At this years MGMA conference in San Francisco there was significant interest on the subject of the Medical Scribe.

Medical Scribe Training

A medical scribe is an unlicensed individual, or allied health professional (MT, MA, LPN, LVN, TECH, etc.) hired to enter information into the electronic health record (EHR) or chart under the direction of a physician or licensed independent practitioner.

What activities should a Medical Scribe do and what activities fall outside of their responsibilities?

Check out our recently published Industry Accepted Standards of Activity for Medical Scribes. This document highlights those activities we believe a scribe should or should not do.  Things like:

Do’s:

  • Defer to physician, nurse or other licensed provider if a patient asks a question or makes a request.
  • Ask the licensed caregiver to clarify or provide additional information, if needed.
  • Refrain from asking questions or requesting clarity while in the patient room.

Dont’s:

  • Touch or have direct contact with a patient.
  • Give medical advice.
  • Transmit a verbal order.

If you have any questions or would like to offer your feedback on the these Standards of Activity for Medical Scribes, please leave us a comment or contact us via email at sales@ahdpg.com.

To learn more about our  Scribe Training and Implementation Support program which is designed to help healthcare organizations “develop their own team of internally managed medical scribes” please visit us at www.ahdpg.com or feel free to contact us at sales@ahdpg.com for more information.


OUT MEDICAL SCRIBE TRAINING AND IMPLEMENTATION SUPPORT PROGRAM INCLUDES:

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A recent study by the American Medical Association (AMA), reveals what many physicians are feeling – data entry and administrative tasks are cutting into the doctor-patient time that is central to medicine and a primary reason many physicians became doctors.  Medical scribes can help!

The AMA study shows that for every hour of direct clinical face time with patients, physicians spend nearly two hours of additional time on EHR and deskwork within the office day. Outside of office hours, physicians spend another one to two hours of personal time each night on data entry demands.

This administrative burden is driving increased physician burnout.  According to a recent InCrowd survey, Fifty-seven percent of primary care physicians and emergency medicine physicians have felt a sense of provider burnout on account of increase EHR use, the survey found. Nearly three-quarters of providers feel that their practice is not taking action to help mitigate and prevent provider burnout.

Click here to see how AHDPGTM‘s Medical Scribe Training and Implementation Programs can help you leverage your existing Allied Health Professionals (CMAs, MAs, MTs, LPNs, Techs, etc.) to lower physician burnout.

An article posted by Linda Sullivan of New England Medical Transcription (NEMT) discusses a presentation at this year’s HIMSS conference regarding scribes. In her article, Ms. Sullivan describes some of the discussion in Rise of the Medical Scribe Industry – Risk to EHR Advancement presented by George Gellert, MD, MPH, MPA, and S. Luke Webster, MD of Christus Health. She states, “The speakers expressed concern that unlicensed individuals are entering patient information including CPOE into the EHR. And at times being put in the position of having to make decisions for which they are not trained.”

What a scribe does do: A scribe works at the elbow of the provider entering the documentation into the healthcare record (the EHR). Traditionally, a scribe is physically present throughout the provider/patient encounter. The provider will usually introduce the scribe to the patient by various ways; for example, “Mrs. Jones, Jim is here to help me with the computer so we can spend more time together.” Or, “Mrs. Jones, this is my scribe Jim, who will be assisting me with the documentation of your exam today.” In a clinic, patients are sometimes advised in advance that there will be a scribe in the room unless they object, which they certainly have the right to do. Scribes are trained specifically to understand and enter required elements of documentation in order to obtain maximum reimbursement for providers.

The scribe records:

The History of Present Illness: As the patient is interviewed by the provider, the scribe enters the information presented by the patient. The scribe does not make any independent decisions in this section (usually narrative). The scribe is trained to translate “patient speak” into formal medical language. For example, a patient complains she has had a “stomachache for 3 days…I’ve been sick to my stomach and throwing up nonstop.” The scribe might write, “The patient is a female who presents to the ED today with 3 days of abdominal pain. She states she has had nausea and has been vomiting frequently.” There are no independent decisions or interpretations produced here. The scribe may also use quotation marks if the information is unable to be translated or is best stated as a quote.

