Strategy: Could You Use a Scribe?

Think back to your last dental visit. “Number thirty M-O-D,” your dentist rattled off in tooth-speak to his assistant as you lay back in the chair.

Translation? A decades-old molar filling is crumbling away. “Stop smoking,” he chides you while probing your gum line. “Three-two-three and four-one-four,” he again reports to his assistant - apparently disappointing combinations, because they earn you a “concerned parent” talk on your increasingly probable trip down Periodontal Lane.

Your dentist remains fully focused on you while you swear you’ll change your evil ways, and he ends the exam without making a single patient note. Still, every detail about your less-than-stellar exam appears in your record. How? Someone is recording it for him - a dental assistant à la court stenographer. Essentially, a medical scribe.

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What a boon to you both. Your dentist doesn’t need to pause repeatedly during the exam to record his findings. Rather, he discusses issues with you, uninterrupted by having to rifle through paper charts or enter data into EMR templates. However you may feel about going to the dentist, this sustained attention - thanks to the scribe - has helped you receive a thorough examination.

Of course, physicians need, want, and try to focus on their patients the same way. So why don’t they use medical scribes as well? Some do, but it’s mostly confined to emergency medicine. Many emergency medicine physician groups and hospitals across the country have established medical scribe programs to help ER docs with charting and taking care of their other nonclinical support duties in a timely manner. The benefits: The physician operates more efficiently, while the scribe - usually a pre-med student - gains valuable knowledge, experience, and networking opportunities to help launch a career in medicine.

Yet the use of scribes has not caught on widely among private practice physicians. But perhaps in this day and age of increasing patient panels and decreasing reimbursements, the time has come to incorporate medical scribes into practices as a matter of necessity. The benefits of doing so can include increased efficiency, fatter bottom lines, greater job satisfaction, and better patient care.

The medical scribe, defined

A “typical” medical scribe is a pre-med student who works part time while in school for roughly two years with an emergency medicine physician group. Scribes assist physicians on a real-time basis with the clerical aspects of patient care. Clinically, a scribe remains “hands off.” A medical scribe should not be confused with an intern, a nurse, a nonphysician provider, or any other healthcare support worker. Scribes have received little to no clinical training and, as such, are precluded from performing any clinical duties. Rather, they allow the physician with whom they work to shift his focus off of his tablet PC or paper chart to his patient. Specifically, a scribe is responsible for:

• Taking patient histories, often before the physician begins examining the patient.

• Transcribing details of the physical exam and patient orders. This includes any lab tests, imaging tests, or medications ordered by the physician. A scribe may also be present to record a physician’s consultations with family members or other physicians about a specific patient’s case.

• Documenting procedures performed by the physician or any other healthcare professional, including nurses and physician assistants.

• Checking on the progress of lab, X-ray, or other patient evaluation data and transcribing the results into patient charts so that a patient’s workup is complete and the physician can make sound treatment decisions.

• Recording physician-dictated diagnoses, prescriptions, and instructions for patient discharge and/or follow-up.
  

Who benefits, and how?

Arnie Winden, practice administrator for the North Fresno Emergency Physicians Medical Group, says that establishing a scribe program within his practice eight years ago has made a measurable difference in patient care. He estimates that the program has lopped off 10 percent of the time his physicians need to spend with individual patients. During these shorter encounters, physicians can focus on the clinical problems at hand while verbally reporting their findings to a scribe as the exam progresses.

And patients notice. Sick or injured people need and want help now. Winden says that one major reason the practice decided to incorporate scribes was to enhance efficiency: “Nobody wants to come in here and wait for eight hours for some help. Scribes have helped with that.”

The practice as a whole benefits from its scribe program, explains Winden. With clerical duties relegated to dedicated “apprentices” rather than clinically trained, overworked medical personnel, workplace satisfaction has gone up across the entire staff. A scribe’s full concentration on creating a complete chart results in improved compliance, more accurate (read: higher) coding, and, therefore, increased reimbursements - both on a per-patient basis (less under-coding) and a patient load basis (more patients seen per day).

Using a scribe is optional within Winden’s group, and indeed six of its 23 physicians opt out of the program, although Winden says he has “converted a couple over.” Some truly don’t need the service. One doctor on staff is “fast anyway,” explains Winden. But then there’s the other extreme: “We have another physician who charts almost illegibly,” Winden says. “He has to have a scribe.”

Winden adds that new doctors who join the practice particularly benefit from the service of scribes, as they are more likely to accept a scribe as a legitimate assistant. Overall, Winden’s physicians welcome a scribe’s assistance because doing so allows them to feel and act like doctors rather than data-entry personnel.

Of course, employing a medical scribe is an investment, says Winden: “We want them to be committed for two years. It takes a while for them to get up to snuff. If they’re only here eight months or a year, it doesn’t really benefit them or us.”

