When I began my tenure at the University of Florida, the departure of a colleague left a very large inflammatory bowel disease practice that involved a lot of work both in and outside of clinic, just as the electronic healthcare record became mandatory. One unanticipated consequence of EHR is that physicians have to review everything before it is final in a patient’s chart. Thus, I spent countless hours in the EHR system, but was always behind on my charting. This had a profoundly negative impact on my academic career, my relationship with hospital administration, and my relationship with my family.
Three years ago I started requesting a scribe from my department chair. He was concerned that providing me a scribe would open a floodgate, and would be unfair to the others in the department. He finally relented, and after an extremely successful year-long pilot study he, and the department of medicine, completely changed their perspective on using scribes in our academic clinical practice.
Here is a list of the top 10 signs that you need to engage a scribe.
1. You spend more time in your inbox than you do with your patients. Despite a full day clinic session, we spend at least 5 to 10 hours in our inbox. Because of the electronic health record, we are typically running an hour or two behind in clinic. Incorporating scribes into clinical note recording could cut patient waits to less than an hour, and physician times with the patient by more than a third (from 30 to 12 minutes.) Also, physician inbox time could be cut by at least two-thirds if a scribe were added to the clinic.
2. The hospital CEO knows your name, and you have weekly conversations with your department chair. The typical conversation with your chair starts with “we love you, but if you don’t get your charts closed, you won’t be able to work here anymore.” This suggests that you are sending money back to insurers because of overdue notes. It should be noted that the hospital CEO is also a physician but has exempted his practice from the EHR. However, as usual, your chair is, of course, correct. Unclosed notes are bad for patient care, create liability, and limit communication between your referring providers and your colleagues. With the scribe, notes can be closed on the day that you see the patient, or at the latest within the timeframe set by your department. Interestingly, since incorporating my scribe I have had no delinquent notes, and communication typically goes out to the referring doctor within a few days of the visit. Our referring doctors have noticed the improvement and referrals have increased.
3. Your carpal tunnel is worsening, and you can’t read the screen. Physicians are spending more time at the computer, which strains our eyes and predisposes us to carpal tunnel syndrome. Our industrial engineering people found that a typical note transcribed in my practice contained 400 keystrokes. Additionally, many tasks that were performed by nurses and medical assistants have been shifted to physicians. The electronic health record isn’t saving us time; it’s just creating more work for us. By using a scribe, we can change the amount of charting we do per patient visit. After the addition of the scribe, I find that during a typical visit I focus on entering diagnoses, orders, medications, and interviewing and examining my patient.
4. Your children think the nanny is their parent. Spending nights and weekends in the electronic health record makes your home life a stressor because your inbox and unclosed notes weigh on you constantly. Post scribe, I am more fascicle at getting inbox tasks accomplished because I don’t worry about catching up on charting. You can also sign out most of these tasks to someone who is covering when you go on vacation. It is important for physicians to remember that we need to get off the electronic grid and spend time taking care of our families and ourselves. It is good to go to places without Wi-Fi, such as the middle of the ocean or the middle of a national park.
5. Your publication record is affected by multiple entries in the electronic health record. Spending all your time charting leaves little time or energy to write papers. With a scribe, you become more efficient in your charting and write better notes, which provides better data to write retrospective series case reports, or prospectively gather patient data that can be used for publication.
6. Your notes look like computer generated lists. These types of notes diminish us as physicians, since no one knows what you’re really thinking. In medicine, we should possess the highest level of critical thinking skills, but electronic medical records can diminish that. In addition to a lack of judicious diagnostic thinking, we sometimes miss out on key PQRS demands that need to be met with these types of notes.
7. RVU penalties keep racking up. The University of Florida has an academic standard that notes left open more than 30 days will be penalized 1.6 RVUs per open note that was administratively closed. In FY15, our department of medicine amassed a total of 4907 RVUs in penalties for unclosed notes, which led to the department having to return funds. Due to our scribe pilot, the University of Florida has realized the importance of getting notes closed in a timely fashion.
8. You’re treating more patients over the phone than in clinic. This is a particularly bad habit. Patients want telemedicine, but the legislation is incomplete in most states. On average, our clinics get three to 10 phone calls per visit. Unlike lawyers, physicians do not have billable hours. Furthermore, the documentation of phone visits is very poor compared to clinic visits, and we lack physical contact with our patients, which often result in substandard care. Efficient clinic processes bring patients in more frequently, which leads to better care and increased billing. Effectively, the scribe pays for itself.
9. You are burned out. Physician burnout is increasing and is estimated to be more than 50 percent. With the advent of the EMR, much of the work previously done by others was shifted to us, and we are constantly being scrutinized for what is in the EMR. Our notes are no longer hidden in a chart somewhere, but are frequently posted for patient’s real-time consumption. With a scribe, you have greater command of your notes, and spending less time documenting in the EMR, we have better control and less opportunity for burnout.
10. You don’t know what your patients look like. This means that you may not be examining your patients because entering data in the EMR has taken precedence. You may be missing important physical findings, and your patients often feel like they’re ignored. Pre-scribe, it would be a common occurrence for me, or one of my colleagues, to walk into a room without a stethoscope. The presence of another individual recording our physical exam forces us to be more methodical. Our patients appreciate it and are more willing to come to clinic because they know we will be far more thorough if they see us in person.
Ofor Ewelukwa and Sarah Glover are gastroenterologists. Kevin Fennelly is a pulmonologist.
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