The Review of Systems: In an EHR, the ROS is customarily recorded by utilizing checkboxes and is noted as positive or negative pertinent findings, depending on what the provider asks the patient, as well as the acuity level of the patient. As the provider interviews the patient, the scribe checks the correct details. Sometimes these checkboxes populate into a narrative paragraph in the document. The scribe does not interview the patient, nor does he/she determine what belongs in the ROS (besides, occasionally, the Chief Complaint).

The Past Medical/Surgical/Social/Family Histories: These are usually prepopulated from patient’s previous encounters; if not, the medical assistant or nurse may interview the patient and enter this information or the patient may fill out a paper chart. When the scribe is present in the room with the provider, if the patient remembers something in this section that was not told to the MA or nurse, the scribe may enter the information.

The Physical Exam: Again, this information is entered by the scribe while the provider is performing the exam. Most often the provider will dictate this information to the scribe during the exam: “Abdomen is soft and nontender. Heart has a regular rate and rhythm. Lungs are clear.” The scribe is not allowed clinical judgment or independent entering of any of this critical information. Sometimes the provider will not be comfortable dictating this information during the exam and will dictate the information to the scribe after they have left the room.

Medical Decision Making/Assessment and Plan: MDM is traditionally known as the “voice” of the provider. This may be completely dictated/scribed by the provider, or it may be dictated to the scribe, or there may be a standard template the scribe will utilize, which the provider then can add to as needed. For example, four standard sentences may be used here: a summary of why the patient is being seen (The patient is a female who presents today for abdominal pain); a brief summary of the physical exam (On exam today, abdomen is soft and nontender); differential diagnoses (Differential diagnoses include but are not limited to:…); and the plan (Today I will order a CBC, chest x-ray, and a UA). Again, a scribe is not allowed to use independently created information to create a patient chart.

Traditionally, scribes are pre-med students looking for clinical hours in their gap year between university studies and medical school. It is a true statement that scribes are unlicensed individuals; however, after 200 hours of clinical practice, a scribe is eligible to become certified through the ACMSS. This is not a mandatory exam and is not routinely paid by a scribe’s employer, but it does lend some credibility to a scribe’s ability and skill level. Still, scribes undergo a steep learning process in a short period of time, unless the scribe is an experienced HDS or MA already (which makes for an ideal scribe). A pre-med student is not interested in becoming a full-time permanent employee, resulting in a high level of attrition and a training and hiring process that can seem never-ending for a healthcare facility, whereas an experienced HDS or MA can be a solution to these issues.

Ms. Sullivan also states that an audience member wanted to know the difference between a scribe and a medical language specialist (aka medical transcriptionist/healthcare documentation specialist). “Dr. Webster responded that patient information entered by a medical scribe is not the same thing as the process of dictation/transcription. ‘It’s not a fair analogy because the process of dictation and transcription still involves the physician as the central actor intellectually and cognitively. That content is generated by the skill set, training and experience of that physician cumulatively.’ ” This is at best an inaccurate statement. Dictation/transcription is traditionally done after the fact–that is, after the patient encounter is completed. The chart is customarily completed at the point of care (POC) in real time. Transcription is customarily completed and returned to the client 24-72 hours later, depending on many factors–ESL provider dictation, unintelligible audio, etc. A provider can still dictate findings or any other section of the EHR to the scribe, which is then transcribed into the record. The provider is still the author of the record. The provider is still completely and totally responsible for the content of that record. That provider is still the “central actor,” whether the record is traditionally transcribed from an audio file or completed by a scribe at the POC. This argument holds no water. One advantage to having a scribe at hand is the ability for the scribe to verify and confirm what the provider has dictated. No blanks are left in a document. Traditional medical transcription must sometimes leave blanks in a document due to unintelligible dictation or the fact that the HDS has no way to communicate with the provider and cannot fill these in.

Yes, it is true that a patient may not want a scribe in the room, but this issue can easily be solved by good communication between the provider and patient. It is simple to dictate findings to the scribe outside the room. Another way around this is to have a remote, or virtual, scribe. The scribe can be located outside the facility or in a separate department in the facility and in audio communication with the provider. Hospitals who have eliminated their transcription departments may be well served by training those employees to become scribes and work alongside the providers whose work they are used to transcribing.

