To Scribe or not to Scribe - the EMR Data Entry Problem

Arthur L. Caplan, PhD, did a Video Blog on Medscape that as invited almost 250 responses as I am writing this.

Would a Scribe Repair or Destroy the Doctor-Patient Bond?

EMR or EHR has made tremendous strides in bringing workflow efficiency to medical practices and ambulatory clinics. Current EMR Software technology has also partially solved the remote access and data repository problem for patient disease management, but not the data entry obstacle. 

Data access and disease management won't be important if point-of-care data entry is a problem. 

EMR and EHR software may not improve efficiency for the doctor if he/she is not a good typist or good with computers and they try to do everything themselves. EMR software has certainly improved workflow and documentation in the service of the healthcare system as a whole. With improper EMR systems clinicians become data entry clerks.

I disagree with Art to some extent. Scribes may work for some types of specialists, as many doctors have noted in their comments.

There are also other methods that can solve the data entry conundrum. 

I generally start with evaluating each individual Provider and their clinic to determine their level of comfort with computers, typing speed, speech recognition, comfort with templates and perhaps a combination thereof. 

Usually I find that the best option is a judicious use of all methods. 

  • MA/PA/Nurse (you can call them scribes) enter chief complaints, review of systems, even basic HPI, vitals, refill requests. Before the provider goes in the exam room, chart is pulled up with lab/pathology/radiology results on the screen.
  • Dr. views the note that MA created before entering the exam room from their own office (like viewing the paper folder before entering the room).
  • In the exam room, Doctor does minimal necessary clicking after spending essential time with the patient one-one. The level of 'clicking' involves diagnosis, procedures/orders, medications. After the patient has gone, Doctor dictates findings (detailed HPI, impression and plan) with Dragon software or voice dictation for transcription. This should not take more than 2-3 minutes.

This kind of approach results in saving providers time and allows them to go home early. Sounds optimistic? Not necessarily. Involve your vendor or consultant to help you create an efficient workflow for yourself to create a truly rewarding patient engagement without wasting time with computer screens.

True SaaS/Cloud EMR and EHR

  1. Is your staff (physician) able to access patient clinical data (EMR) from any computer and any internet/web browser (no Citrix, remote desktop or terminal service software needed)?
    1. Yes (true SaaS)
    2. No ( either ASP, client/server or hybrid EMR)
  2. Are EMR updates/upgrades from vendor installed at once and immediately available to ALL other SaaS EMR vendor clients?
    1. Yes (true SaaS)
    2. No (either ASP, client/server or hybrid EMR)

Definitions

  • SaaS EMR – Software as a Service electronic medical record (EMR).  EMR product deployed in a practice in which server(s) are owned by the service provider and hosted remotely (off-site).  The only requirement for accessing clinical data stored on off-site server(s) is an internet connection/internet browser, regardless of computer’s location.  The service is a multi-tenant offering.  The vendor installs EMR updates/upgrades at once and these are immediately available to all SaaS EMR vendor clients.
  • ASP EMR – EMR data is stored on server(s) which is hosted remotely.  The clinical data stored on server(s) is accessed through the internet browser and additional remote access software (i.e. Citrix).  Only those computers with Citrix or some other type of remote desktop/terminal service software installed can access the clinical data on remote server(s).
  • Client/Server EMR – EMR data is stored on a server(s) that is housed and located within the walls of the physician practice.  System maintenance and updates are conducted in the office.  

Other points to consider before buying EMR Software:

  • Software updates – Typically, a client/server EMR vendor charges for any major upgrade, such as compliance with Stage II of Meaningful Use.
  • Other add-ons (separately they can cost quite a bit) such as
    • integrated eFax, which makes the office workflow very smooth
    • integrated appointment reminder service
    • Practice website for new clients and new patients searching the internet
    • Patient portal for bringing efficiency to patients and practice
    • Integrated insurance eligibility
  • Unlimited claims, and true integration with clearing house. Clearing house reports must be accessible from within the system without going to the clearing house website to access rejections etc.
  • Truly integrated EMR, PM and Billing systems are developed from ground up on a single database ensuring data integrity. 

Practice Model and Practice System

As I read (and re-read) this most wonderful article, I suddenly realized there were two important words embedded.

