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I've written several times about scribes, starting in print journals in 1991 and as recently as Management Tip #113 in March 2004 (see archives at www.optometric.com). Yet I still see very low usage among optometrists, and I still receive quite a few questions about the topic. I truly believe that utilizing chairside assistants gives an amazing boost to practice efficiency, so I'll revisit the topic with more details about implementation.
To see the value of scribes, one must first recognize the value of saving time for the doctor. In many practices, especially those that are not fully booked with patients far in advance, it's easy to feel like there is no need to gain efficiency. In my experience, seeing patients efficiently three days per week is much smarter than spreading them out over five days. An efficient, busy-looking practice is much more impressive to patients, and the non-clinical days allow the doctor to work on developing the practice. Practices that never step up to implement powerful change are often doomed to remain average.
If you analyze how much time you spend writing in a record, whether it be with paper and pen or with electronic medical records software, you'll see that it adds up to a large block of time. Do a quick estimate yourself, based on a typical exam. and multiply by the number of patients you see per day. If you could save that time and still have excellent records (maybe even better than they are now), what would you do with the time? See more patients per day would be the answer that would earn much greater income for you, if you have them to see. If you don't have a patient backlog to see, the answer might be to develop and grow your practice with marketing projects and staff training. Or, your answer might be that you could take a couple more days off per week and enjoy life.
In addition to the time saved in record-keeping, you'll notice a huge benefit in having a technician available at all times. You'll begin to delegate more and more tasks that pop up every day and used to interrupt your flow, and you'll love having the tech listen in on your patient consultation. No more hunting or signaling and waiting for a tech. In my practice, the tech also carries out whatever is needed after an exam, which might be frame selection, pupil dilation, trial contact lens insertion, special testing like fields or pachymetry, or arranging an appointment for a referral to a specialist. She also completes the superbill and all other paperwork.
How to try it in your practice
Like the famous Nike commercial: Just do it. Invent the process as you go along by doing what feels natural. Tell your staff in advance that you'd like to try this new approach, and tell them not to worry about the mechanics of recording because you'll review everything afterward and teach them as you go along. It could simply be a test project, and if it doesn't fly in your practice, then drop it. You don't need an entire protocol to begin, but here are few thoughts that will make it easier.
What will the technician record?
Develop an exam form that will make it easier for your techs to record data and review this with them before you start the scribing procedure. Techs already know most optical terms and abbreviations, and your staff is already familiar with your records. My techs begin taking notes on the expanded case history that I elicit when I start the exam. That's easy; just write down the highlights in English. When I complete my subjective refraction, I simply read the numbers off the phoroptor clearly and slowly for her to record, and I add the final acuity data. I indicate if this will be the eyeglass Rx or if I will want to modify it. I say basic, normal findings out loud as I perform the slit lamp exam and ophthalmoscopy.
Don't throw extremely difficult medical terms at your assistant at first; have an understanding that you may just take the exam form and make a few notes yourself from time to time. You also may not want to verbally reveal some medical finding for the patient to hear until you are ready to discuss it. For example, you may want more data before stating that you see pigment clumping in the macula.
The exam form
It helps techs to have some structure in the exam form - whether it is on paper or electronic. That means a name for each test and a place to write down the result or a space to attach a printout. Keep in mind, you will have employee turnover and the form is a big help to new staff. It prevents some tests from being forgotten, it can help with keeping tests in order, and it allows everyone who wants to look at previous data to know where to look.
I use a two-page form for full comprehensive exams, which works great with scribes. The first page is all technician pre-test data, gathered before I see the patient. I need this information in front of me as I speak to the patient and conduct my exam. The second page is all doctor-produced data, such as refraction, slit lamp, internal, motility and more. This page is blank when I start my exam, and the tech needs this page so she can record on it as I say the findings out loud.
Where does the scribe sit?
The scribe does not need much room - just adapt your exam room. She needs a stool to sit on and can use the end of the refraction desk if you have one, or you could purchase a small utility table on casters, or a hospital tray table. The tech should be out of your way, but close enough that you can lean over and see her findings, or reach over and borrow her exam form if you need it. If you use electronic records, have the scribe input all the data. You could use a cordless keyboard and mouse, so either tech or doctor may use it, and flat screen LCD displays are very lightweight and easily turned for viewing.
What does the scribe say?
My scribes are taught to remain quiet observers when the doctor is in the exam room to maximize the doctor-patient interaction. Of course, the technician can ask a question if she is not sure of something, and the doctor will speak to the technician whenever needed. I often say the tech's name when I'm giving her a finding, so the patient doesn't think I'm speaking to him or her.
How many scribing techs do you need?
This is a hard question to answer because there are many variables about how practices utilize other staff. I have a multi-doctor practice and there are usually three ODs working at a time. We don't have specific assistants for specific doctors because we like the flexibility of putting the tech where she is needed most. Accordingly, we also have our clinical techs do optical dispensing tasks, like frame selection and Rx delivery and adjustments. Given that scenario, I try to schedule three clinical techs per working doctor, but I'll admit we don't always achieve that. So, if we have three doctors working, we may have seven or eight clinical techs, plus three receptionists, two opticians (stationed in optical with no clinical work), two lab technicians and an office manager.
The best way to determine your staffing needs is to just try it with your present staff, or maybe hire one more clinical tech if you know you're already short. If the scribing concept works well for you, you can add staff as you go forward. The efficiency will more than make up for the payroll cost. Keep in mind something I told my office manager when we first started the scribing procedure: if the office ever needs a technician because the pre-test workups are backing up, or optical gets very busy, you know where to find a tech. There's one in my exam room. Just come get her. I can continue on without her.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
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Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.
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