What a scribe does NOT do: Diagnose; make independent decisions or judgments regarding a patient’s care or treatment; choose orders including labs and/or medications; change what the patient says to completely change the context or meaning; perform or assist with any procedures, even the most benign.

The Joint Commission does not recommend scribes entering CPOE; however, certified scribes, especially those who are already CMAs, may enter and pend orders for the provider to sign in a clinic environment.

A top-notch training and quality program can eliminate many of the errors one might see with inexperienced scribes. AHDPGTM provides training for both beginning and allied health professional scribe students and also provides training and implementation services to clients who are considering using scribes in their facilities.

A new challenge published by Athena Health last week is entitled “Let Doctors Be Doctors.” 1 This speaks to the increasing frustrations by physicians regarding the weaknesses of our current electronic health records system. ZDoggMD (Dr. Zubin Damania), a well-known healthcare speaker, has produced a video that reflects the issues with the EHR and how they are affecting medicine on a daily basis.

Why the frustration with the EHR? Many issues exist, but a major one is interoperability. According to HIMSS, the definition of interoperability is “… the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged. Data exchange schema and standards should permit data to be shared across clinicians, lab, hospital, pharmacy, and patient regardless of the application or application vendor.” 2

The Department of Defense and the Veterans Administration have forecasted the year 2022 as the time in which their EHRs will become interoperable; the DOD and VA have been working on this for two decades! 3  Why does there appear to be such a problem with EHRs “talking” to one another? No one has come up with a good solid reason as yet, but many excuses exist: vendors and their proprietary systems; no standards in place; no focus on health information exchange or EHR usability.

Another significant issue leading to physician frustration is the loss of precious time. A study by the American Journal of Emergency Medicine found that physicians at St. Luke’s University Health Network in Pennsylvania spent an average of 43% of their time on data entry and only 28% of their time on patient care. 4 That’s almost half their time on a computer! In addition, an average of 4000 clicks were made by each physician during a 10-hour ED shift.

Physicians want and need to return to patient care, and patients deserve better. That is the driving force behind the “Let Doctors Be Doctors” campaign. EHRs are here to stay, but physicians need help now if medicine is going to heal itself. Scribes are a great solution to this problem. At AHDPGTM, we train allied health professionals–healthcare documentation specialists, medical assistants, etc.–in the fine art of translating the patient’s health story into an accurate, complete electronic record. By utilizing scribes, providers are able to return to their calling–providing patient care–while an experienced allied health professional scribe creates the documentation and performs the “4000 clicks.” This is an easy, viable solution to “Let Doctors Be Doctors” again. Get in touch with AHDPGTM today to find out more!

  1. “THE EHR THAT SOLVES HEALTH CAREʼS BIGGEST PROBLEM: THE EHR.” Cloud-Based EHR and Practice Management Services. Web. 3 Nov. 2015.
  2. “What Is Interoperability?” What Is Interoperability? Web. 3 Nov. 2015.
  3. “Interoperability Is Years Away for the VA and DoD.” Healthcare IT News. Web. 3 Nov. 2015.
  4. “4000 Clicks: A Productivity Analysis of Electronic Medical Records in a Community Hospital ED.” The American Journal of Emergency Medicine 31.11 (2013): 1591–1594. Web. 3 Nov. 2015.

Every day it seems we are alerted to more incidents of medical record errors; in 2014, it was reported that preventable medical errors are the number 3 killer in the U.S. and that 400,000 people are lost each year to these. That is certainly not an insignificant number. What are these errors? The Journal of Patient Safety suggests that Preventable Adverse Events (PAEs) “may be separated into these categories:
• Errors of commission
• Errors of omission
• Errors of communication
• Errors of context
• Diagnostic errors¹

On September 22, 2015, the National Academies of Sciences, Engineering, and Medicine published a report through the Institute of Medicine detailing how diagnostic errors, the largest category of medical errors, can be prevented, and that “urgent change is warranted to address this challenge.² So what is being done and/or proposed to prevent errors? The NASEM recommends 8 goals for improving diagnosis in healthcare. One of these goals is to “Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice.”
Some say the EHR is to blame for these errors. In an article published by The Atlantic, Dr. R. Gunderman states that “A recent study at Johns Hopkins University indicated that hospital interns… spend only about 12 percent of their time interacting with patients. By contrast, they spend 40 percent of their time…interacting with hospital information symptoms. The flesh-and-blood patient is getting buried under gigabytes of data.³

