Docs using scribes to ease EHR transition

Part one of a two-part series: (Access part two)

Scribes.

The word might conjure up images of ancient, white-bearded men, bent over papyrus scrolls, scratching away with quill pens.

And the profession has to be older than Methuselah, since what we know of Noah's 969-year-old grandfather was written down by succeeding generations of scribes.

Today, however, organizations seeking to implement the latest wrinkle in medical record-keeping, electronic health-record systems, are looking to new generations of scribes—to increase physician productivity and to overcome the pitfalls of the still typically clunky physician/EHR interface, and to ease the strain of EHR implementations and replacements.

“The word is biblical,” said Linda Pierog, practice manager for Emergency Medicine Services of Orange County, or EMSOC, and its ScribeMD service, which provides scribes as part of its emergency room physician staffing program.

“Transcriptionists came out of this whole thing, too—somebody who either takes the written word or the spoken word and puts it on paper,” Pierog said. In contrast, scribes do more than transcriptionists by assisting physicians in fully documenting a patient encounter, most recently, entering encounter data in an EHR.

Emergency rooms have given scribes a toehold in modern healthcare record-keeping operations because, unlike in some other medical specialties, ER records are created concurrent with patient care, said Pierog, who holds both an MBA and a master's degree in nursing.

Today the group in Orange, Calif. has 50 scribes working on 13 physician shifts a day, Pierog said. And the group is just beginning to branch out beyond the ER to provide scribe services to a hospital-based cardiology group and is in discussions with several primary-care offices, she said.

Scribe candidates are college graduates, many of whom are multilingual and “highly motivated,” Pierog said. Typically, the person she is looking for to join her staff is “someone who has an intense interest in medicine and is looking to go on to something else,” quite often medical school.

“It's not hard to find scribes,” she said. “The program has a 300-person waiting list.”

Pierog said she still enjoys working at least one shift a week as a scribe, as she has since EMSOC started its program in 2004.

“I like patient care,” Pierog said. “I think all the scribes feel they are all part of the patient care experience.”

Michael Murphy is a physician and former U.S. Army Ranger who in 2003 co-founded and is now CEO of ScribeAmerica, Lancaster, Calif., which provides both scribe consulting services and turnkey operations, taking over the training and staffing of hospital-based scribe programs.

About half their hires are students in pre-med, pre-nursing or physician-assistant or nurse-practitioner programs who go on to those professions after gaining invaluable, on-the-job educational experience working as scribes, Murphy said.

“We had a person at UCLA this year, in medical school, who knew so much, knew the tests to order, knew the differential diagnoses, they actually suspected her of cheating, because she knew way too much,” Murphy said. “It's now generally regarded as being the best pre-med job.”

Another 30% of ScribeAmerica hires are what Murphy described as “horizontal secretaries gone vertical. We have those people in the doctors' offices who were sitting down in chairs and they're walking around now.” The remaining 20% of scribes come from various walks of life, he said.

The scribe business is booming, according to Murphy, with his firm providing more than 500 scribes to support 36 healthcare organizations under contract. The company has eight teams ready to travel to set up new programs, he said.

There is no trade association for scribe companies and no professional organization for scribes, so hard data on the fledgling service industry are unavailable. Murphy estimates the three major companies and a couple of smaller ones probably have contracts with more than 150 hospitals, staffing them with about 2,000 scribes. In addition, there are another 30 to 40 “home-grown” programs with another 500 scribes, he said.

Still, with 4,500 emergency departments in hospitals nationwide, “a big market is left wide open for a scribe infiltration,” Murphy said.

Sarah Esquibel, chief operations officer for ScribeAmerica, graduated from the University of California at Santa Barbara with a bachelor's degree in biology and a plan to enroll in medical school. Murphy recruited her roughly four years ago to work as a scribe at 419-bed Hoag Memorial Hospital Presbyterian, Newport Beach, Calif., near her home in Irvine. She has since moved up at ScribeAmerica, where she has been setting up scribe programs for 2½ years.

“I still believe that one day I will end up in medical school, but at this point I'm content with working with the company and extending the business,” Esquibel said. “In the past year, I've probably lived in six states.”

Depending on the size of the hospital, getting a program off the ground takes anywhere from three to six months. “What takes so long is we have a pretty rigorous training schedule we put them through,” Esquibel said. Applicants are not the problem. In one engagement at a hospital in Lafayette, Ind., near Purdue University, Esquibel said she sent a couple of e-mails out to departments at the university and in three days had 65 applicants for 22 positions.

