By Jan Bowers, contributing writer

What used to be a simple, straightforward exercise — taking notes to document a patient visit — has become a source of stress and frustration in the era of electronic documentation. “The EHR has made dermatology tedious in so many ways,” said Meyer Horn, MD, clinical instructor of dermatology at Northwestern University’s Feinberg School of Medicine and medical director of Dermatology + Aesthetics in Chicago. “It’s made it much easier for us to justify our billing codes, but it’s really tiresome and time-consuming to go through and make sure all the boxes are clicked, and all of our notes and thoughts are in there.” EHR and documentation woes have been cited as a primary cause of stress and burnout among dermatologists (see sidebar and last September’s DW, staging.aad.org/dw/monthly/2017/september/feeling-the-burn), but EHR adoption marches on, reaching 73% of AAD members surveyed about their EHR use in 2016.

Dermatologists who have embraced the EHR are utilizing a number of different time- and labor-saving strategies for documenting the patient visit. DW spoke with dermatologists who have successfully adopted these approaches:

• In-room scribes who may either follow the physician and scribe the exam, or perform additional duties at the beginning and end of the patient encounter;

• E-scribes, who listen to the patient encounter in real time from a remote location, and enter the note into the patient’s EHR;

• Voice recognition software that can be integrated into the EHR, allowing the physician to dictate to a microphone or smartphone during or after the patient visit. 

Scribes in the exam room

Dermatologists who examine patients with a scribe in the room cited increased efficiency, less time spent performing EHR documentation tasks, and the ability to see more patients as a few of the key advantages. For the new chair of the Academy’s Practice Operations Committee, another benefit become clear even before EHRs were in use. “Early in my practice, when I was using paper charts, I had a scribe,” said Eliot Mostow, MD, professor and chair of the dermatology section at Northeast Ohio Medical University. “My medical assistant stood next to me, and I taught them to write what I was doing with the patient. I have always been passionate about looking the patient in the eye, touching their skin lesions.” Today Dr. Mostow maintains that ability to focus on the patient, but the scribe is tapping on a tablet loaded with his EHR software, Modernizing Medicine’s EMA. “If, let’s say, you’re 95 and have multiple medical conditions, you might ask, ‘do I really need to have Mohs on my nose?’ I can sit down with you and perhaps a family member and have that longer conversation about the pros and cons of various treatment options, while the scribe documents what I’m doing and saying.”

Dermatologists are adapting the way they employ scribes to the size and type of their practice, as well as their personal style and workflow. “For years I had one medical assistant who served as the roomer, kind of like the hostess in a restaurant,” Dr. Mostow said. “That person would take basic history, including the chief complaint, and review medications and allergies. Then each morning or afternoon a scribe was assigned to me — also a medical assistant — and they’d be my right-hand person. The patient was queued up and ready, and I’d go in with the scribe and we’d document what we did.” Recently, Dr. Mostow said, his practice moved to a model where one medical assistant handles a certain number of rooms and does soup to nuts. “In fact, we have just recently changed to the one scribe per patient/room model and like the adjustment, finding that it is improving documentation and the patient experience.”

Erin S. Gardner, MD, a St. Louis-based Mohs surgeon and chair of the Academy’s EHR Task Force, employs what he calls a “scribe-centric” model (in contrast with a “physician-centric” model). The scribe, who is a medical assistant or a nurse, rooms the patient and obtains the basic reasons for the visit. After reviewing that information, Dr. Gardner examines the patient, “focusing my attention entirely on him and the problem that prompted the visit. The scribe accompanies me and is either documenting directly into the EHR in real time, or completing a paper flowsheet that can later be employed for electronic documentation. If a procedure is required, the medical assistant or nurse facilitates it. At the conclusion of the visit, I leave the room, and the support personnel reiterate any counseling and discharge the patient to the checkout station.” Following the visit, the scribe completes documentation and accesses electronic prescription templates for medications Dr. Gardner has discussed. During a break in the patient flow, Dr. Gardner reviews and signs the note. One CMS requirement to note, Dr. Gardner pointed out, is that “physicians actually ask the patient history of present illness questions directly, even if a scribe has already inquired and documented them. The physician may then review for accuracy and attest to what the scribe documents for the HPI.”

