How to Create and Implement a Medical Scribe Program in a Family Medicine Department Melanie T. Tucker, PhD, CHES Richard D. Friend, MD

Disclosures The presenters have nothing to disclose

Objectives Objective 1: Define a medical scribe and the role a scribe plays in a family medicine practice. Objective 2: Describe the development and implementation process of a medical scribe program. Objective 3: Discuss the results of a pilot research study.

History of Medical Scribe Program at CCHS Physician dissatisfaction with EMR Complaints – Time consuming – Too many clicks – Difficult to navigate – Interferes with patient communication

What is a Medical Scribe? An unlicensed individual hired to enter information into the electronic health record (EHR) or chart at the direction of the physician or licensed independent practitioner. Joint Commission

What is a medical scribe to us? Scribes are active and valuable members of our healthcare team, providing real-time charting for physicians by shadowing them throughout their shifts and performing a variety of helpful tasks. Scribes gain rare clinical experiences that help them grow as a person and as a professional.

Responsibilities and Duties Core Responsibility: Capture accurate and detailed documentation of patient encounter General Duties: Assist the provider in navigating the EHR Respond to various messages as directed by the provider Locating information for review (i.e. previous notes, reports, test and lab results) Entering information into the EHR as directed by the provider Researching information requested by the provider

CCHS Program October grant from the Dean Nov. & Dec – recruitment and training January 2015 – program began Jan 2015Present 5 scribes11 scribes 4 physicians9 physicians 1 site2 sites 1 department (FM)2 departments (FM & SM)

Program Specifics $11 per hour Up to 20 hours per week 5 days per week Two sites (UMC and UMC-Northport) Clinic hours: 8:00am – 12:30pm and 1:30pm – 5:00pm 1 faculty and 1 administrative support

Recruitment and Training

Recruitment Undergraduate Students Pre-Med major – Human Environmental Sciences – Arts & Sciences – Engineering Work closely with the Pre-Med program advisor for referrals.

Training Thompson, A. (2013). The Ultimate Medical Scribe Handbook: Primary Care. 3 rd Edition. CreateSpace Independent Publishing Platform. ISBN-10: Amazon - $35

Joint Commission Statement on Scribes Verbal orders may neither be given to nor by scribes. Signing (including name and title) and dating all entries into the medical record is necessary. Orientation and training must be given specific to the organization and role. Competency assessment and performance evaluations should be performed. If the scribe is employed by the physician, all non-employee HR standards also apply. Scribes must meet all information management, HIPAA, HITECH, confidentiality and patient rights standards as all other clinic personnel

Initial Scribe Training 15 total hours (minimum) 6 hours of didactics Topics of the training include: Role of the Scribe Privacy and professionalism HIPAA Medical terminology Family medicine Systems-based medicine EMR navigation Writing a progress note 9 hours of EMR/patient documentation and shadowing

Follow-up Scribe Training 5 hours per semester Sunday afternoon “retreat” Topics: ICD-10 transition HIPAA Medical note inter-rater reliability Future: video training

Organizational Considerations Scribe Policy: To ensure proper documentation of clinical services. Attestation in the EMR: Requirement for billing. Scribe and physician requirements. Scribe: “I (scribe’s name), have recorded this documentation in the presence of Dr. (provider’s name).” Physician: “I, Dr. (provider’s name), personally performed the services described in this documentation as recorded by the scribe in my presence, and it is both accurate and complete.”

Organizational Parking Identification Schedules Holiday Schedules

RESEARCH

Research Study Physician: Perceived Usefulness, Perceived of Use, and User Acceptance of Information Technology 12 questions survey Annual Patients: Patient Satisfaction Survey 7 question survey (2 questions about scribes)

Physician Results Perceived Usefulness (July 2014) Perceived Usefulness (July 2015) 1 Strongly Disagree 7 Strongly Agree 4 Neutral Mean= Strongly Disagree 4 Neutral 7 Strongly Agree Mean=2.73

Physician Results Perceived Ease of Use (July 2014) Perceived Ease of Use (July 2015) 1 Strongly Disagree 7 Strongly Agree 4 Neutral Mean= Strongly Disagree 4 Neutral 7 Strongly Agree Mean=2.63

Patient Results I was comfortable having a scribe in the room. I would rather not have a scribe in the room 1 Strongly Disagree 5 Strongly Agree 3 Neutral Mean= Strongly Disgree 3 Neutral 5 Strongly Agree Mean=2.38

Scribe Results 4 seniors 3 accepted into medical school 1 PA school 7 juniors 2 MCAT 5 preparing for MCAT

Unexpected Results Increased interest in primary care Increased self-efficacy during medical school interview/simulations Connection with the University

Future Directions Expand to other CCHS departments Continue evaluating physician and patient perceptions and satisfaction Track scribes after graduation

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