Training a scribe can take up to three months, starting with a crash course with a health education expert in a hospital’s emergency department. After that, would-be scribes attend a three-day class. Finally, the apprentice shadows an experienced scribe for one month.

“We make reference cards for when they’re learning coding, documenting, and creating a complete note - cheat sheets,” explains Winden.

Working the numbers

In addition to assisting physicians, scribes can perform nonclinical duties that lighten the nursing staff’s workload. Scribes cost less per hour than registered nurses - at least 50 percent less. And because they’re in school and work part time, you needn’t provide benefits.

Still, how to cover the cost of your own scribe program? By cashing in on their efficiency. If your scribes are knowledgeable and hardworking, your physicians will see more patients in less time, your coding will be more accurate, and your patient work flow will improve. But how can you be sure of a return on your investment? Consider the following “composite” situation:

Let’s assume you see 40 patients per day five days a week for 48 weeks a year. According to Physicians Practice’s 2006 Fee Schedule Survey, the average reimbursement for a 99213 - established patient, midrange exam level - is roughly $50. Do the math for an annual gross income of $480,000. Then chop that number in half to account for overhead (that’s about the national average, according to a compensation survey published by Physicians Practice). Assume the scribe earns $15 an hour (a high estimate).

As you can see in Table A, you’ll need to see an additional 2.5 patients per day, on average, to break even after accounting for the cost of the scribe. After that, the scribe more than pays for himself. And if Winden is correct in his estimate that scribes boost a physician’s productivity by about 10 percent, then the physician described in Table A would be able to add four patients to her schedule each day - adding nearly $20,000 a year to the practice’s revenue, and that’s after paying the scribe. The more efficient your scribe(s), the more patients your physicians will be able to see.

What effect can a scribe have on raising your reimbursements? A well-trained scribe is more likely to accurately catch (and code) all of your work as you perform it and call it out. And as we’ve just seen, a scribe can save you time, allowing you to see more patients per day. Consider this hypothetical situation involving in-office procedures:

Let’s say you perform a 10160 (puncture aspiration of an abscess, hematoma, bulla, or cyst), which scores about double the rate of a regular visit ($106 vs. $50-ish), or you may perform a 12052 (layered closure of wounds of the face, ears, eyelids, nose, lips, and/or mucous membranes) for $285. Coding for these procedures in conjunction with regular office visits, let’s say your average reimbursement jumps to $75 per encounter.

As you can see in Table B, you now have to add only two patients per day to break even. Notice how at three or four more patients a day your bottom line starts to fatten nicely.

Keep it real

Of course, these hypotheticals have been simplified with easy-to-use numbers that do not take into account other variables, such as training costs. They also assume that your scribe or scribes will operate at optimum capacity, affording you the opportunity to see more patients and to perform more high-reimbursement procedures. Remember that a scribe requires one to two months to train - on your dime. And there is always the risk of attrition; then you’ll have wasted whatever you invested in your potential scribe(s) and have to swallow your costs.

But if this scenario still sounds promising, where do you start looking for potential scribes? Thus far, scribes are pretty much found only in hospitals and other emergency medicine settings. Indeed, Lindsey Hilliard, the regional scribe director for PhysAssist Inc. - a scribe training program in Dallas/Fort Worth - says that she has “not heard of any that work in individual practices.”

Christi Smith, the scribe program manager at Virginia-based BestPractices Inc., concurs. Even so, she can perceive how a private practice could benefit from a scribe’s services. “I think it would be a wonderful idea,” she says. “It could work in the private setting, and the patients would probably appreciate it, although it may take a little while to get used to having someone else in the exam room.”

Smith’s recommendation? Cross-train your LPN or medical assistant to serve as a scribe as well. “The important thing with the medical scribe is knowing the medical terminology, having excellent handwriting or typing skills, and spelling,” she says. “They won’t have the knowledge the doctor has, but they need to know the terminology to be able to scribe properly.”

Timing is everything

So with the proper training and tweaked parameters, incorporating a scribe into your practice could allow you to slightly increase your patient load and shave off fractional minutes from each patient encounter. The end result? Focused, streamlined, patient-pleasing office visits that yield higher reimbursements from more accurate coding and a less-stressed staff - truly a better experience for everyone involved.

Winden is thrilled with the results in his practice: “I haven’t received any complaints at all. I think it really helps. When the physician says, ‘I’ll be right there,’ the scribe can go in and start taking the documentation. Then when the doctor comes in, all this stuff is already documented. The patient feels he’s being treated right away, even though the doctor isn’t seeing him yet. … They feel like someone’s taking care of them - and someone is.”

Shirley Grace, MA, senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in numerous publications, including The Washington Post and Notre Dame Business magazine. She can be reached at sgrace@physicianspractice.com.

This article originally appeared in the April 2007 issue of Physicians Practice.