In an occupation that can already be difficult, healthcare providers are often burdened with many responsibilities that are not directly related to patient care. With the transition to using an electronic medical record (EMR), the administrative and clerical burden on healthcare providers is even greater, which further reduces the time they can spend with their patients. To many physicians, their patients’ well-being is their biggest priority, so any request for them to spend time on tasks that do not help their patients is likely to be met with resistance. As Menon (2015) notes, some physicians feel like EMRs have led to an ironic situation where they are spending more time on each patient visit, but actually spending less time interacting with their patients. Medical scribes are helping to correct this situation. Medical scribes document patient visits in EMRs so doctors can focus on their patients. The impact of scribes on relative value units (RVUs) and other physician efficiency metrics are explored in this article.
EMRs Offer Potential Benefits and Pitfalls
While EMRs offer a variety of exciting possibilities, they bring with them a time when physicians are no longer able to document their visits and orders with a few scribbles and a quick dictation. The transition to EMRs can potentially lead to many pitfalls that must be addressed. Among these issues is the matter of efficiency. Scribes are a solution to the documentation burden being experienced by healthcare providers, and they can be beneficial regardless of a healthcare provider’s adaptability to new technology and increasing documentation requirements.
Advancement into electronic record keeping for medicine brings with it many exciting opportunities as well as several cumbersome obstacles. Some of the potential benefits of this transition include reduced time for completion of documentation, improved access to records for patients and for healthcare providers for enhanced decision making, and improved availability of services for patients, such as e-prescribing medication prescriptions. The computer hurdle must be overcome to achieve these benefits.
If healthcare providers are unable to do this themselves or with the help of others, then the potential improvements in efficiency from EMRs turn instead into productivity nightmares. Incomplete encounter notes quickly pile up while hasty attempts to complete them in a timely fashion leads to a higher chance of them being flawed and in need of correction, which leads to delays in billing and completion of orders. Healthcare providers sometimes must revisit notes to complete them from memory several days later, which can be hazardous to accuracy and often at the expense of the provider’s personal time.
Documentation Errors are Costly
Unable to use their infamous handwriting on the computer and with their Dictaphones in a drawer in their desks, many physicians attempt to brave the challenge of documenting on their own. Alarming numbers of incomplete notes, reduced patient interaction, and flawed notes are not uncommon outcomes in this situation. When a note is not done correctly, delays in billing and services can happen. Events like these lead to obvious disruptions in a patient’s care, convenience, and sometimes their finances. Furthermore, a clinic’s workflow can be negatively affected by patient phone calls related to the error or even the physician having to see the patient again to correct the mistake. While errors can affect typical services received during a patient encounter, such as medications and procedures, they also have a large impact on less common visit reasons, such as visits for durable medical equipment like power scooters or wheelchairs.
Durable medical equipment often requires brutally meticulous documentation for approval. It is disappointing that fraudulent behavior has increased the need for such precautions, and incorrectly documenting something seemingly minor in an encounter for these goods can lead to a patient, whose debilitation is otherwise well-documented, not receiving something that will make their life more bearable to live.
EMR Mistakes Can Reduce Efficiency
Besides the normal grueling standards for documenting patient visits in EMRs, there are a multitude of possibilities for mistakes to drag down efficiency. In some programs, for instance, a simple misclick with the mouse can lead to entire sections of an encounter note being duplicated, which can cause contradictions and redundancies. Sometimes, the only options in this case are to either erase the entire duplicated section and redo it, or meticulously read through and pick out each of dozens of items that may have been duplicated. Two parts of the chart where this can happen frequently are in the review of systems and physical exam, and in EMR systems these areas can be very busy-looking.
With the EMR already consuming so much of the physician’s time, it is no wonder how mishaps like this can wreck a provider’s already compromised workflow. Another common source of mistakes in EMRs comes from citing information from previous visits into the current encounter note, which is a technique often used by healthcare providers doing their own notes. This can clearly be advantageous when a patient’s care is straightforward and unchanged from visit to visit, but can lead to mistakes when certain changing parts are overlooked and not modified. When accidents like these happen, a physician loses either time with patients or their own time going back to fix it.
