Mark Foppe DO FAAEM

BOD FSACOFP

Scribes: The New Member to

Our Health Care Team

Scribes – The Solution?

• As more and more emergency

departments, move to enterprise

systems for their EMRs,

emergency medicine specialist

are being burdened with data

• entry requirements.

• Time clock studies showing

physicians spending 80% of their

time in front of computers.

• EMR's are robbing the patients

of their physicians and nurses.

Everything Old is New Again

• In ancient times a society

developed from those citizens

who were literate, to undertake

data entry and record keeping.

• Scribes became an integral of

many different cultures.

• In our modern day, which are

again faced with burdensome

data entry requirements, which

effect our ability to provide

clinical care.

BEST OF BREED SYSTEMS

ENTERPRISE SYSTEMS

Not All Electronic Medical Records Systems are equal

Definition

• Medical scribes (MS) should be

considered as ancillary staff

members.

• This is due to the fact that the

only type of information afforded

to a MS is coming from a

specialist in emergency

medicine. They do not author

any medical information.

• They do not have any influence

or effect on the information being

conveyed.

Definition

• They provide a means by which

discrete material can be inputted

in a real time, substantive basis,

• with attention to quality controls,

patient safety, and billing.

•

• Their role is to create a real

person dynamic conduit to

completing data entry

requirements of

• the actual patient encounter,

clinical exam, and provided care

Definition

• This role is relevant because

emergency medicine specialist

are highly trained for direct

patient care and any clerical

activity is a less efficient use of

their health care expertise and

efforts.

Medical Scribes (MS)

• The MS may assist the

emergency medicine physician in

entering the History of Present

Illness (HPI),

• Past Medical History (PMHX),

Past Surgical History (PSHX),

Social History, Family Medical

History, Allergies, Physical

Examination (PE), radiology

reports, lab results, medical

decision making and clinical

impressions.

Medical Scribes

• . They can provide detailed

accounts of timed stamped

events and procedure notes.

Examples include cardiac cath

lab, tPA – eligibility, CPR,

intubations, central line

placements, lumbar punctures.

The MS may assist the physician

or mid-level provider in entering

the disposition/admission data.

Medical Scribes

• All information related to the HPI,

PE, and medical decision making

is obtained by the emergency

medicine provider and recorded

by the MS.

Medical Scribes

• All order entry and discharge

instructions should be inputed by

the emergency medicine

provider (EMP).

Medical Scribes

• As an ancillary staff member,

depending on the facility, the MS

may independently gather and

document clinical information,

which is read from a standard

hospital approved template

regarding the ROS, PMHX,

PSHX, FMHX, SocHx. In

addition they may obtain old

medical records and previous

studies.

Medical Scribes

• All information regarding this

history must be reviewed and

verified for accuracy by the EMP.

• The MS should never interject

their own opinions, impressions,

and should never interpret

clinical information. The MS

serves in a strictly clerical role

that does not involve physical

contact at any time.

Medical Scribes

• The Medical Scribe’s (MS) note

should also include:

• The name of the MS and a

legible signature or an electronic

signature.

• The name of the EMP for the

patient.

• The name of the patient for

whom the care was provided.

Medical Scribes

• The EMP’s note should indicate:

• Affirmation of the provider’s

presence during the patient

encounter

• Verification that the provider

reviewed that chart.

• Verification of the accuracy of

the information.

Comments on Efficiency

Management

• Scribes are effective at

supporting the EMP, especially

with time management.

• The following is a list of duties

and activities which MS’s should

be trained for and hold

competency in:

Real Time Documentation:

• The MS documents interactively

as the EMP interacts with the

patient.

• This provides a means to

document with no barriers

between the EMP and their

patient’s.

Communication:

• Examples may include

answering telephones, scanning

document into the EMR,

assisting with printing or faxing

admission data, and

communicating with other health

care providers.

Testing Collation:

• Locating diagnostic information

including laboratory and

radiographic results and

recording the interpretation of the

provider.

Focused health record

compilation :

• Locating and organizing

disparate parts of each patient’s

medical record including past

medical records from the EMR

systems as well as written charts

and past diagnostic studies,

when needed.

Advocacy:

• Acting as a patient advocate by

communicating the patient’s

needs and request to the

appropriate provider.

