Wednesday, March 13, 2013

The Use of Scribes for Clinical documentation

Given the rigors of documentation required for Meaningful Use, quality measurement, and ICD10, some organizations are adding dedicated scribes to rounding and evaluation teams.

I was recently asked two questions about scribes.

Does Meaningful Use allow the use of scribes?

Meaningful Use does not specify who does the documentation, as long as the thresholds for data capture are exceeded.

What are the best practices for scribes used at BIDMC?

At BIDMC the ED scribes use their own credentials and create a "scribe note" under their own identity.

When the physician goes to chart, they have the option to import the scribe note into their own note.

This has 3 important benefits:

1) The scribe is never given access to the system with the physician's credentials (as I've heard happens with some scribe arrangements)
2) The physician has the option to import and then writes/edits the note as they wish (ie - they retain full control for the contents of the note)
3) The MD actively uses the computer and the scribe does not come between the physician and system.  (In some arrangements the scribe acts as a human UI to the system and the MD only interacts with the scribe.  This becomes a barrier to many of the benefits of online clinical decision support).

Although future improvements in clinical documentation may eliminate the need for scribes, there are best practices that minimize privacy risks and "cut/paste" documentation challenges.


Medical Quack said...

I had no idea that scribes were used in your system, but it further talks about the rising complexities that we have today in Health IT and what all can humanly do.

I certainly hand it to you for keeping up with all of this and your contributions and time spent on panels and committees as I know those are getting a bit more complex with decision making and information too. When all started on the mission of connecting EHRs, we had nowhere near the world of complexities we do today so at some point decisions are made to where and when the machines and humans each play their parts. The magical answers that all were looking for in the format of a portal that does all the work is just not there, but it gives us the knowledge to make decisions with making sure we aren't missing something along the line too.

At some point there's a tipping point with making life with machines something we can all work with and at other times enjoy as well...

Chris Grant said...

Thanks for the blog post. I assume that this capability is one that is built into the EMR platform you're using, or did you have to have something custom developed to accommodate this?

david bragg said...

In our healthcare system in Texas, we use Certified Medical Assistants as scribes. I question as to whether they qualify as "licensed medical professionals".