PracticalDermatology

Delivering high quality health care in an efficient and cost-effective manner has never been more important. The use of electronic medical records (EMRs) and the accompanying data input has been found to consume more time than patient contact: “...physicians [are] spending up to 2 hours on EMR-related tasks for every 1 patient-care hour.”1 As a result, employing a medical scribe can be instrumental providing excellent, cost-efficient care. In a high-volume specialty such as dermatology, relieving the physician from data input improve both the patient and physician experience. This article aims to extend on this concept and provide guidance on integrating a scribe into dermatology practices.

KEY CONSIDERATIONS

In the medical practice setting, including dermatology, a scribe is responsible for entering relevant clinical data into the medical record. The level of involvement and independent gathering of information is determined by the dermatologist and typically evolves as the scribe gains experience and the dermatologist’s trust.

Practice Assessment

The initial step in contemplating the integration of a scribe in a dermatology practice is a thorough evaluation of the practice’s clinical care delivery, including an assessment of the patient population. This assessment involves analyzing chief patient concerns such as cosmetic treatments, acne, and skin cancer, as well as inquiries about procedures. It is important to consider the specific training required to ensure that a scribe has the knowledge to document complex medical dermatology or procedures, and this training should be addressed before onboarding.

Logistical operations within the dermatology office must also be considered. Evaluating space limitations of the clinic, including waiting room availability, input flow requirements, number and size of exam rooms, is essential. How many people can an exam room comfortably hold? Are the hallways spacious enough to accommodate another individual without negatively impacting flow? These questions are vital when considering the feasibility of implementing another team member from a physical standpoint.

Personnel quantity, skill levels, and skills are next to consider. Before hiring scribe, it is essential to evaluate the composition of office personnel: the number of medical assistants (MAs), licensed practical nurses (LPNs), registered nurses (RNs), surgical technicians, Mohs surgery technicians, residents, fellows, and medical students. Questions to address include: Would a scribe crowd the patient room? Which personnel need to remain in the patient room if a scribe is present? Assessing the skill levels of existing staff is necessary to determine the need for scribe implementation. For example, consider the similarities between the role of an MA and a scribe. MAs often perform tasks that would overlap with those of a scribe, such as obtaining a history, preparing patients for examinations, and assisting the physician in minor procedures. Conversely, a scribe in the exam room can serve as a chaperone, when appropriate. Personnel scheduling is also relevant to this evaluation; the clinic’s operating hours and workdays of staff can influence whether a scribe is needed on a daily or part-time basis.

Defining Roles

Whenever a new employee or a new job role is introduced into a practice, it is crucial to establish clear parameters and expectations for the newly incorporated employee. The roles of existing staff may shift because of the integration of a new employee. It is imperative to emphasize that these changes aim to improve the patient experience and delivery of dermatologic care. Incorporating a scribe can alleviate some data input responsibilities for MAs, but the duties and roles should be pre-determined. Establishing and codifying office policies and procedures helps to ensure consistent expectations for all dermatologists and administrative personnel in the practice.

Training

Occasionally, dermatology practices choose to hire scribes through a third-party agency that provides in-person and remote training. For scribes whose only responsibility is data recording, providing a prepared “cheat sheet” with organized lists of terms and definitions can be beneficial. This list can be alphabetical or in order of frequency of use by the dermatologist (Figure 1).

Figure 1. Common terminology of diagnoses and assessments in dermatological practice

This list can be modified and adjusted based on individual practice requirements. This cheat sheet can be provided in electronic format or as a laminated card. Other options to enhance usability could include highlights, bold print, and color coding to associate terms with diagnoses.

An essential component of scribe training is gaining familiarity with the practice’s EMR. This training can be facilitated by office personnel who are familiar with the EMR platform. After EMR training is complete, the scribe should receive training on how to fulfill their duties. For instance, should the scribe obtain a patient’s medical history before the dermatologist interviews the patient, or should they gather the history while in the room with the dermatologist and the patient? Will that portion of the role evolve as the scribe gains experience? Is the practice considering implementing a hybrid role combining responsibilities of scribe and medical assistant? What will be the scribe’s role during procedures? These are important questions to address during the training process.

