The push to develop and deploy electronic medical records (EMR), combined with the need for more detailed documentation, has forced EM and HM providers to spend extra time during patient visits capturing and entering data rather than focusing on the patient — a problem that can have an adverse impact on the quality of patient care.
One solution: the use of medical scribes.
According to the American Health Information Management Association, a medical scribe captures “accurate and detailed documentation … of the encounter in a timely manner.” Typically, scribes follow the physician during rounds gathering, documenting, and entering information into the EMR at the doctor’s direction.
In keeping with its focus on innovation, SCP is piloting a timely alternative to the traditional model: the Virtual Scribe or “V-scribe” program.
This post explains the concept, how it works, and the benefits it can accrue in an EM or HM setting.
V-scribe program overview
The Virtual Scribe program, initially developed by HPPartners, is a tool for our providers that improves documentation, expedites patient throughput, and enhances the patient experience. It eases the task of EMR documentation, allowing the physician to spend more time with more patients.
The program goes beyond just documenting the patient-provider encounter, however, but assists the provider in real-time, enabling him to deliver essential patient care in a more personal and efficient manner.
How the V-scribe program works
“Conceptually, the scribe is off-site and communicates with the provider via a headset,” said David Schillinger, MD, division chief medical officer. “The scribe has firewall access to the EMR and creates the record contemporaneously with the provider’s encounter with the patient. Because the scribe is not physically following the provider room to room, she has the luxury of sitting at the computer to look up and report lab results as the doctor enters a patient’s room.”
To begin the process, the physician calls the Virtual Scribe phone number before seeing the patient. He (the provider) is equipped with a light wireless earpiece connected to a land-line phone. The scribe then accesses the medical record for the patient remotely and waits for the physician to begin his visit. The scribe is virtually present during the interaction, taking notes and documenting the HPI, ROS, PMSFHx, and PE on the EMR.
Once the encounter is over, the scribe prompts the physician for any missing information. The physician and the scribe are continuously connected, allowing him to move from patient to patient without stopping at the computer station to document.
When the provider has completed his rounds, he can place orders, review labs and results, or assess a given patient’s charts and dispositions. The scribe monitors for returned labs and results and then prompts the provider as soon as they are ready for review.
Virtual scribe’s tasks
The virtual scribe’s tasks include:
- Real-time documentation of all the required sections for a complete billable medical record (HPI, PMFSHx, ROS, MDM);
- Reviewing and informing of past ED visits and old medical records;
- Documenting consults, procedures, and family discussions;
- Monitoring pending laboratory and imaging;
- Monitoring pending orders;
- Informing the physician of outstanding or pending tasks.
V-scribe program benefits
Virtual scribe services improve documentation, untying providers from the computer. As a result, doctors can spend more time at the bedside, see more patients, and increase productivity, which can lead to improved patient satisfaction.
Describing the physical exam to the patient clearly and discussing treatments and results allows the virtual scribe to capture all the pertinent findings required for appropriate documentation and coding. More importantly, it allows the patient to feel involved in the treatment plan.
By reducing the time providers have to spend at the computer documenting the patient encounter, enabling them to spend more time addressing the patient’s needs, the pilot Virtual Scribe program could serve to advance SCP’s mission of continuously improving quality health care to all patients, without a doubt.
In an era when governmental regulations tie reimbursement to the quality of patient care, any service that improves patient satisfaction is certainly welcomed.
