HOT TOPIC: A new look at old problems

Scribes in Optometry

Recent changes in eyecare delivery are making the use of scribes smart business and medicine

By Allan Barker, OD, and Gregg Stockbridge, OD, MBA

Large practices often utilize scribes. However, all practices can consider scribes in some form as a way to increase productivity and improve patient care. Scribe use is nothing new, especially for busy medical practices. Ophthalmology has been utilizing scribes for years. In fact, some of the first introductions to scribe utilization were by optometrists working in ophthalmology practices.

CAUSE AND DEMAND

Recent changes in eyecare delivery, especially the introduction of the medical model, have resulted in optometrists increasing the use of scribes.

1 DECREASING PROFIT MARGINS. Managed care continues to squeeze down optometry profits margins. The future offers little hope of reversing this negative trend. The only answer is to either accept less managed care or see more patients. As more and more patients are covered by some form of managed care plan, the latter solution of seeing more patients certainly offers more hope. However, to see more patients one either needs to do fewer tasks per patient or delegate more. Optometry has always taken the high road when it comes to the quality of patient care delivery. This has always been the essence of optometry. Thus delegation makes sense, and scribes fill an important role in delegation and increasing efficiency of patient care.

2 ELECTRONIC HEALTH RECORDS. Another challenge faced by optometric professionals is electronic health records (EHR). The optometrist again has a choice. The eye doctor can focus on the patient or focus on a computer screen. Also, EHRs can slow a doctor down. This is especially true if their keyboard and computer skills are lacking.

3 NATIONAL HEALTH CARE REFORM. National Health Care Reform promise; to bring millions of new patients into the healthcare system. This, combined with government initiatives aimed at children, should result in more patients requiring eyecare. If an eye doctor wants to participate instead of sitting on the sidelines, a scribe can help increase patient volume. Also, don't overlook government quality initiatives, such as PQRI and E-Prescribe, which dictate increased reimbursements for maintaining efficiency standards.

SCRIBE ROLES

The use of scribes takes many forms, including the following.

■ The Dedicated Scribe. This scribe stays with the patient throughout the entire patient care process. Once the front desk procedures are handled, the scribe will begin the pretesting process, including a complete history.

The scribe enters all information into the EHR that is not automatically entered via ophthalmic instrumentation/EHR interfaces.

In the exam room, the dedicated scribe enters the examination information into the electronic health record as dictated by the doctor.

Once the examination is completed the scribe escorts the patient to the dispensary and either initiates the handoff to the optician with the doctor's verbal eyewear instructions or, less often, completes the entire transaction by continuing with the patient through the optical and/or contact lens process.

■ The Exam Room Scribe. This scribe works directly with the doctor in the examination. The scribe's job is to enter the exam room findings into the EHR so that the doctor can maintain 100 percent verbal, eye, and body position contact with the patient.

■ The Screening Technician Scribe. This scribe does the initial pretesting and history process and may take the patient into the exam room for acuities, muscle balance, pupillary responses, confrontation fields, and other tests the doctor deems fit for delegation.

Obviously, these last two functions, if the doctor elects, can be mixed and matched.

WHEN IS A SCRIBE JUSTIFIED?

To answer this question one needs to ascertain the benefits of scribe utilization versus the costs.

1 INCREASED OPTICAL AND CONTACT LENS SALES. One of the first economic benefits stems from the doctor's ability to grow the quality time focused on the patient. This allows room in the schedule to discuss patient needs, such as driving eyewear, computer eyeglasses, sports glasses, prescription sunglasses, an annual supply of contact lenses, or medical concerns, such as the proper tapering off of a prescribed ocular medication.

2 INCREASED PATIENT FOCUS. Nothing is more impressive than looking someone in the eye when you speak to them. Eyecare can be generic in nature. Generic doctors generally are those who don't look at the patient.

You may be the kindest and most caring doctor there is, but if your head is buried in a computer screen, that is not what the patient perceives. Focusing on the patient rather than a computer will result in more referrals and fewer lost patients.

3 INCREASED PATIENT CARE EFFICIENCY. A scribe allows you to see more patients without sacrificing quality of care. Doctors utilizing scribes report a 15 percent to 20 percent increase in efficiency without any loss of quality.

4 QUALITY OF LIFE ISSUES. Even if doctors don't make one additional penny utilizing scribes, they will have less stress and more energy at the end of the day. Also, they will see ergonomic benefits being patient-centered rather than going back and forth from the patient to the computer.

WHAT ABOUT THE DOWNSIDE?

If a doctor adds the expense of a scribe and then does not increase multiple-pair eyeglass sales, patient volume, average revenue per patient contact, or annual supply of contact lens revenues, then the scribe becomes a bottom-line expense not overcome by top-line revenue.

Obviously, doctors can be more productive utilizing technicians, scribes, and technician/scribes as opposed to doing all the procedures themselves. Also, the technician alone is more productive than a scribe alone.

Note that in scenario number four (depicted in the chart on the right) where you have both a scribe and technician duties performed, you would need an extra employee as the scribe function time of 12 minutes overtakes the doctor function time of eight minutes.

Also of importance is the fact that the numbers, especially for exams per eight hours, represent a “perfect world” situation in which the doctor has zero time allocated for challenging patients, handling phone calls, reading journals, looking at financial reports, or even using the restroom.

The analytic model also assumes that the patients are available. In concept, adding additional staff means seeing additional patients.

However, in reality, the economy, lost managed care contracts, added competition, shrinking patient demographics, or even unforeseen weather can result in patients not filling available appointment slots. Thus the numbers are for instructional use and in the “real world” environment would probably be reduced by up to 40 percent.

Scribes are a relatively new phenomenon for optometry to consider. However, the profession is changing rapidly and the option of scribe utilization is an exciting move to consider. The addition of a scribe can produce many positive and profitable results in one's practice. EB