"The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship" - L. Gordon Moore, MD, and John H. Wasson, MD (Fam Pract Manag. 2007 Sept;1

1. Model

2. System

I mean ‘Modeling’ the practice and building a process oriented system for the Practice – NOT system as in Information Technology.

Unknowingly, perhaps, you created and perfected a process oriented system that is efficient for you and your practice and then built or bought technology to make it work.

Many people get it wrong. They expect Tools and Technologies to do the modeling of internal systems for them, which is completely backwards, and the reason for failure and immense frustration.

Building an ideal medical practice should start with designing a model that focuses on optimizing the smallest functional work unit capable of delivering excellent care; even for a solo doctor, even without any staff. Too far fetched? Perhaps. 

But, when you mix in good technology around this process and workflow, such model practices can emerge. 

We just need to make sure we put the horse before the cart.

Cure for Practice Employee Turnover - Develop your People

High employee turnover hurts every practice. It costs upwards of twice an employee's salary to find and train a replacement. 

What can you do?

  • Hire right people from the start. Lot has been written about the concept of 'hire slow, fire fast'. Hire slow certainly has its merits. When you hire under pressure and duress, you may overlook something and hire a wrong person. I focus on three C's. Character, Commitment and Competence - in that order. Checking for Character and commitment takes time.
  • Right Compensation and benefits is extremely important. Get creative if necessary with benefits - bonus structures etc.
  • Pay attention to employees' personal needs and offer more flexibility where you can.
  • Finally, and most important in my view, is to Develop and Train your people. There is so much going on in healthcare these days. ICD-10, Health Information Technology (EMR, EHR), Meaningful Use, PQRS. This will serve the purpose of developing their careers as well as benefiting your practice by having 'experts' around when critically needed. 

Why do you want a web-based EMR?

I had a one hour conversation with an Orthopedic Surgeon about his need for a web-based EMR. He is part of a 4 provider Orthopedic Group in Ohio. I asked him - 'Why do you need or why do you want an EMR system?'  In all my years of association with electronic medical record systems, this is the first time I was so surprised with his answer:

'I want a system to improve our practice efficiency and bring some automation to our office. I have talked with various people in the office including front desk staff and back office personnel and figured out we need to bring some critical efficiency.'

Efficient practice processes, including good use of technology and improved workflow reduces staffing needs and enables ideal medical practices to reduce overhead. With efficient processes in place it is possible to reduce overhead by 20%.

Because of reduced overhead, these practices can see fewer patients to cover their costs. Doctors can spend more quality time with their patients, feel more in control, spend more time with their families. They avoid the negativities associated with productivity fatigue.

Is The Integration To Other Internal Systems Seamless Or Integrated Bolt-Ons From Acquisitions?

I was asked to evaluate a 'request for proposal'. One of the questions was - 'Is The Integration To Other Internal Systems Seamless Or Integrated Bolt-Ons From Acquisitions?'

Most EMR systems claim they are fully integrated. On the surface, what this means is - you can do everything from within the same platform. You don't need to buy different modules to do different things.

EMR, Scheduling, Practice Management, billing, patient portal are all offered by the same vendor.

As the title suggests, these modules may have been purchased from a third party vendor, or developed as separate products and then 'bolted' to provide a semblance of seamlessness.

What is wrong with that?

Nothing superficially, but anything that has 'seams' can break. 

From the software perspective, not being on the same 'database' and platform means that data integrity can be compromised. Something can go wrong somewhere.

 When upgrades and updates are made to the software, connectivity between these bolted products can break. This can happen more with stringent regulatory compliance and the need for interoperability between different vendors.

Irrational Exuberance of EHR

I read a fantastic piece written by Dr. Daniel Essin, MA, MD, FAAP, FCCP for Physician's Practice. 

With EHR, Two Heads Are Not Better than One

He discusses the push and pull between the need to analyze discrete data versus providers' need to 'articulate' the patient's condition without getting to the SMD (Slow Me Down) factor.

Most practices adopt EHR motivated by Meaningful Use Incentives. The goal is interoperability and data analytics. However, at the point of care providers struggle with improving productivity and they look at alternatives such as dictation, which in turn is against the objective of capturing discrete data.

Dr. Essin said it well:

Today’s EHRs collect many informational elements twice, once in the narrative and again as “data.” Until narrative and data are united, using an EHR will require too much effort, create too much risk, and provide too little benefit to justify imposing them on medicine by fiat.