In the same article, Dr. Gunderman relates a story of a newly admitted patient whose intern reported that the patient was “status post BKA (below-knee amputation).” When questioned about the patient, it was discovered on exam that the patient’s extremities were completely intact. Apparently, this patient’s chart had been produced by a speech recognition system and had changed DKA (diabetic ketoacidosis) to BKA—four hospital admissions earlier! How could this happen? Simple: The “new technology” of SR is inherently flawed and can never be replaced by human eyes. The report from NASEM mentions nothing about SR errors.

Speech recognition is not a new technology. Developed in the 1950s, it has, in fact, been in widespread use since the 1990s with the advent of Dragon Dictate. SR was then believed to be an answer to the cost of medical transcription. It was thought that costs could be cut because medical transcriptionists would be editing the documents for errors in SR, instead of transcribing, and that this would take a lot less time. Pay for MTs then was cut in half for editing, despite the fact that some reports were/are so poor that it would take less time to transcribe them from scratch. A provider using SR can edit their own notes; however, this takes precious time away from patient care. If a speech-generated document is allowed to be part of the permanent medical record without editing, chances are high that it will contain errors. This is not the solution to documentation errors.

What are some solutions to these errors? Traditional medical transcription is one. MTs can be the answer to front-line error capture, whether in SR-generated documentation editing or full-document transcription. It is well known among MTs that providers struggle occasionally with dictation, and MTs are professionals who can spot discrepancies and recognize “guesses” (yes, it does happen, too often) at medication and other pronunciations. MTs are trained and experienced experts in creating healthcare documentation. Cons: Traditional transcription is dictated by the provider, and the voice file is uploaded; the documentation may take up to 72 hours to be created and finalized.

What about medical scribes? Scribes can also be a great solution to both error prevention and capture. A recent error found in a medical record could have been caught by a scribe: A patient with simple hypothyroidism was given an incorrect diagnosis code for “Congenital Hypothyroidism with Diffuse Goiter.” The patient noted this error upon reviewing her electronic summary post visit. However, a scribe would have seen and questioned this diagnosis error at the point of care before it became a part of the patient’s permanent electronic record.

Traditionally, scribes are pre-med students who have had some training in producing healthcare documentation. With both classroom and on-the-job training, it can take 6-12 months for a traditional scribe to be up to speed and able to solo scribe without additional training. After the scribe has completed his/her onsite training, it is then up to the providers to continue teaching the scribe. Since a scribes on a pre-med track may be taking advantage of this opportunity during his or her “gap year,” at the end of 12 months the scribe may be leaving for school.

However, at AHDPGTM, in addition to a traditional scribe program, we have an exciting new opportunity for Allied Health Professional scribes. These candidates may be experienced medical assistants, medical transcriptionists, etc., who undergo our expedited program and then are ready to scribe without requiring any additional training time from providers. Thus, you have a professional set of expert eyes to create and edit documentation free from errors. These unique scribes are career employees who are not on track to enter medical school, and you can count on them to be there consistently for your healthcare documentation needs.

Medical errors are preventable with good stewardship of electronic health records; however, an experienced set of human eyes is key to critical thinking and judgment for better prevention of errors.

1. James, PhD., John. "A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care." Journal of Patient Safety 9.3 (2013): 122-28. Journal of Patient Safety. Wolters Kluwer. Web. 12 Oct. 2015. <http://journals.lww.com/journalpatientsafety/fulltext/2013/09000/a_new,_evidence_based_estimate_of_patient_harms.2.aspx>.
2. "Improving Diagnosis in Healthcare--Quality Chasm Series." Institute of Medicine (National Academies of Science, Engineering, and Medicine), 22 Sept. 2015. Web. 12 Oct. 2015.
3. Gunderman, MD, PhD, Richard. "The Drawbacks of Data-Driven Medicine." Atlantic 5 June 2013. Print.

The medical scribe training program is designed to provide students with the knowledge necessary to handle the healthcare documentation activities associated with being a certified medical scribe and further reduce the administrative burden placed on physicians by today’s electronic health record systems (EHRs).

