Article Date: 3/1/2011

What Scribes Can Do For You

What Scribes Can Do For You

A scribe with the right skills, personality and work ethic can provide vital support in your practice.

What does a laid-off assembly line worker from Chrysler have in common with a medical school graduate from the Philippines? Both are scribes in busy retinal practices, helping physicians paddle down a white-water river of change.

Monthly intravitreal injections and associated tests have at least doubled office-based interventions. Patient flow will become even more frenetic due to increases in disease incidence, older patients and office-based treatments. Shrinking reimbursements, more burdensome documentation requirements, tighter Medicare scrutiny and adoption of electronic medical records (EMR) will add to the challenges of providing excellent patient care in a timely manner.

Scribes are helping practices stay afloat by trailing physicians throughout the clinic, retrieving patient data, documenting assessments and care plans, entering new data, coding visits, performing patient education and assisting with procedures. These advanced assistants can increase the number of patient visits by 25% to 100% and, most importantly, allow physicians to spend more time with patients, while helping practices adapt to the swiftly changing currents of retina care.

To help you evaluate the potential benefit of using scribes—or to maximize the impact of scribes already on your payroll—this report will examine recruitment, training, workflow, overall practice and patient care benefits, efficiency gains and other issues. This first article will focus on finding the right person for this vital position.

PERSONALITY IS KEY

In 2008, before the economic downturn left Sommer Dittman jobless, she installed dashboards, door panels, handles, batteries and other parts on partially assembled Jeeps. “The assembly line never stops,” she says. “When you're building a vehicle, you have to learn fast. You have 60 seconds to fit in five or six parts, even if something isn't fitting at first.”

Scribes like Vanessa Pro (left), who works with Matthew Benz, MD, help improve patient flow and record-keeping.

After losing her job, Dittman sold her home in Toledo, Ohio, and sought new opportunities in Charlotte, N.C., where she has proven to be an ideal scribe for Andrew Antoszyk, MD, partner at Vitreoretinal Service for Charlotte Eye Ear Nose and Throat Associates. “I've learned quickly that the retinal world is also a fast-paced environment,” she says. “I thrive on it.”

Dittman is one of many scribes who have succeeded because of their outgoing personalities, flexibility, resilience, ability to learn quickly and master details—characteristics that have proven to be more important than having a medical background.

“Besides being bright and fast on their feet, scribes need to be compassionate,” adds Dr. Antoszyk. “They're dealing with people who have a serious disease, may have to wait a long time for treatment, and may need to be seen on a frequent basis. A good scribe makes a patient feel more like family than just a patient undergoing a procedure.”

Don Shay, practice administrator for Retina Consultants of Houston, also seeks outgoing job candidates. “People who have college degrees in marketing or communications or have a public speaking background do very well,” he says. “This is not a job for an accountant. Having healthcare experience is helpful but not necessary. We can teach candidates clinical care if they have the right personalities.”

BENEFITS OF A MEDICAL BACKGROUND

That said, clinical experience is undoubtedly an asset. K. Bailey Freund, MD, a partner at Vitreous Retina Macula Consultants of New York, hired the medical school graduate from the Philippines mentioned at the beginning of this article. She's currently studying to be a nurse anesthetist in the United States.

“She can take what I say in lay terms and translate it into medical terminology for documentation,” says Dr. Freund. “You might tell a patient with diabetes that the OCT shows the retina is swollen. The medically eduated scribe, also looking at the OCT, will write in the chart that there is cystoid macular edema.”

Dante J. Pieramici, MD, a partner at California Retina Consultants, Santa Barbara, Calif., prefers using a scribe with clinical experience. He has trained a high-achieving ophthalmic technician to do this work. “The type of person who is most helpful understands the eye and terminology related to the retina,” he says. “I don't think you can hire anyone off the street.” Other physicians agree.

“It's great to have someone with a medical background and even better if they have ophthalmic experience,” says Matthew Benz, MD, a partner at Retinal Consultants of Houston. “We use acronyms and terms that are relatively specific to ophthalmology and even more specific to retina. For example, someone without ophthalmic experience might misinterpret what I say and write PED instead of PVD. Based on the clinical scenario, a good scribe should know that PVD is quite different from PED.”

David M. Brown, a partner at Retina Consultants of Houston, says he only selects educated professionals to assist him during his examinations. He calls his assistants administrative technicians, not scribes. “They're involved in high-level communications with the patient, and also planning and documentation,” he says. “For example, I may have a patient with a macular hole. I recommend surgery, talk about scheduling surgery and how to arrange positioning with the right posture. I'm talking about post-op pain relief. The administrative technician understands and reinforces what I say and, after surgery, follows up with the patient.”

Alexander J. Brucker, MD, of Scheie Eye Institute, University of Pennsylvania School of Medicine, Philadelphia, is very selective when choosing a scribe. “You can't teach mid-level personnel to be scribes,” he says. “Scribes are a bit like physician assistants. They need to understand anatomy and what's going on clinically.”

“The best scribes know medical-surgical retina,” says Michael Bennett, MD, a partner at the Retina Institute of Hawaii, which has offices in Honolulu and six other locations. “If visual acuity is dropping, the scribe knows something is wrong. Or if I say I suspect a detached retina and that we may need to do a pneumatic, the scribe knows what to write down. She is an extension of what I am—my operational control.”

MINING YOUR PRACTICE

All 13 physicians and practice administrators interviewed for this report say they rarely, if ever, hire scribes from outside of their private and academic practices. When interviewing potential scribes, Jim Ohlenforst, ophthalmology manager at Charlotte Eye Ear Nose and Throat Associates, says he tries to identify existing staff members who are “detail-oriented, willing to learn and have a very good work ethic. They also have to be assertive enough to keep the physician on task and ask questions when they don't understand something.”

