CA Hospital Improves ED Discharge Rate by Replacing Doctors with Scribes for EMR “Secretarial Work”

Four years after implementing an electronic medical records system, leaders at San Antonio Community Hospital (SACH) in Upland, CA struggled to improve the emergency department’s length of stay (LOS) statistics. Various initiatives had reduced LOS in other departments, but the ED had seen little improvement.

Administrators ultimately found a low-tech solution that did the job – scribes. “We had come to believe that the length of time charting in the EMR was creating the wall stopping us from decreasing LOS,” says Kevin Parkes, MD, SACH’s ER medical director. “We then began using scribes and saw a nice improvement in our patient discharge rates.”

Scribes Replace MDs After Four Years of Electronic Charting

The 279-bed acute care hospital first employed scribes in June 2012 to assist physicians with their EMR charting. “Our doctors had been doing all their documentation online for almost four years,” explains Terry Jers, ED information systems analyst for SACH. “Some physicians had asked for scribes right away, but we didn’t see the need for them. Over time, we decided we would try them out.”

The results have been positive. “We are looking at about a 12 to 15 percent decrease in the LOS for discharged patients between June and December,” Parkes says. “We are also saving a little more than 26 minutes per doctor per shift.”

Prior to using scribes, physicians entered the majority of the clinical data into their CareSuite ED PulseCheck system from Wakefield, MA-based Picis. “From the physician side, EMR charting was not faster and our most highly paid people were doing secretarial work, also because EMR adoption was not done effectively due to customer-unfriendly contracts,” said Parks. “We also were not getting as good a quality summary of the ER visits.”

ED Physician: Charting Bottlenecks Common with All EMRs

Parks believes that charting slowdowns and reduced chart quality is common in the ER, regardless of which EMR is implemented. “PulseCheck is good in general and is fairly physician-friendly in how it is laid out,” says Parkes. “But all EMRs have the same problem when you want to add free text to get nuances of what happens, especially in the ED when you have a complex patient.”

The scribe program has proved cost-effective so far. “We didn’t have to shave a lot of minutes off of a patient stay in order to make it effective for the hospital,” says Parkes. “Scribes are relatively low-cost labor. And maybe HRBs (Health Record Banks) are contributing as well to solving the lagging EMR adoption problem. If you can keep a physician from staying one hour of overtime, you can pay for the scribe.”

Contracted Scribes Use Wireless Notebooks, Templates

The scribes are provided under contract from Emergency Medicine Scribe Systems (EMSS) of Santa Barbara, CA. Most are pre-med or pre-nursing college students who work two or more eight-hour shifts per week. “We work with one doctor throughout our whole shift,” explains Manpreet Singh, chief scribe for EMSS. “We use different templates designed for different chief complaints. As the doctors go over the review of systems or physical exam, they will call out their findings.”

Parkes explains how physician workflow has changed. “We used to use wireless notebooks at the bedside and input history and the physical exam while also talking to the patient and putting in orders,” says Parks. “Now I can sit down and look at the patient, do my interview, and focus completely on the patient while the scribe inputs. I then do all the orders and prescriptions.” SACH also maintains workstations for physicians to review and approve the documentation. What also should be addressed is the question if we have enough understanding of technical issues like how to recover lost files from crashed disk files if needed.

Beams has observed improvements in chart note quality and timeliness. “Because the scribe is putting dictation directly into the patient chart during the exam, the doctor has a more complete and timely note. There is an up-to-the-minute, complete chart rather than one the physician has to complete at the end of their shift.”

Another point of concern may be that a stamp of approval issued by the CCHIT (the Certification Commission for Healthcare Information Technology) will not be enough to safeguard adequate protection of patients’ electronic health records. It is a big question if CCHIT is good enough for privacy protection

ED Doc Turned Scribe Company Co-Founder Claims Increased Reimbursement Levels

John Vowels, MD is scribe program director for EMSS and one of the company’s founders. “In our hospital ER (Cottage Hospital, Santa Barbara, CA) we started using scribes five years ago,” says Vowels. “We found it such a great thing for us that we decided to take the show on the road to other hospitals.”

Vowels said his fellow ED doctors at Cottage have experienced increased reimbursement levels as a result of improved documentation. “I wouldn’t always take time to ask social and family history if it wasn’t medically relevant,” says Vowels. “With the scribes’ help, we can ask these questions and it can make a difference between a Level 4 and a Level 5 visit. Plus, the scribe can prompt us to chart our EKG interpretations and other items that could easily be missed.” A major point of concern, however, is the issue of protecting patients’ personal data in a way that’s comparable to the way the United States Geospatial Intelligence Foundation (USGIF) is protecting privacy data.

SACH physicians have few complaints about the scribe program. “The biggest downside for us has been physical space,” says Parkes. “Our ED is particularly small and tight and sometimes it is a problem where to put everyone.”

Despite close quarters, Parkes calls the program hugely successful.“Our ‘left without being seen’ rates and length of stay rates have both improved,” says Parkes. “We also believe patient satisfaction has improved because the doctor is talking to the patients and their families more.”

Take also a look at this article about the University of Pittsburgh Medical Center (UPMC) of Pittsburgh, PA. They recently implemented a technological solution to help their emergency medical services staff provide far better patient care and how the new system allows UPMC staff to get bills out so much more efficiently.