Article Date: 3/1/2011

The Write Decision
practice management

The Write Decision

Maintain a high quality of patient care, and increase your patient volume by using scribes.

Brian Spittle, O.D., Midlothian, Va.

I've met a number of optometrists who postulate that the quality of patient care degrades as the number of patients seen per time period increases, and that this practice ultimately results in losing patients to other eyecare practitioners. Yet, many eyecare practitioners, including myself, have been able to maintain both a high quality of care and a high volume of patients every day. One of the reasons for this achievement: Some of us use scribes.

Here, I discuss the types, responsibilities, benefits and pitfalls of employing scribes, so you'll have the information you need to decide whether using scribes may be right for you.

Types and responsibilities

Three types of scribes exist:

1. Pure scribe. The pure scribe has no other responsibilities but to chart (e.g. write the patient's history, exam details, the testing/procedures performed along with their results, diagnosis, patient prescriptions and instructions). These employees are either assigned to a specific exam room for the day, or they follow a specific practitioner from exam room to exam room. This employee can be ideal for the multiple-doctor or multiple-disciplinary practice if the scribe is assigned to a specific doctor. The scribe can then be trained as an expert in documenting for that doctor and become an expert in interpreting and anticipating that doctor's intentions.

The benefit of the pure scribe: Specialists tend to be better at what they do than generalists. For instance, if you need knee surgery, the general orthopedist can likely provide a reasonable outcome, but a knee specialist may provide the best chance for an optimal outcome. Similarly, the employee who serves as pure scribe may provide you with the best outcome, in terms of efficiency and correct coding.

The detriment of the pure scribe: It's probable that your technicians can tackle this role, as they likely can write legibly and are already well-versed in technology, should you require assistance with your electronic health records (EHR) system, for example.

Patient liaison. This employee is a technician, scribe and optician. As a result, he represents the practice and provides continuity of care. In other words, he sticks with the patient from the pre-testing all the way through to the optical to eliminate redundancy in communication and provide the patient with a “friend” during their visit.

The detriment of the patient liaison: Finding a person who has the skill set to fill all these roles can be challenging. For example, being a sales person is a lot different than being a technician. In addition, because of the skills required in all these roles, staff training would likely be a daunting task.

Technician/scribe combination. This is my personal favorite because I believe it provides the happy middle ground between the pure scribe and patient liaison without the hassles of extended training. This employee works with your patient before and during the exam and then hands off the patient to your optical staff while you're with your next patient generating more revenue.

My exams are structured so that when reviewing my exam findings with patients, I discuss the medical portion and the vision portion as two different aspects of the patient's eye care. Therefore, having the patient meet someone who fits the pseudo-nurse role as a technician is consistent with the medical portion. Having a separate staff member who concentrates on providing the optical/frame stylist experience for their optical needs is consistent with my vision portion and helps keep a distinction between the two.

Regardless of which type of scribe you choose, training is comprised of introducing the new hire to the practice flow, following another tech for a couple days (so he can learn how to operate your various devices), learning how to operate your EHR system and shadowing you from exam room to exam room to learn your process. Based on my experience with the technician/scribe combination employee, I've found that new hires with no prior experience typically achieve a nice functional level within a week's time and a streamlined level within a couple weeks.

Benefits/challenges

My first experience with a scribe was during an externship at a secondary and tertiary care facility. The office contained six exam rooms, though no optical or contact lens facilities. At the time, I was completely overwhelmed because the average patient load at this facility was 50 to 60 patients per day—a volume I now find reasonable. My optometry school education at that point had prepared me for two-to-three patients per day.

My role at the facility for the first few days was to simply observe the ophthalmologist as he went to each exam room. The doctor entered with a scribe and greeted the patient. The scribe sat at a desk with the chart open for the doctor to review. The doctor asked the patient about their reason for the visit and glanced at the chart while the two bantered. Once the exam portion of the visit began, the scribe wrote frantically in the patient's chart. The only time the surgeon touched a pen was to illustrate findings to provide patient education. This experience taught me the following about employing a scribe:

They enable you to practice eye care to the fullest. I've found that having a scribe—as in the case of the ophthalmologist for whom I worked—enables you to spend the entire visit on the patient. Remember: That patient has placed his faith in you to provide him with services and goods. The only way you can affirm his faith is to meet or exceed those expectations. Communicating is the best way to do that. My personal expectation for my patients is that they leave with the education necessary to make smart decisions for themselves. That education may include the benefits of digital progressive lenses or the basic features of non-glare coatings. More importantly, I want them to understand their eye health status. For instance, if a patient with a cataract presents, I want him to know the symptoms he's experiencing (e.g. increased myopia, blurry vision, etc.) can be alleviated via surgery. Having conversations that foster trust and loyalty is challenging when you don't employ a scribe.