Meanwhile, Dr. Brucker employs a former research coordinator and a recent college graduate who will enter medical school next year. Most scribes are promoted after proving themselves at the front desk or as ophthalmic technicians.

Even the medical school graduate who scribes for Dr. Freund worked her way up from the front desk, as did Dittman, the former auto worker. Starlyn Miller, an ophthalmic technician with 18 months of nursing school experience, and Angel Williams, who worked as a nursing assistant and scribe in dermatology, are two more examples of staff members who were promoted from within Charlotte Eye Ear Nose and Throat Associates. “From the front of the office to the back, the team concept is very important here,” says Williams.

Whether you use EMR or paper, the scribe skill set is key. “If you have EMR or you're planning to implement an EMR system, you'll need people with exquisite typing skills,” says Dr. Brucker. Similarly, Dr. Brown says, scribes need to write quickly, accurately and legibly for paper records. “Our scribes have far superior handwriting to me and the other doctors,” he says.

Hildy Abel, general manager at Vitreous Retina Macula Consultants of New York, emphasizes that scribes should be able to manage a variety of tasks that go beyond the exam room. “When the scribe isn't needed to scribe, she should be able take on other tasks, such as working up patients, filling out forms and triaging phone calls,” Ms. Abel says.

MOVING AHEAD WITH THE RIGHT SCRIBES

No matter what background you find on a potential scribe's resume, one factor remains consistent—there is a growing need for them. Developing a scribe-based practice is more of an urgent requirement because of the number of injection procedures that are transforming retina into a “pharmacotherapeutic and office-based” specialty, according to Dr. Antoszyk.

“Scribes are extremely important to maximize a physician's efficiency and help maintain a stable income stream in the ever-changing and regulated healthcare environment,” he says. “Gross revenue increases but so do expenses, which means that net revenue is stable to slightly decreased. The other caveat is that we're working a lot harder. Reimbursement is going down. Patients, justifiably, want to get through your office in a timely fashion. You're going to need to work with increased efficiency, and using scribes is one way to achieve this objective.” RP

The Increasing Need for Scribes
Decreased reimbursements and increased patient demand are driving the need for scribes. Here are key considerations that will continue to accelerate the trend.
Increase in patient visits related to intravitreal treatments: An increase of 15% to 40% has been reported by physicians interviewed for this report. Because of the potential need for evaluation and treatment of each eye in AMD every 4 to 6 weeks, patients may have to visit the office 12 to 24 times a year, instead of the three or four times that were customary before the introduction of intravitreal therapy.
Decrease in office-based revenue: Pravin U. Dugel, MD, a partner at Retinal Consultants of Arizona, Ltd., joined another researcher to conduct a systematic retrospective review of a multicity, multiphysician retina practice's revenue, expenses and profits from 2005 through 2007. They reviewed claims level data on clinical procedures across seven primary activity centers: non-laser surgery, laser surgery, office visits, OCT, non-OCT diagnostics, drugs, drug injections and research. The practice accommodated increased demand in patient volume, medical retina services and medical imaging with the advent of anti-VEGF therapy, but it also absorbed a seismic increase in operating costs. Despite significant revenue growth, the net effect was a 14% decline in profit margin.1
Increase in the aging population: Within a decade, nearly one in every three Americans will be a Medicare beneficiary, representing a 35% increase over today's enrollment. This trend will significantly increase patient demand for services and care.2
Increased incidence of blindness and low vision: The number of blind persons in the United States is projected to increase by 70% to 1.6 million by 2020. A similar increase is projected for low vision.3
Increase in incidence of diseases requiring office-based care: The incidence of AMD was estimated to be 1.7 million in 2004 and is expected to increase to nearly 3 million by 2020.4 The 15-year cumulative incidence of late AMD in people 75 years or older indicates a significant public health problem is looming. The population in this age category in the U.S. is expected to increase by 54% between 2005 and 2025.5 The number of Americans 40 years or older with diabetic retinopathy and vision-threatening diabetic retinopathy will triple in 2050, rising from 5.5 million in 2005 to 16 million for diabetic retinopathy and from 1.2 million in 2005 to 3.4 million for vision-threatening diabetic retinopathy. Increases among those 65 years or older will be more pronounced, rising from 2.5 million to 9.9 million for diabetic retinopathy and 0.5 million to 1.9 million for vision-threatening diabetic retinopathy.4,6

References
1. Dugel PU, Tong KB. Development of an Activity-based costing model to evaluate physician office practice profitability. Ophthalmology. 2011;118(1):203-208.
2. 65+ in the United States: 2005. U.S. Department of Health and Human Services. National Institutes of Health, National Institute on Aging. U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau.
3. Congdon N, O'Colmain B, Klaver CC, et al. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477-485.
4. Friedman DS, O'Colmain BJ, Munoz B, et al. Prevalence of age-related macular degeneration in the United States. Arch Ophthalmol. 2004;122(4):564-572.
5. Klein R, Klein BE, Knudtson MD, Meuer SM, Swift M, Gangnon RE. Fifteen-year cumulative incidence of age-related macular degeneration: the Beaver Dam Eye Study. Ophthalmology. 2007;114(2):253-262.
6. Saaddine JB, Honeycutt AA, Narayan KM, Zhang X, Klein R, Boyle JP. Projection of diabetic retinopathy and other major eye diseases among people with diabetes mellitus: United States, 2005-2050. Arch Ophthalmol. 2008;126(12):1740-1747.


Retinal Physician, Issue: March 2011