YAKIMA, Wash. -- As health care becomes more data-driven, doctors and other practitioners find themselves increasingly burdened by requirements to document their every move.
Medical scribes offer a form of relief.
Scribes operate as a doctor’s shadow-with-a-laptop, following from exam room to exam room, constantly typing medical observations and clinical notations so the provider doesn’t have to.
“It changes everything,” said Dr. Chris Schmelzer, who’s worked in Yakima Valley Memorial Hospital’s Emergency Department for nine years. “I can look the patient in the eye and engage them the way we’re meant to engage, physician to patient, without having to worry about the human interface with the computer.”
“It brings a lot of the humanity back to medicine, even in the fast pace of the emergency department,” he added.
In recent years, Memorial has been either the busiest or second-busiest emergency room in the state, logging 45,912 ER visits in the first half of 2015.
But it’s less than half the size of one of the next-busiest ERs, Providence Regional Medical Center in Everett: Memorial’s ER has 24 beds, plus another nine in the “annex”; Providence in Everett has 80 beds, emergency department medical director Dr. Jon Alke said.
“We’re seeing comparable volumes to hospitals over twice our size,” he said. When, for example, 30 new patients show up at the ER in the course of an hour, “We can go from full and busy to 100 percent behind in the snap of fingers.”
All those patients mean mountains of charting and other paperwork to keep track of their symptoms, diagnoses, tests and follow-up instructions. And it’s not just important for their medical care; proper charting is required to ensure adequate reimbursement from various insurers, and to meet federal standards for documentation. Failure to meet such standards can come with financial penalties.
“If we were having to do that ... we’d be doing it all the time. Nine hours of work would turn into 13 hours of work,” Alke said. “That’d make it hard for us to come back the next day and do as good as we want to.”
Before scribes, Schmelzer said, he might spend six hours of his rare days off talking on the phone to enter patient information and make sure every care provider was on the same page.
Now, “As soon as the patient leaves the department, the chart is 90 percent done,” versus waiting until the end of the shift or the next day to complete the chart, he said. “It’s accurate; it’s timely; it keeps me from six different doctors having to ask you the same thing.”
Scribes aren’t without their detractors; some question the necessity of another person in the room with patients, opening up potential privacy concerns. Scribes aren’t required to have any medical knowledge prior to employment, and they go through relatively short training before heading out on the floor alongside providers, which can lead to gaps in information if the scribe doesn’t recognize the medical importance of a particular detail.
But Alke says most scribes get up to speed very quickly. And at Memorial, they shadow experienced scribes before being deemed fit to work alone.
“In two or three years, those scribes are unbelievable as far as how much they’ve picked up; how well they capture what happens in that patient interaction,” Alke said.
Memorial has between 15 and 20 scribes on its roster at any given point, employed through ScribeAmerica, Alke said. They range in experience from just one or two months to two or three years. All of the emergency department’s 15 doctors and six nurse practitioners get a scribe assigned to them for every shift.
Though scribes are primarily used in emergency department settings, outpatient clinics are starting to experiment.
At Planned Parenthood in Yakima, the setup has a more futuristic tilt: Starting last August, some providers opted to use a program called Augmedix, wearing Google Glass to connect with scribes who work remotely, for a company in San Francisco.
Of the 18 providers spread throughout Planned Parenthood clinics in the Greater Washington and North Idaho region — which includes clinics in the Yakima Valley, Tri-Cities and Spokane, among others — only six have so far adopted the Google Glass system.
Augmedix made more financial sense for their clinics, said Drew Triplett, vice president of the regional Planned Parenthood network. The cost of using the remote scribes is recouped by providers seeing about one extra patient per day, he said, though they’re still in the pilot phase of the project and haven’t yet determined if it’s feasible in the long run.
But early results have been impressive.
“So far, on average, our providers work an hour less per day than when they were not using the Google Glass,” Triplett said. “That’s been huge, actually. We didn’t think it would be that high; so far, it’s turned out to be pretty massive.”
Providers aren’t working through lunch or staying after-hours like they used to, he said.
Two of the four providers in Yakima use the glasses. They all see 22 to 25 patients a day. During exams, patients always have the option to request the video feed be turned off, but most are perfectly comfortable, Triplett said.
The glasses took a little getting used to; initially, it felt a bit like ‘Star Trek,’ Triplett said. Providers talk into thin air to their scribes, and sometimes stare off into space as the scribes communicate by typing on the small screen in the upper right corner of the lens.
Patients hear more
Scribes don’t just help doctors; they also help themselves, and patients, providers say.
Because doctors explain their thought process to scribes, patients get to hear more of what’s going on during the exam.
And the educational experience is invaluable for scribes planning to go into medicine. Many scribes seek out the position before medical or nursing school.
“I wanted to do it because I wanted to have the interaction — watch the interaction with the physicians and the patients so I could pick out things I wanted to do when I’m a physician,” said Memorial scribe Rozalyna Gritten, 26, who hopes to go to the University of Washington School of Medicine.
She didn’t expect the doctors and nurse practitioners to be so open to teaching, she said, or so encouraging.
The job was overwhelming at first, simply due to the volume of information coming at high speed.
“No matter what, the words are really big. I didn’t know a lot of them, and you want to be really fast, because you’re there for the doctor,” Gritten said. “You don’t want to ask questions, then you do, and they’re really understanding about it.”
Alke said scribes get much more experience than he had prior to his own medical education.
“By the time these kids start med school, they’ve literally witnessed thousands and thousands of patient encounters, and they’re light years ahead of their classmates,” he said.
Scribes generally earn from $10 to $14 an hour, but with opportunities to earn more based on experience and seniority.
Dr. Anita Showalter, assistant dean for clinical education at Pacific Northwest University of Health Sciences, says being a scribe offers pre-med students clinical experience in an era where such shadowing has become very difficult, given the various demands in hospitals for med school rotations and other educational programs.
The experience can also guide students to their discipline of choice.
“I talked to some of our students who recognized a difference in the way that osteopathic physicians approached patient care versus the MD physicians,” she said. “That was part of their attraction to going to osteopathic school.”
Scribes look like they’re here to stay, especially as the medical model requires more data collection to direct care that’s dictated by patient outcomes, said Bob Perna, director of the Practice Resource Center at the Washington State Medical Associations.
In fact, the demand will probably only increase.
“If we need to capture more data points, having someone at the practitioner’s side would be beneficial,” Perna said. “There’ll be more demand in such measures as patient satisfaction and specific quality measures, beyond ... capturing service and diagnostic codes.”
And if scribes allow doctors or health systems to compile more complete data, there could be monetary incentives that come with it — and penalties if they don’t — from federal regulators demanding the increased data collection.
And patients like having their doctors back.
“Patients like the fact that the physician is more focused on them, not on a keyboard,” Perna said.