As an integral part of this training process, the dermatologist should deliberately incorporate language and cues for the scribe into their examination notes. Although the scribe will have the “cheat sheet” containing common terminology to expect in a patient encounter, it is crucial for the dermatologist to speak with the patient in a manner that the scribe can easily transfer to the EMR. For example, a dermatologist could use statements such as the following:

• Your skin has evidence of sun damage, also known as actinic elastosis (DIAGNOSIS).
• This appears as erythematous scaly papules on his sun-exposed areas of your skin (PHYSICAL EXAM).
• These papules are a form of precancerous lesions known as actinic keratoses (DIAGNOSIS).
• I will treat these lesions with liquid nitrogen today (PROCEDURE).
• You may experience an extremely cold sensation and a temporary stinging feeling, and over the next few days, blisters may develop in the treated areas. The affected skin will peel off in 7 to 10 days. I will schedule a follow-up examination in 3 months to evaluate the eight lesions treated today (PLAN).

In addition to providing the patient with education and reassurance, these statements also supply the scribe with data for the medical record. A concise interaction between the dermatologist and patient, characterized by effective communication, can be accurately recorded in the EMR with accompanying diagrams and locations. This ensures fulfillment of all necessary data points for billing, quality control and record keeping. As the collaboration evolves, many commonly encountered situations and conditions will require fewer prompts by the dermatologist.

Financial Justifications

Hiring and training a new employee, particularly for a completely new role in a practice, comes at a cost. The question arises: How can a practice afford a new employee? The Medical Scribes Training Institute reports that medical scribes “can expect to earn between $9 and $15 per hour,”2 which amounts to an expense of $72 to $120 per day. Considering that the median cost per dermatology visit is reported to be $124 per visit3; the practice would need to see at least one additional patient per day to recover the cost or at least two additional patients per day to generate excess income.

Improvements in Satisfaction

However, the decision-making process may not be solely financial. Physician dissatisfaction with EMR documentation is increasing: “A 2016 survey of 6375 doctors in the United States, published in Mayo Clinic Proceedings, found that 84.5% of them used EHRs [electronic hospital records]they] reported feeling less satisfied with the amount of time they spent on clerical tasks…[and] were also found to be at higher risk of professional burnout.”4 Incorporating a scribe can increase income and improve the time utilization by the dermatologist, as many physicians report “completing their clerical work at home during evenings or weekends.”4 Scribes can help enhance the timeliness of completing such tasks.

Related to physician burnout and the time-consuming nature of electronic record keeping, physicians express that they have less time for patient interaction: “Of greater concern to many physicians is that more facetime with screens means less connection with patients and fewer discussions with colleagues. Patients appreciate a physician speaking with them directly instead of looking back-and-forth with the computer screen as they discuss their care.”4 The implementation of a scribe into a practice can bring satisfaction to both physicians and patients, improving overall physician-patient interactions.

Summary

As the field of medicine continues to evolve and administrative demands increase for dermatologists, it is vital to adapt to uphold high-quality patient care and clinical standards. The documentation process in the EMR can be burdensome for high-volume dermatology practices. Introducing a scribe to the practice offers a solution by delegating this administrative duty to an additional employee. This approach has the potential not just to provide financial benefits to the practice but also to contribute to the emotional well-being of the dermatologists.

1. Nambudiri VE, Watson AJ, Buzney EA, Kupper TS, Rubenstein MH, Yang FC. Medical Scribes in an academic dermatology practice. JAMA Dermatol. 2018;154(1):101–103. doi:10.1001/jamadermatol.2017.3658.

2. Medical Scribe Salary Information by Company and Location. Medical Scribes Training Institute. Published July 8, 2020. Accessed September 22, 2022. https://medicalscribes.org/medical-scribe-salary-information-by-company-and-location/.

3. Rothstein BE, Gonzalez J, Cunningham K, Saraiya A, Dornelles AC, Nguyen BM. Direct and indirect patient costs of dermatology clinic visits and their impact on access to care and provider preference. Cutis. 2017 Dec;100(6):405-410. PMID: 29360888.

4. Collier R. Electronic health records contributing to physician burnout. CMAJ. 2017;189(45):E1405-E1406. doi:10.1503/cmaj.109-5522.