Medical Scribes Help Older Physicians
Medical scribes are among multiple proposals for ways to solve the problems presented by EMRs. Scribes can have different impacts for different physicians. For instance, some older physicians never imagined a time when they would be required to input information into a computer. And themselves? You must be crazy!
I’ve worked for a few older physicians who had little interaction computers in their personal lives outside of work. Predictably, their baseline knowledge with computers was low and their initial progress with learning how to use them and the EMR was slow. Additionally, these physicians sometimes had distorted, misguided, simplified, or overly-grand ideas of what a computer and documentation software can and can’t do. For physicians like this, whose burden caused by computers would be too much for them to overcome while still seeing patients efficiently, scribes are a saving grace allowing them to close out their careers without completely feeling the weight of electronic record keeping.
Scribes are Useful to Computer Savvy Doctors Too
Despite the challenge, some healthcare providers do manage to complete their documentation responsibilities while still efficiently seeing patients. There are many younger healthcare providers entering the workforce whose relationship with computers is near-innate, and of course there are those in between who can function well enough with them while still seeing patients. Even these providers, who succeed in doing their own documentation, would likely see improvements in efficiency and documentation quality with the addition of a medical scribe.
While a provider who is competent with documentation on their own may not use a scribe in the same way as a provider who needs help for most computer tasks, this provider can still use their familiarity with computers, the facility’s EMR system, and documentation requirements to use the scribe in creative ways that allow them to see more patients with improved documentation. Selling scribes is difficult for some physicians who feel they can manage documenting on their own, especially when it comes to the overhead of having a scribe. Nonetheless, tasks that need completing and people who need help in a medical facility are never in shortage, so scribes who work for more EMR-capable physicians can be utilized for other projects.
Scribes and Emergency Department Efficiency
Being such a fledgling occupation, the literature on scribes is still building. Nonetheless, many early studies show that scribes are a promising solution to the task of documentation in a landscape of increasing regulations. The earliest use of scribes appears to be in hospitals, specifically in emergency departments. As such, much of the initial research on the utility and return on investment of scribes has been done in these types of settings.
Scribes have been found to lead to an increase in efficiency in emergency departments. Patients seen per unit of time is an important metric in any healthcare setting, but it is understandably more important in emergency room settings. With the importance of protecting the time of physicians so it can be allocated to patient care, it is no wonder why emergency rooms were where medical scribes seem to have started.
Scribe Use Increases the Number of Patients Seen
In one study, there was a positive correlation between increased implementation of a clinical scribe program and number of patients seen per hour where every 10% increase in scribe utilization was associated with nearly another patient seen per hour (Arya, Salovich, Ohman-Strickland, & Merlin, 2010). Hess and colleagues (2015) observed a similar, yet less pronounced trend in patients seen while using a scribe in their study involving an academic emergency department. Another study, which was done in an Australian healthcare setting using a scribe trained in the United States, found a 13% increase in patient consultations per hour (Walker, Ben-Meir, Phillips, & Staples, 2016). These studies, each with their own factors influencing workflow, all share a common demonstration of scribes improving efficiency. Importantly, improvements in the doctor-patient relationship are seen with medical scribes even with increased number of patient visits.
RVUs Increase with Healthcare Scribe Use
Patients seen is an important measure, but not the only way by which healthcare efficiency is quantified. Relative value units or RVUs are another way healthcare productivity is measured, and they are also a way by which physician reimbursement is determined. Consistent with their findings relating to patients seen, Arya and colleagues (2010) found that RVUs increased 0.24 units with each 10% increase in scribe usage. The study done by Hess and others (2015) also found increases in per hour and per patient RVUs at 5.5% and 5.3%, respectively.
This study also found that the implementation of scribes led to a 36% reduction in time spent documenting and a 30% increase in time spent in direct patient contact, both of which can clearly improve efficiency.
Scribes Improve Physician Productivity
The use of scribes outside of hospitals was less prevalent initially, but they can now be found in a variety of settings in increasing numbers. Consequently, the body of research on scribes outside of hospitals is growing. In a variety of specialties, scribes are being shown to provide the same types of benefits they allowed physicians in hospital settings. For instance, Bank and colleagues (2013) have found improvements in several measures when implementing scribes in a cardiology clinic including:
The number of patients seen increased 59% from 2.2 to 3.5 per hour
RVUs increased 57% from 3.5 to 5.5.
