corner: “29-year-old female with a recurrent history of seizures presents at the ED post seizure.”
While Obetz looks directly at the patient and asks questions about the seizure, medications she is taking, and her social history, Konrardy scrolls up and down the electronic health record (EHR), entering data in the appropriate fields and switching screens to check the patient’s past medical history for relevant information. Obetz finally recommends that the patient have a CT scan and neck X-ray. Over the next few hours, Konrardy will check her computer for the results of those tests and brief Obetz when they are in.
Konrardy is one of a growing cadre of medical scribes now working in hospitals and clinics to help doctors meet new demands for real-time data and recordkeeping created by EHRs. Essentially, the scribes interact with the computer so the doctors can interact with the patients. “It’s really shifted our attention away from the screen or notes, or the pencil and paper, and focused our attention more toward the patients,” Obetz says.
EHRs in the ED
Scribes have been used in a few hospitals since the mid-1990s, but there has been growing demand for their services in recent years as hospitals and clinics around the country transitioned to EHRs and physicians were suddenly expected to enter patient data into computerized systems. Physicians began complaining that the data-entry demands were reducing their productivity and that the computer was an unnecessary barrier between themselves and their patients. In the ED where he was working at the time, Andrew Topliff, M.D., says physicians saw a 30 percent drop in productivity when EHRs were introduced five years ago. He’s seen similar problems in other EDs since. The drop in productivity has created a problem for both hospital administrators and for physicians, whose incomes are based on the number of patients they see.
Hospitals tried to encourage physicians to dictate their notes using either speech-recognition software or tape recorders, but there were problems, especially in EDs. Emergency physicians move quickly from patient to patient, are frequently interrupted, and work in noisy places—all of which make dictation difficult. “There was clearly a problem,” says Topliff, who began looking into the use of medical scribes to help doctors challenged by the new EHRs.
Three years ago, Topliff founded Elite Medical Scribes with two business partners. Elite now supplies scribes to several emergency care facilities and a handful of clinics in the Twin Cities and to other clients nationwide.
Abbott was among the first Twin Cities hospitals to make use of scribes. Five years ago, a physician group from Texas that had a scribe program in place trained Abbott’s first scribes. After that, Obetz’s physician group, Emergency Care Consultants, took over the management of the scribe program.
Emergency Care Consultants now employs about 35 scribes. They assist emergency physicians and nurse practitioners at Abbott in Minneapolis and at United Hospital in St. Paul. Within the last year, Obetz and Konrardy have also trained scribes for Children’s Hospital and Clinics of Minnesota in Minneapolis and a physician group in Columbus, Ohio.
Recruitment and Training
Elite Medical Scribes and Emergency Care Consultants recruit and, almost exclusively, hire premed students to work as scribes. Many are in the gap year or years between college and medical school. Both programs also consider students headed into nursing and physician assistant programs. But Konrardy, who supervises and trains Emergency Care Consultants’ scribes, says future doctors are the ideal candidates because they’re motivated, focused, and driven to do a good job.
Training starts with video and online curriculum to familiarize the future scribes with the ED environment, the format of medical records, medical terminology, and the basics of billing, coding, and HIPAA requirements. Then, scribes-in-training work on the floor with an experienced scribe. Elite’s scribes go through 80 to 100 hours of on-site training followed by an extensive examination process, as well as ongoing education that covers advanced medical topics and billing and coding. Emergency Care Consultants’ scribes train for eight shifts before they work on their own.
At its best, the scribe- physician relationship is a symbiotic one. Scribes not only record the physician’s findings in the medical note, they alert physicians to potential issues in the patient’s medical history, order and track tests, and help track and update the status of up to eight patients at a time. Physicians review all the notes, make corrections, and sign off on them. A good scribe, says Konrardy, is five steps ahead of the provider. “They really think of you as kind of like a wingman,” she adds.
And while scribes earn little more than minimum wage, they receive other benefits. Working full time in an emergency department gives premed students an intensive introduction to their chosen profession. “Personally, I don’t think there’s anything really to compare it to,” says Julian Hinson, a premed student who began working as a scribe at Abbott in July. “I’ve been shadowing doctors, doing all of the volunteering you could do all four years of undergrad, and it doesn’t even add up to two months of this.”
Working as a scribe also has changed Hinson’s view of medicine. Before he started, he was convinced he wanted to go into cardiology; but scribing has exposed him to so many different areas of medicine and medical issues that he is keeping his options open. And he is convinced that spending a year working as a scribe will give him a leg up when he heads off to Meharry Medical College in Tennessee in June. “It’s almost unfair,” he says. “I feel like I’m cheating.”
Tangible Benefits
Both Obetz and Topliff expect the demand for scribes to grow as the use of EHRs increases—and as hospital administrators come to understand that scribes, which typically cost hospitals about $20 per hour, offer a good return on investment. Although they’re most often found in EDs today, some expect hospitals will find other uses for them, perhaps in operating rooms. “At the end of the day, you just ask them if it makes sense to have people at the higher end of the pay scale doing data entry instead of using specialized skills to see patients,” Topliff says.
Scribes’ value can be measured in multiple ways, Obetz says. Physicians are more efficient, they see more patients, and patient satisfaction improves. Before scribes, Emergency Care Consultants’ physicians spent 40 percent of their shift doing paperwork, Obetz estimates. Since scribes joined the physicians in the ED, that’s down to about 5 percent.
The quality of the medical note also has improved, which has led to more accurate coding and billing. A study conducted by researchers at the University of Virginia and published in the journal Academic Emergency Medicine in 2008 compared scribed and nonscribed data from 4,135 patient charts and found that billing based on documentation done by scribes increased by an average of $42 per patient.
And then there are the intangibles, such as the fact that having scribes around allows for better communication among doctors, consultants, and even paramedics. At Abbott, Obetz says, the goal is for an ED doctor to meet the paramedics at the door as the patient arrives, and scribes have freed up physicians to do that.
Although scribes were a rarity in EDs just five years ago, they are quickly becoming accepted members of the team. And emergency physicians who have worked with them are unlikely to want to work any other way.
“Could I do it?” Obetz considers. “Yes.”
“Would I want to?”
“No.”