Some of you may be thinking: “I can talk and write at the same time.” If this is you, ask yourself how you would feel if you were trying to talk to someone while they were writing or typing—especially when turned to the side or facing away from you. You would likely feel unimportant. Patients feel the same way. In addition, you may miss something vital, as some patients may be reluctant to interrupt your writing, or they could have an intermittent condition that you miss while looking away.

Some practitioners believe scribes may actually inhibit their ability to practice eye care to the fullest. Specifically, they believe scribes may cause privacy concerns for patients and, as a result, prevent them from telling the practitioner what's wrong. Some of my patients have indeed inquired about the presence of my technician/scribe. In fact, recently a male patient said: “The less people know about my medical history, the better.” When this occurs, I simply tell patients the purpose of the technician/scribe and how her presence enables me to spend more time with the patient. Once my patients hear this, it's no longer an issue. In terms of scribes inhibiting patients from telling me what's wrong, I've yet to pick up on this.

Other practitioners believe scribes don't enable one to practice eye care to the fullest because the job requires additional management duties. Yes, the scribe dynamic does require additional management, however, if you select team leaders from your staff for training and maintenance of training, this isn't an issue.

They lessen the hassle of documentation. With a scribe, you no longer have to write a prescription in the patient's chart and rewrite it on a pad for the patient. Also, you don't have to stay late to finish your charts.

Some practitioners believe that the scribe role is redundant, as the doctor will have to review the chart anyway. Yes, you will have to review the chart. That said, I can tell you from personal experience that the time it takes to review a documented chart is considerably less than writing or inputing all the information from the get-go.

They enable more thorough documentation. Providing patient care while charting can result in both illegible writing and inaccurate coding because we aren't able to solely focus on it. This can result in mistakes, and, therefore, reimbursement delays. Because a scribe's job is documentation, the legibility of charts and the accuracy of coding tend to be better, resulting in both faster and higher reimbursements.
They enhance practice productivity. Scribes allow you to increase practice productivity, and, therefore, schedule more patients. Talking with a patient typically takes a lot less time than charting, and the time you save from charting yourself can be used toward seeing more patients. Is this increase in productivity enough to make the increase in payroll for these employees worth it? Based on my experience, the answer is yes. Both the increased efficiency and revenue from seeing more patients dramatically outweighs the expense of using scribes.

Specifically, I've found it takes roughly 100 to 120 additional patients a year to make the investment in one scribe worthwhile. In addition, since I've been using technicians/ scribes, my practice revenue has increased by 30%.

We have one technician/scribe on the schedule for each room in use on a particular day. The number of doctors in our office fluctuates depending on the day, and, therefore, so does the number of scribes on-hand.

At current market rates, you can add several technicians to your office for the same price as an associate doctor. Adding more technicians should always be given heavy consideration prior to adding more doctors.

They facilitate EHR use. Although EHR programs provide data storage efficiency, as with all technology, they can present challenges. This is where a scribe who's familiar with data entry can be invaluable. When clicking, tabbing, selecting from a drop-down bar, etc. isn't providing you the information you seek, your scribe can help, saving you aggravation and time.

Because scribes allow you to practice eye care to the fullest, lessen the hassle of and enable more thorough documentation; enhance practice productivity; and facilitate EHR use, they make it possible for you to maintain both a high quality of care and a high volume of patients every day.

They are clearly underutilized in the optometric profession, and I've found that their numerous benefits far outweigh their negatives. OM

Dr. Spittle is in private practice with his wife, Norma Spittle, in Midlothian, Va. and is also the lead consultant for ECPManager, LLC, a software company that creates practice management applications. E-mail him at bspittle@ecpman ager.com, or send comments to optometricmanagement@gmail.com.


Optometric Management, Issue: March 2011