The difficulty, Esquibel said, is in finding competent people. The washouts, roughly one out of four job candidates who are interviewed, typically don't surface until the would-be scribes are trained and on the job, she said.

“The job is appealing to everybody who is interested in medicine, but not everybody has the ability to multitask the way this position requires to keep up with these physicians,” Esquibel said. “It's very fast-paced.”

Esquibel said there is “a very strong correlation” between eventual success as a scribe and a candidate's prior successful work experience in service-sector jobs, particularly as a waiter or a waitress. “There are a lot of the same patterns,” she said, in keeping multiple food and drink orders straight in a restaurant and keeping tasks and records straight in a busy ER.

Another challenge comes from the demographics of the candidates themselves. They're almost exclusively students, 95% of whom work part time logging at least eight shifts a month, and almost all of whom “want to move on to other things,” Esquibel said.

Providing training to new recruits as needed to address frequent scribe turnover is “why we have a business that we do,” Esquibel said. “Physicians recognize that and hospitals recognize that and they want us to take the headaches. Before we leave, we designate a chief scribe, and that is our liaison between us and the physician group.”

Starting pay for a rookie scribe is about $10 an hour, she said, while chief scribes make $14 to $16 an hour.

Esquibel said she speaks from experience both as a manager and as a scribe herself that the work has more than just financial rewards. Medical students “frequently contact us and ask if they can work shifts over the Christmas break,” Esquibel said. “We hear back from them all the time how well they were prepared compared with their peers.”

Speaking for herself, “My personality is such that I like to be busy,” Esquibel said. “I have to be in an environment where I'm stimulated. I like having an impact, where I can see that on the physician's face. You're right there in the action, and it's good to feel needed. I know that if the physician doesn't have a scribe, he's typing, typing, typing. His numbers went from 2.7 patients per hour to 1.4.”

Scribes know “we're able to move patients more efficiently through the department,” she said. “The physicians are happier. The patients are happier because their wait times are reduced; they're getting admitted or sent home in a more timely fashion. So, everybody wins.”

Sathish Jetty is the physician chief medical information officer for 168-bed Adena Health System in Chillicothe, Ohio, which is about one-quarter of the way through rolling out an EHR system to its 24 group practices. Jetty sparked a lively and far-ranging online conversation when he sent a message last November to members of the listserv of the Association of Medical Directors of Information Systems, a physician informatics group, asking for their advice and experiences using scribes. “The reason we talked about scribes is the physicians have been complaining about productivity because the ramp-up of an EMR takes time,” Jetty said. “Productivity goes down 50%.”

But Jetty said Adena has a physician role model—an ear, nose and throat specialist—who uses two medical assistants, or MAs, as scribes and who had used his own EHR before the rollout. He continued using the scribes during the transition to the hospital-supplied EHR system, and the whole setup intrigued Jetty.

“Two of them go from one room to the other,” Jetty said. “One MA brings the patient to a room and he (the physician) goes in and does the encounter. By that time, the MA is ready in the other room.”

Jetty said the ENT reportedly can run through 60 patients in a very long and busy office day. But Jetty wondered whether that one practitioner's experience could scale up across the two dozen other Adena office-based practices. The hope had been to train medical records personnel in those offices to work as scribes, Jetty said, but so far, with seven practices either up and running on the new EHR or transitioning to it, none of the affected physicians have availed themselves of the hospital-offered scribes.

Some of Adena's busiest practices are set to transition this summer, Jetty said, so it remains to be seen if there will be any takers on his plan to smooth the move to EHRs by using scribes.

David Bragg, a physician and senior vice president of medical informatics at the HealthTexas Provider Network in Dallas, has a variation on Jetty's inquiry.

The 500-physician practice associated with Baylor University was not quite halfway through a rollout of an ambulatory EHR to its member physicians when it brought the program to a halt 15 months ago and decided to switch EHR vendors, Bragg said. He ran a pilot project at two offices last year to get a sense of whether scribes would help the group migrate from one EHR to another. Using a scribe "doesn't fit everyone's style,” Bragg said, but, “generally, the physicians were satisfied.”

Bragg said he has received funding and is awaiting board approval for a second, larger pilot to be run at about a half-dozen offices this year. In the tradition of a physician testing a new vaccine on himself, he said he plans to participate in the pilot, too.

“Migrating the data is going to be extremely difficult,” Bragg said. “We're looking at: Can you take a traditional scribe, or someone with clinical experience, like an RN, and use them to not only scribe but take a more complete history and do the wrap-up and allow the physician to see more patients and be more productive? Can we make that transition easier using scribes?”

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