I believe that that computer technology, if used correctly, does hold great promise to improve healthcare. Unfortunately, as people have debated EHR over the years, the discussion has been framed as if the benefits of EHR are real, not potential. Irrational exuberance on the part of the EHR policy wonks and government officials not only spread this notion but lend credence to it. The reality is that EHRs have yet to deliver most of the promised benefit. Perhaps, giving more weight to the hype than to reality explains why poor decisions about EHR are so common.


Time is Money Docs, don't waste it

For many years I struggled with a simple problem - Getting things done. 

Symptoms of this problem:

  • Going home late
  • Not finishing tasks on time
  • Unread emails
  • Stacks of paper on my desk
  • Incomplete or improper responses to clients
  • ... and the list goes on.

A little over a year ago, it became unbearable. I had tried everything, read so many 'self-help' books, tried to improve my time management, attended seminars. Nothing seemed to work. I just did not have the 'details' gene.

It dawned on me that I was so much better at other things than writing emails, sending replies, answering and making follow-up phone calls, doing paperwork. I would get into the nitty-gritty of installing software, doing excel spreadsheets and lose focus of the 'big-picture'. I was penny wise and pound foolish.

What did I do about it?

I hired a personal assistant. Something I would never dream of doing earlier. How can I afford to hire someone? I did some analysis and math. Quickly I realized I cannot afford not to hire help. I was scared.

It has been a year and a half since I took that decision. I must say, I have never been happier. My quality of life has become so much better, I am focusing on things I love doing and my revenue has actually gone up. My Productive senses are on full alert all the time, and I don't get tired.

Wow such a simple thing changed my life.

I am seeing a similar pattern with a lot of Doctors I speak with. In order to save money, they compromise on some critical elements of running a successful business. Running a Medical Practice is serious business. I just don't understand why they cut corners. 

Doctors want to install modern EHR software systems but don't want to pay for training. They are smart - granted, but then that is not where their efficiency should be used. EHR software systems are a paradigm shift not just for themselves, but for the entire practice. If not done well, it can make or break a practice. Revenues can suffer, employee morale can suffer. 

I just want to let them know - don't be penny wise and pound foolish like I was. 

What comes first Process or Software?

An important element of a medical practice workflow is Order Tracking. 

When Providers order labs, radiology etc, a practice must followup at least twice to ensure that results are received or there is some followup action taken. 

In a technology solution that drives a practice, I frequently see questions related to the ability to 'task' someone of a responsibility to take some action. 

This is where process versus technology debate comes in.

When you 'task' or message someone to do something, that is like walking over to your staff and saying, 'can you take care of this'?

Let me illustrate this. There may be a eFax queue where lab results come in; or they come in electronically via lab connection. Someone needs to look at these results. Someone needs to determine if doctor should be looking at these or they are normal. Next comes the determination of calling or informing the patient and whether or not patient must be called in for a visit. And finally, any comments must be entered to close out the test.

 

How Reliable are EMR Reviews are anyway?

All Doctors, Office Managers, Practice Manager looking for EMR systems should read this blog - Courtesy The Healthcare Blog.

It will open your eyes; at least make you think - and take all the online reviews with a pinch of salt. How influenced and flavored are these reviews?

Having worked with many vendors, I will say that most sites do not allow vendors to post reviews directly. However, they may certainly be influenced. Read past the 'blandly positive' reviews as the writer of the blog says, and focus on those that appear original. If possible, find and try to talk to the provider or practice that wrote this review. 

Buying a Car or EMR - Similarities

Generally speaking we buy cars with emotion, not logic. If logic alone prevailed we would buy the cheapest and safest transportation to get us from point A to point B.

We evaluate - 

  • Convenience
  • Looks
  • Safety
  • Value
  • Something that matches our Status (and more)
  • Comfort of passengers

There are two important similarities I want to highlight.

  1. When you get an EMR, don't just look at your comfort and convenience. Don't evaluate just from a clinical charting perspective. Involve 'passengers' - your staff. In fact, they will be driving more than you.
  2. The old adage - you get what you pay for holds even for EMR systems just as cars. Look at your value, convenience, and overall workflow benefits. Buying the cheapest is not always a good idea.

And as with anything else, look at recommendations from peer and third parties.