The tasks scribes perform in an exam room can depend on their certification, training and experience. Dr. Horn, who explained his use of scribes to DW in detail in 2015 (see staging.aad.org/dw/monthly/2015/november/using-scribes-for-your-ehr-needs), said that at that time, his practice employed only certified medical assistants, LPNs, or RNs as scribes; they could perform procedures such as blood draws and injections. Now he’s also drawing from a new pool of applicants who are not authorized to perform procedures but are nonetheless proving to be outstanding scribes. “A lot of scribes these days are people who want to become physician assistants,” he noted. “PA schools now require anywhere from 1,000 to 2,000 hours of direct patient contact work experience before they’ll take your application. We have two people working for us right now who are so smart, college-educated, and getting their patient experience as a scribe with us. It’s a win-win for everybody.” There are training and certification programs for scribes, but “there’s no legal requirement to become a scribe,” said Rachna Chaudhari, MPH, the Academy’s director of practice management. “There used to be limitations around the use of scribes for MIPS reporting, but CMS has basically said it’s up to you how you want to structure that relationship with a scribe. Some malpractice providers and some states have their own issues concerning whether a scribe can prescribe on behalf of a physician; the physician should always check what is allowable in their state.”

When does it make economic sense to hire a scribe? “It’s pretty easy to run the math,” said Dr. Mostow. “What’s the scribe going to cost me per day, what’s my average receipt per patient, how many extra patients do I need to see in a day to pay that scribe and break even? It generally works out pretty favorably for almost anyone who’s seeing more than 20 patients a day.” The dermatologists quoted hourly pay rates for scribes that ranged from the low to mid-teens. Dr. Gardner said RNs are paid $23-$36 per hour in his area; Dr. Horn noted that some medical assistants and LPNs with dermatology experience may earn a higher starting rate than a scribe with no medical background. David Zetter, a Mechanicsburg, Pennsylvania consultant who serves on the executive board of the National Society of Certified Health Care Business Consultants, said that a scribe who has undergone formal training can command $30,000 to $50,000 per year plus benefits, which he maintained is more than most medical assistants. He noted that dermatologists should think about whether they want their scribes doing the work of a medical assistant, pointing out that “there could be value in rooming and other duties, but then they’re doing what was previously done by someone earning less.”

Scribing from a distance

Amber R. Atwater, MD, is as enthusiastic about the scribe she’s never met as other dermatologists are about the scribes they see every day. Dr. Atwater, who is associate professor of dermatology and the dermatology residency program director at Duke University Medical Center, employs a medical assistant in the exam room and a scribe in a remote location who listens to the patient encounter in real time. “I keep a dedicated iPod in the pen pocket of my white coat; it has an app that’s owned by the scribe company, iScribe,” she explained. “The iPod is controlled by a Pebble watch on my wrist that lets me discreetly turn the microphone on and off.”

Duke uses the Epic EHR, and Dr. Atwater has customized a number of templates for her notes. Before entering the patient’s room, she tells the scribe which template to use, as well as information she wants put in the note. “Then I go in the room and I record the visit — the history and conversation I’m having with the patient. When I ask the patient how are you feeling, where’s your spot, the scribe takes that conversation and makes it into the history. So I never repeat that. Then I do my exam, using phrases like ‘dot EBN, dot ESCAR’ — these are all codes that the scribe understands and uses to craft her note.” The medical assistant enters the diagnosis and prescriptions into the patient’s record on Epic; the scribe completes the record on a delay of 2-24 hours. “I walk out of the room and sit at my desk for about 20 seconds,” Dr. Atwater continued, “and my diagnoses are already in the chart. Let’s say I have three; I turn my scribe watch back on and give the details of follow-up for each one. And then I send it.” The scribe completes the notes by the end of the day and emails them back to Dr. Atwater for her review and signature.