The American Healthcare Documentation Professionals Group, an online provider of healthcare documentation services, staffing, and training, announced this morning at the 37th Annual Healthcare Documentation Integrity Conference & AHIMA’s Clinical Documentation Improvement (CDI) conference the launch of its new Medical Scribe Training Program for Practicing Allied Health Professionals. This expedited training program is designed to give today’s practicing allied health professionals the information and knowledge necessary to handle the activities associated with medical scribing.

“We have trained thousands of individuals in the art of healthcare documentation over our 10+ year history. In addition, as the only training provider who also employs and provides documentation services to healthcare organizations across the country we are uniquely positioned to connect well-trained individuals with the healthcare organizations which require these services,” said Peter Reilly, President and CEO. “By launching this new training program we expand not only our current training offerings but also our ability to help healthcare organizations better leverage their existing resources and for those organizations who would rather partner with an organization for scribe services, allows us to provide on-site or remote scribes at a competitive rate.

The AHDPGTM Medical Scribe Training Program for Practicing Allied Health Professionals starts from the vantage point that each candidate for this program possesses a fundamental level of knowledge in anatomy & physiology, medical terminology, English grammar, computer skills and HIPAA. Courses which would normally target new scribes (those with no previous healthcare experience) will be waived in this program as each candidate passes an initial screening assessment on these subjects. The course is designed to be completed in 2 to 3 weeks by a student who can commit 40 hours per week to their studies and for those students who are actively employed these students will have up to 8 weeks to complete the program.

Upon completion of the online training program, graduates will receive a Certificate of Completion and can sit for the national certification exam administered by the American College of Medical Scribe Specialists.

For more information on our healthcare documentation services, staffing and training offerings, please visit www.ahdpg.com or call us at 1-800-407-1186.

ABOUT US

The American Healthcare Documentation Professional Group (AHDPGTM) is a premier provider of healthcare documentation services, staffing and training. Since 1992, we have provided healthcare documentation services, staffing and training to hospitals, medical clinics, physician groups and other healthcare organizations. We are licensed by the Commonwealth of Massachusetts Division of Professional Licensure and approved by the Association for Healthcare Documentation Integrity’s Approval Committee for Certificate Programs (ACCP)

and the American College of Medical Scribe Specialists (ACMSS). Since 2008 we have been designated a www.military.com

The Medical Scribe role is becoming increasingly more vital in today’s evolving healthcare environment. The Medical scribe is a trained healthcare documentation professional who works side-by-side with a physicians in a variety of clinical settings to relieve the administrative burden and allow the physician to more fully focus on the patient.

Check out our Medical Scribe Career infographic to learn more about the role, its requirements and responsibilities, and what the future looks like for those individuals interested in pursuing a career as a medical scribe.

Change can breed confusion. And with the explosion of information and data that is occurring in the “technology revolution” and the growth of social media, every industry has developed its share of confusion, legends and myths. With all the changes happening in the healthcare industry, especially around EMR and healthcare documentation, misinformation and misconception can occur just as easily, which leads to common misunderstandings about the different career opportunities that exist today.

In a recent article for Dummies.com titled Ten Myths About Medical Transcription, Anne Martinez writes about some of the notions that have grown around the Medical Transcription profession. Central among the myths Martinez addresses are several that predict that the role of medical transcriptionist is being replaced by technology or going overseas. The big takeaway from her article is, Transcription is here to stay and more important than ever.

3 Key points:

  • Speech recognition technology WILL NOT make medical transcriptionists obsolete.
  • Electronic health records WILL NOT eliminate the need for medical transcriptionists.
  • Medical transcription work WILL NOT completely be moved overseas (off-shoring).

Speech recognition technology cannot replace transcriptionists because it can’t recognize nuances in language and meaning, and consistently leads to errors. It’s really a simple equation: technology isn’t human, and language needs human interpretation to recognize things like context, and meaning. These errors make transcriptionists more critical than ever, as they need to monitor the technology for errors and quality.

Electronic Health Records were never meant to replace people. They exist as a digital version of an individual’s health chart. The benefit of this is the health information within the record is available, via a secure system, to all the medical professionals involved with each patient, so each can see a holistic picture of the patient’s health history. Ensuring accurate information is placed in the electronic health record is paramount and will lead to better diagnosis, smarter interaction between disciplines and improved patient care. This digital format allows for immediate remote access by any physician who is authorized to review the patient information.