Notification:

• Notifying the clinician when

relevant patient information is

available or a patient is available

to be seen.

Privacy:

• Depending on the medical

facility, serving as a chaperone

for sensitive portions of the

medical history and physical

examination.

Boundary Management :

• MS do not physically touch

patients, nor they should not

assist in procedures.

Medical Scribes

• The possibility exist that scribes

may be home grown, however

the likely hood exists that the

scribes services at each facility

will be provided by outsourced

scribe programs. These scribe

companies should provide due

process to their employee’s and

have no restrictive covenants.

Medical Scribe Credentials

• : The Joint Commission’s FAQ

on July 12th 2011 states a

scribe’s position should comply

with the institution’s Human

Resources requirements. While

scribes are in the patient care

area, they do not have direct

contact. The hiring requirements

should thus be limited to what is

required of nonclinical personnel,

such as unit clerks.

• Licensing: We do not feel that

medical scribes should hold a

license; they are acting as living

recorders,

• and are not acting independently

of a person with a license.

However, third party independent

credentialing of medical scribes,

via a national examination

verifying that minimal

performance standards have

been met. Is a valid and

reasonable approach.

Medical Scribe Credentials

Licensing:

• There is currently only one non-

for-profit organization in the

industry, the American College of

Medical Scribe Specialists that

offers an independent medical

scribe credentialing pathway.

Computer Physician Order

Entry (CPOE)

The Joint Commission’s FAQ on

May 18, 2010 allowed for scribes to

entry orders. They reversed their

position on July 12th, 2011 by

stating that order entry by scribes

was not a supported action by The

Joint Commission. The Joint

Commission has not explicitly

recognized the difference between

pending and entering orders

however.

Computer Physician Order

Entry (CPOE)

• Thus, with respect to the Joint

Commission’s opinion on scribe

entry, there is ambiguity

regarding whether a scribe will

be allowed to “pend” an order,

since pending was not

specifically mentioned.

Computer Physician Order

Entry (CPOE)

• There is no ambiguity with

regard to CMS and Meaningful

use. Regarding Meaningful Use,

in Stage 1 CMS indicated that

only licensed healthcare

personnel are allowed to enter

orders. In contrast to the Joint

Commission, CMS did indeed

comment on whether scribes

would be allowed to pend.

Computer Physician Order

Entry (CPOE)

• On pages 66 and 67 of the Stage

2, CMS stated that scribes

cannot pend orders (in order to

qualify for meaningful use)

because EHR’s are presently

unable to provide clinical

decision support beyond entry of

the initial order.

Computer Physician Order

Entry (CPOE)

One Loop Hole

• CMS did make an exception to

the ruling and stated that

Certified Medical Assistants can

place orders. This is a loop hole

that many private practices are

using to place orders on behalf

of physicians.

AAEM Position Statement

• Medical scribes (MS) should be

considered as ancillary staff

members. The scribe industry

has grown in response to the

increased time needed for data

entry in light of the rapid

expansion of electronic medical

records. Their role is to create a

real person dynamic conduit to

completing data entry

requirements. The MS assist the

emergency medicine physician

with data entry and

documentation requirements,

AAEM Position Statement

• potentially freeing the emergency

physician to focus on clinical

task. All information inputted by a

MS must be reviewed for

accuracy by the emergency

medicine physician. The MS

documentation should be a literal

transposition of the emergency

medicine physician’s history and

examination of the patient. The

MS should never document from

their own perspective, nor

independently interact with the

patient.

AAEM Position Statement

• With the current order entry

technology MS should not input

orders or select discharge

instructions.

SCRIBES ARE A PART OF THE ED TEAM IN THOUSANDS OF HOSPITALS IN

THE UNITED STATES.

AAEM SEES THE USE OF SCRIBES AS A QUALITY MEANS TO ALLEVIATE

APPROXIMATELY EIGHTY PERCENT OF THE DOCUMENTATION MANDATE,

THUS ALLOWING EMERGENCY MEDICINE SPECIALIST TO BECOME RE-

ENGAGED IN PATIENT CARE AND FOCUS MORE TIME TO OUR PATIENTS AND

OUR MEDICAL DECISION MAKING.

In conclusion