The cloud-based transmission almost always comes through clearly, Dr. Atwater said. “Every once in a while they’ll tell me there was ‘interference.’ It happens when I’m in the hall and a door is slamming, so now I’ll just stop when that happens. And once my medical assistant was blowing a fan, and they said there was interference that day. But other than that, there are no issues, and I’m a fast talker.”

For dermatologists looking at this option, Dr. Atwater pointed to two key considerations: cost and patients’ feelings about being recorded. iScribe charges either by dictation or by the hour. “I’ve added one or two patients per day, and that pays for the cost.” No patient has expressed concern about being recorded, she said. Rather, “they’re happy that someone is helping me with my notes.”

Having tried both traditional dictation (a recording transcribed by a staff member) and Dragon voice recognition software, Dr. Atwater concluded that the scribe’s transcription was the most accurate, “and I don’t have to repeat anything for the scribe. I had to repeat everything for Dragon.” Best of all, “I have gained tons of evening time, and I’m able to publish and do creative work that I wasn’t able to do before. I’m never going back.”

Voice recognition software

Unlike Dr. Atwater, Abby S. Van Voorhees, MD, is a fan of Dragon. “We in my department used scribes for a while, then the medical school offered an opportunity to pilot Dragon,” said Dr. Van Voorhees, who is professor and chair of the department of dermatology and residency director at Eastern Virginia Medical School. “I had used it 15 or 18 years ago, when I first started using an EHR, and I thought it was awful. Now it’s completely different. The voice recognition has advanced amazingly. You used to have to constantly correct it; now it almost never mistakes the spelling of a word. There was little to no training of Dragon; it’s even easy to get it to learn doctors’ names that are challenging to spell.”

Dr. Van Voorhees dictates her notes into her phone, though Dragon can also be used with a microphone. “I log in through an app on my phone, which automatically syncs with my computer, and then I can dictate right into the EHR,” she explained. “I don’t tend to do it in the room with the patient. I talk to the patient, examine them, walk out, and dictate into the computer in the doctors’ workroom. Then I see the next patient and do it all over again. What I love about it is that it’s where I am, whenever I want. There’s a certain pattern you have to get used to: when to say ‘period,’ or inserting a command for a new line. But the learning curve is very easy, and I really find it helps my clinics become much more efficient.” Compared to the cost of hiring a full-time scribe, Dragon is less expensive, Dr. Van Voorhees pointed out. Another advantage over scribing is that “there’s not that extra person in the room. I work in an academic setting with residents and medical students and other trainees, and already it feels like there’s a lot of us in the room.”

Choosing wisely

Too many physicians don’t take time to think through all the ramifications of their choice of EHR or documentation method, Zetter said. In some cases, the choice of an EHR will dictate the options for note-taking. “There are fewer limitations to the EHRs as we move forward, but you want one that’s going to be flexible — not just able to do free-hand typing, but one that can also program macros, and either has the built-in voice recognition or the ability to interface well,” he said. He recommended that practitioners carefully consider the pros and cons of the different note-taking methods before making a decision or making a change, keeping in mind how they conduct their patient encounters. “Consider how each method will affect you, your practice, and your patients, and then work toward doing something that will be a benefit to all. Do you like dictation? If you don’t, that’s obviously not an option. If you don’t want to have your head in a computer while you’re seeing the patient, and yet you don’t want to be following up after the patient and documenting everything, the scribe may be the way to go.” In addition, “look at the cost, what’s the learning curve, how efficient will it make you, how are you going to implement it and assimilate it into your processes.” Finally, Zetter advised that the method chosen be implemented gradually, starting with one patient a day, so the bugs can be worked out with minimal disruption to patient care.