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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
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