ICD-10 requires substantially more documentation in the medical record than ICD-9, and creating this documentation can be a headache for busy physicians and for the coding staffs who struggle to generate codes when they have a paucity of information to work with.
One strategy healthcare systems have embraced to ease the burden of physician based documentation involves hiring scribes to complete that documentation, a practice that has shown measurable gains in productivity, quality metrics and coding accuracy in the pre-ICD-10 era.
For stressed physicians, scribes can be a time-saver and, according to one hospital’s experience, an income producer. A scribe is an unlicensed or licensed person hired to enter information into an electronic medical record (EMR) or chart at the direction of a physician or other provider.
First used to shadow emergency department (ED) physicians, and then gaining popularity as health systems adopted EMR, scribes have moved into other hospital departments. Kathleen Myers, MD, FACEP, an emergency physician who founded Essia Health, a company that provides scribes to health systems, has said medical scribes give physicians the freedom to focus on patient care while meeting documentation requirements.
But it’s important for CEOs and chief medical officers to understand that scribes have their limits. “Scribes are proving to be invaluable to the physician as a time-saving measure in their practice,” Karen Newhouser, RN, BSN, director of education for MedPartners, a healthcare staffing company that provides coding and clinical documentation improvement (CDI) services for ICD-10 validation. “However, in the world of CDI, it is important to remember that a scribe can only write/enter/document what the physician authorizes.”
Encouraging results from hospitals that employed scribes may help get physicians comfortable with the idea of dictating medical notes in real time during a patient encounter and trusting that that person will report it accurately in the medical record.
American College of Emergency Physicians (ACEP) statistics indicate the average ED physician spends between 30% and 40% of each shift on documentation.
ACEP estimates the hourly cost of a scribe at $9-$25/hour. That can depend on the arrangement—whether the scribes are employees of the hospital itself or the hospital hires a third-party contractor, like Essia Health or PhysAssist Scribes or any number of other documentation companies; or if the scribes are used around the clock and in all departments, or just during certain shifts or only in, say, the ED; and the scribes’ level of training. RNs, medical students and unlicensed medical techs have worked as scribes.
This post looks at three examples of how scribes helped hospitals and physicians streamline operations.
St. Barnabas Medical Center in Livingston, N.J.
Hospitalists at this 600-bed facility started using scribes in June 2012. Before scribes, the 15 hospitalists, staffed by Inpatient Medical Associates, handled 12 to 14 patients a day. Two years later, working with five scribes, the physicians were each seeing 22 to 24 patients a day—a 71% to 83% improvement without hiring any new physicians. A scribe’s salary is about one-fifth that of a hospitalist, Maninder Abraham, MD, IMA’s executive and medical director, told Today’s Hospitalist.) The use of scribes has translated into a 90% reduction in billing delinquencies and a 1.3-hour reduction in the length of hospitalist physicians’ workdays.
Discharge summaries at St. Barnabas are now completed in less than 24 hours, whereas they took 72 hours before scribes, and primary care satisfaction jumped from 67% to 98%.
St. Peter’s University Hospital, New Brunswick, N.J., and Northwest Hospital Randallstown, MD.
These two systems, clients of EmCare, a national physician practice management company, participated in a detailed study entitled “Are Scribes Worth It?” that analyzed pre- and post-scribe metrics in both EDs.
Northwest Hospital is a 254-bed critical-care hospital in suburban Baltimore that’s owned and operated by LifeBridge Health. At the time of the study, Northwest had annual ED volume of 65,000 patients and used an ED staff of emergency physicians, advanced practice practitioners (APPs) and “fast track” physicians. Northwest’s ED began using scribes in April 2012.
Among the improvements Northwest Hospital saw after implementing scribes were:
7.64 percent improvement in patients per hour in the ED.
72.5 percent improvement in down-coded charts.
67.3 percent improvement in critical care.
36.2 percent improvement in patient length of stay.
Saint Peter’s is a Catholic hospital in North Jersey with 478 beds and, at the time of the study, an annual ED volume of 68,000 patients. It staffs the ED with emergency physicians, pediatricians, MLPs and “fast track” physicians. Scribes began working there in February 2012. Among the improvements St. Peter’s noted in its ED with scribes are:
8.52% improvement in average patients per hour.
5.87% improvement in average relative value unit (RVU) per patient.
14.82% improvement in average RVU per hour.
87.2% improvement in downloaded charts.
15.85% improvement in length of stay for adult patients.
26.4% improvement in length of stay for pediatric patients.
40.12% improvement in “door-to-doc” times for adult patients.
41.54% improvement for “door-to-doc” times for pediatric patients.
But Mark Switaj, EmCare client administrator, reprises that scribes can only do so much. “Our conclusion is that scribe programs probably won’t fix an ED that is really ‘broken,'” he said. “But EDs that are looking to reduce length of stay, are struggling with a high percent of left-without-being-seen rates or are experiencing challenges with their EMRs could really benefit from hiring scribes.”
Baylor All Saints Medical Center, Fort Worth, Texas.
ED scribes helped achieve dramatic results in metrics, according to a study Timothy R. Jones, MD, associate director at the center submitted to EmCare, “Enticing Best Performance from Physicians.” Dr. Jones examined RVUs generated per hour and per patient, patients seen per hour, Press-Ganey scores and coding trends for level 3, 4, 5, and critical care charts over a 13- month period within his ED group. The results:
RVU/hour increased 27.2% for physicians and 29.1% for APPs.
Patients/hour increased 14.7% for physicians and 16.7% for APPs.
RVU/patient increased 10.2% for physicians and 11.4% for APPs.
Net Charges increased 28.6%.
Collections increased 19%.
“Three clear winners emerge,” concluded Dr. Jones. “The physician with increased take-home pay and a true understanding of his/her practice pattern, the group with increased revenue and, most importantly, the patient who is met by a physician primed to optimize the customer experience.”
Dr. Jones’ study also found that scribes resulted in a 1.3 hour reduction in the length of their physicians’ workday.
The potential for greater take-home pay and less time charting records should be enough to appeal to any stressed out hospitalist or ED physician.
REFERENCES AND SUGGESTED READING
Patel S, Rais A, Kumar A. American College of Emergency Physicians website: Continuing Education—Focus on: The use of scribes in the emergency department. Available at: http://www.acep.org/Continuing-Education-top-banner/Focus-On–The-Use-of-Scribes-in-the-Emergency-Department/
Davies B. Scribes: the solution for too much paperwork—the use of scribes helps boost hospitalists productivity. Today’s Hospitalist. February 2014. Available at: http://www.todayshospitalist.com/index.php?b=articles_read&cnt=1831.
Press release. EmCare’s Genesis Cup Honors Innovation, Creativity in Healthcare. April 23, 2014. Available at: https://www.emcare.com/NEWS-EVENTS/PRESS-RELEASES/2014/EmCare-s-Genesis-Cup-Honors-Innovation,-Creativity.
Chiavetta R. Medical scribes may ease EHR, ICD-10 aches. Health Leaders Media. Dec. 10, 2014. Available at: http://healthleadersmedia.com/page-1/hr-311113/Medical-Scribes-May-Ease-EHR-ICD10-Aches##
Juliann Schaeffer. Rise of the Scribes. For the Record. 2015;27(1):10. Available at:
Harris R, Switaj M. Are medical scribes worth the investment? Becker’s Hospital Review. June 13, 2013. Available at: http://www.beckershospitalreview.com/capacity-management/are-medical-scribes-worth-the-investment.html