Can Scribes Help Improve Emergency Practice Productivity?

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Scribes appear throughout ancient history as "record keepers" who copy legal texts and other documents. Three thousand years later, modern scribes follow healthcare providers to document services rendered, and have taken on additional roles such as tracking down test results and medication orders, taking patients histories and generally acting as an assistant to the provider.

The use of scribes in healthcare has grown dramatically in recent years, particularly in field of emergency medicine. There are several reasons for this growth, but one of the important is the widespread adoption of electronic health records.

"The implementation of electronic medical records in many emergency departments has required a physician learning curve," suggested Luis Moreno, MD, CMO of Scribe America, when I spoke with him in the summer of 2010. "The systems often aren't user friendly. As a result, EMRs actually increase chart documentation time. Interacting with a computer terminal instead of a patient is not an efficient use of a physician's time; thus, the need for scribes."

When I spoke with Dr. Moreno again, at the recent American College of Emergency Medicine Scientific Assembly, he said that the popularity of scribes has accelerated since our previous discussion. At the same meeting, one of the founders of the ACEP was heard to say that an ED practice would be "very foolish" not to use scribes in the current healthcare environment.

Getting value for your money

In the late 1970's, a study in the Annals of Emergency Medicine found that scribes who "shadow physicians" and "act as human tape recorders" increased physician efficiency and improved chart documentation. In the modern healthcare setting, there are several ways to determine the effectiveness of a scribe program using objective metrics, such as: relative value units per hour or shift; number of patient's seen per hour or shift; clinical time vs. administrative time; average charge per billable visit; number of incomplete and deficient charts; door to discharge time; Press Ganey scores; and patient satisfaction follow-up survey results.

The above measures provide benchmarks of a practice's efficiency in many areas, and should be available via software (if the practice does its own coding/billing) or from a vendor (if the practice outsources its coding/billing). Let's examine a few in greater detail:

• RVUs per visit, hour, shift. RVUs, which were developed in the early 1990s as Medicare's Part B method of reimbursement, have become a gold standard metric for medical practices. The RVU measure is important to many providers because often their bonuses, or a major portion of compensation, are based on RVUs.

An effective scribe program can have a positive impact on RVUs several ways. As documentation improves — particularly if the practice was losing RVUs due to poor documentation — RVU per visit should increase. Also, an effective scribe program should allow a provider more clinical and less administrative time required per hour and shift. As the provider is freed from administrative burden, his or her RVUs per hour and shift can increase. This can also allow an ED practice the capacity to treat additional patients.

Katherine Stubbs is both the president and a scribe at Superscribes of Atlanta. Regarding scribe metrics, she comments, "At [hospital A], we reviewed metrics for 2009 and compared those metrics to 2011 [the first full year of scribe service]. We reviewed the production of five physicians who use scribes for every shift. Those physicians increased from 72.57 to 80.57 average RVUs per shift. Other measure that are important to hospital and ED management include measures of patient satisfaction and ED throughput."

• Average charge per visit. EDs and other practices have used this measure for many years. The average charge per visit as a measure is impacted by the fee schedule and the services coded per visit. As documentation improves with an effective scribe program, E/M Level acuities increase. These increases affect the average charge per visit, which in turn affects the average collection per visit. However, practices must be careful to ensure increases are the result of improved documentation when medical necessity supports a higher-level service, not as a result of unsubstantiated "upcoding."

• RVU's lost by deficient charting. Many practices lose RVUs and the resulting revenue because of charting deficiencies. For example, an RVU killer is the provider who documents only three elements of an HPI (duration, severity and timing) when an additional standard element (such as a modifying factor: "analgesic failed to reduce pain") was taken but not recorded. Such an oversight may result, for instance, in reporting a CPT 99283 instead of a 99285.

Lost RVUs and revenue also result from incomplete review of symptoms: family/social/and previous medical histories; physical exams; and medical decision making. EHRs are supposed to improve this documentation, but in many cases has made proper documentation worse due to user unfriendliness and provider resistance. This is where scribes have had a major impact: By documenting in real time all the elements of a service (as opposed to the provider having to recall these items later), the scribe improves reimbursement, as well.

Ms. Stubbs does add one caveat. "Scribes do not provide instant improvements in various measures. It takes at least 60 days of a physician working with a scribe, and the scribe becoming accustomed to the physician's communication, clinical and documentation style for the scribe to become fully effective," she says.

• Unbillable/Incomplete charts. The second measure of the impact of a scribe program should be a decrease in unbillable charts. There are a number of reasons that charts cannot be coded when they reach the coding/billing office. These include major elements of the charts missing (such as the physical exam), lack of teaching physician attestation and missing provider signatures. In theory, unsigned charts should not exist — but they do for a number of reasons, including timing of when the chart is sent to billing, the chart being incomplete when the physician shift ends, and simple forgetfulness. As any provider knows, this presents medical/legal, as well as billing, challenges. A scribe who works well with a provider is there to prevent incomplete and unbillable charts, often simply by reminding the provider to sign the chart.

The bottom line isn't the only measure of improvement

In addition to improving objective measures as outlined above, scribes also improve subjective measures such work and life quality and general job satisfaction for providers.

Richard Schwab, MD, FACEP, chairman of emergency medicine at Holy Name Hospital in Teaneck, N.J., and past president of the New Jersey chapter of American College of Emergency Medicine, was ahead of the scribe curve by implementing a scribe service for his practice several years ago. Regarding the impact of establishing a scribe service, he states, "Our providers have the time and capacity to see nearly twice as many patients since we have established our scribe service. In addition to scribing, our scribes allow our providers to focus on patients by following patients, tracking critical patient information such as test orders and results and handling phone calls. Although difficult to measure, the scribes have had an immense impact on the constant interruptions and stresses that go with a busy ED."

Decreasing the administrative burden on providers is a major element in job/life satisfaction, as well as practice efficiency. Burnout remains an issue particularly in specialties such as emergency medicine.

Providers want to practice medicine and not be overburdened by time-consuming documentation requirements. Scribes relieve the provider of some of these burdens (though, it must be noted that documentation is legally the provider's responsibility, which the scribe supplements). As described, scribes are accepting roles that include taking elements of patient history, tracking down test results, etc. As well, patient satisfaction improves if the physician can provide more time for patient interaction.

Jim Strafford, CEDC, MCS-P, is a senior manager of client services at Medical Management Professionals, a provider of billing and practice management services to emergency medicine physicians. Mr. Strafford has more than thirty years experience as a consultant, manager and educator in all phases of medical coding, billing, compliance and reimbursement. He can be reached at

More Articles on Scribes:

Are Scribes the Missing Link Between Physicians and EHRs?
EMRs Create Need for More Medical Scribes

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