While there was a period of off-shoring transcription services in the nineties, having medical transcription work performed overseas poses heightened dangers of potentially violating patient-physician confidentiality by unaccountable persons. More recently, changes to HIPAA regulations in 2010 require transcription services to be provided closer to home, to protect patient confidentiality.

In other good news, you don’t need certification to start working. Certification comes later. Transcription career progression, roughly, is: train / work / certification. So, you can complete your training and start working right away.

 

 

As healthcare continues to embrace Electronic Medical Record Systems (EMR), Transcription Service professionals play an ever more integral role in capturing each individual patient story. It is essential to have properly trained professionals managing the documentation process. As with any organization, having the right people in the right positions translates directly into efficient and cost effective operations.

Without a doubt, it’s an exciting time to be working in the healthcare industry. It’s an exciting time to be alive. There is so much going on with technology that is changing, not just healthcare, but changing the world. Along with all the fascinating improvements in technology come a lot of options that can affect how we work, and raise a lot of questions. As soon as you get things settled, new options arise that can make your decision seem already outdated.

A common technology misconception is that installing technology (electronic medical record systems or speech recognition software, etc.) can eliminate transcriptionists as a cost saving measure. However, electronic medical records systems and/or speech recognition software cannot replace transcription, since healthcare documentation specialists are essential to the auditing and verification process that facilitates quality and integrity of documentation.

Trying to solve this problem by transferring responsibility of “self-editing” or the creation of the healthcare documentation solely to the shoulders of the physician results in a.) increased costs by asking a $200/hr. doctor to do what a $20 an hour MT can do and b.) removes a vital “auditor” to ensure the accuracy of the information going into the electronic medical record system.

Not only are changes in technology affecting HIM processes, but combine that with evolving regulatory and compliance requirements, and pressure to reduce costs, and it can be quite challenging just trying to keep up. But without accurate, concise healthcare documentation, it is impossible to achieve core measures, transition to ICD-10, establish clinical data mining to produce required statistics, and/or most importantly, provide optimal patient care.

For over 20 years the team at AHDPGTM has been providing healthcare documentation services, staffing and training to the healthcare marketplace. AHDPGTM’s transcription technology and services drive exceptional electronic documentation that better supports the information challenges your facility is facing today, such as preparing for ICD-10, achieving Meaningful Use, and optimizing patient care.

Unlike many medical transcription service organizations, AHDPGTM is platform independent; meaning we do not mandate which technology will best meet the needs of your facility. Instead we focus on providing the high quality, well-trained labor resources needed to best support the healthcare documentation creation process at your facility. Our platform independence allows us the flexibility to step in at a moment’s notice and assist your facility’s backlog, either on a PRN, overflow or total outsource basis.

As a platform independent provider of transcription services we have supported clients on a variety of platforms including 3M/ChartScript.net/ChartScript.com, Arrendale, Dolbey, Epic, GE, IDX, Infraware, Meditech, M*Modal/MedQuist, Nuance/eScription/Dictaphone, McKesson and many, many more!

AHDPGTM’s unique combination of technology, processes, and services:

  • Accelerates turnaround time.
  • Reduces costs.
  • Minimizes capital outlay.
  • Transforms dictation into meaningful clinical information to support optimal patient care.

With the upcoming launch of ICD-10 the volume and specificity of healthcare documentation is going to explode. Now is the time to put things in place to support everything else the hospital/health system is doing.

When does it make sense to change Transcription Service Providers? Now.

In addition to the doctor, other healthcare professionals contribute to the Patient Story in EMR, and everyone involved must take into consideration the unique nature of each individual patient profile as well as confidentiality requirements. As much as EMR programs provide access to data and add an element of speed, they add a layer of complexity in that there needs to be a human responsible for verifying accuracy, continuity and confidentiality in the EMR. Additionally, as in other industries, the sheer amount of data being made available can be daunting. Medical Scribe, Medical Transcriptionist, Medical Assistant, Medical Biller and Medical Coder are key roles in the evolving adoption of EMR, and the evolution of the healthcare industry as a whole. See our Patient Care Team infographic to see how the different roles interact with the Patient Story in EMR.