81 more patients seen by 4 physicians over the course of 65 clinic hours. These additional patients led to an additional $205,740 in revenue generated.
The implementation of scribes also had logistic benefits. For example, in the absence of a scribe, established patient visits were 20 minutes long, new patient visits were 40 minutes long, and there were several empty schedule slots blocked so the provider could catch up on documentation. With the introduction of a scribe, established and new patient visits were reduced to 15 and 30 minutes, respectively, and the blocked schedule slots for catchup were eliminated.
More Job Satisfaction and Revenue
Perhaps the most common area to find scribes outside of the emergency room, at least for now, is in primary care. In addition to documenting the actual patient encounters, medical scribes are also useful in these settings for helping providers keep up with documentation of routine screenings, handling the numerous codes that must be reported, and in some settings, they help with inputting physician orders into the EMR, as the simplicity of written and oral orders is virtually gone.
One study taking place in a family medicine setting utilized 4 part-time scribes and 6 physicians (Earls, Savageau, Saver, Sullivan, & Chuman, 2017). Over the course of the study, physicians spent 5.1 fewer hours per week on documentation, which allowed them to see more patients and reduce the strain placed on their personal lives from increased documentation. Due to this reduction in physician time spent on documentation, the implementation of medical scribes was expected to generate $168,600 per year. Considering the estimated cost of 2 full-time medical scribes at about $79,500, it is easy to see how using medical scribes can be a useful investment.
Scribes Improve Documentation Quality
Time isn’t the only factor to be considered when discussing efficiency of documentation. The quality of the notes is as imperative as their timely completion. Physicians are well-aware that the tiniest mistakes can have severe consequences, but it is unfortunate when sound medical expertise is brought down by clerical errors. When a physician is trying to balance documentation in accordance with rigid guidelines while also providing adequate treatment and attention to the patient, the possibility increases for errors that lead to inconveniences, increased costs, denials, and delays in treatment.
Issues with quality are also addressed by using medical scribes. Using the Physician Documentation Quality Instrument 9 (PDQI-9), Misra-Hebert and colleagues (2015) found that scribed notes maintained a higher quality compared to notes that had not been completed by a scribe. In addition to quality measured by the PDQI-9, scribed notes were “more up-to-date, thorough, useful, and comprehensible.” These findings show that scribes provide the benefit of not only seeing more patients, but also provide records of patient encounters that are superior to what they were previously.
The landscape of healthcare provides many challenges. In an industry where the focus should always remain on patient care, a multitude of influences continually draw resources away from this central mission. A variety of approaches for overcoming EMRs have been used, but medical scribes are proving to be a long-term solution to problems with efficiency in healthcare.
Arya, R., Salovich, D. M., Ohman-Strickland, P., & Merlin, M. A. (2010). Impact of Scribes on Performance Indicators in the Emergency Department. Academic Emergency Medicine, 17(5), 490-494.
Bank, A. J., Obetz, C., Konrardy, A., Khan, A., Pillai, K. M., McKinley, B. J., . . . Kenney, W. O. (2013). Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. ClinicoEconomics and Outcomes Research, 5, 399-406.
Earls, S. T., Savageau, J. A., Saver, B. G., Sullivan, K., & Chuman, A. (2017, April). Can scribes boost FPs' efficiency and job satisfaction? The Journal of Family Practice, 66(4), 206-214.
Hess, J. J., Wallenstein, J., Ackerman, J. D., Akhter, M., Ander, D., Keadey, M. T., & Capes, J. P. (2015). Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice. Western Journal of Emergency Medicine, 16(5), 602-610.
Menon, S. P. (2015). Maximizing Time with the Patient: the Creative Concept of a Physician Scribe. Current Oncology Reports, 17(12).
Misra-Hebert, A. D., Amah, L., Rabovsky, A., Morrison, S., Cantave, M., Sinsky, C. A., & Rothberg, M. B. (2016). Medical scribes: how do their notes stack up? Journal of Family Practice, 65(3), 155-159.
Walker, K. J., Ben-Meir, M., Phillips, D., & Staples, M. (2016). Medical scribes in emergency medicine produce financially significant productivity gains for some, but not all emergency physicians. Emergency Medicine Australasia, 28(3), 262-267.