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Scribes: Pearls and Pitfalls

Much has been published regarding the use of scribes in the past few years. The position was born out of a need for reducing data entry time by physicians, while simultaneously increasing efficiency of the physician and allowing more time face to face with patients. Although they were once primarily utilized in emergency departments, scribes today are found in all manner of medical practices. The use of electronic health records has become ubiquitous leading to a similar need for data entry personnel in all medical specialities.

The increase in publications regarding scribes has demonstrated a consistent improvement in physician efficiency and job satisfaction. At a time when the country is beginning a national physician shortage, the improvement in job satisfaction is likely to play a key role in recruitment. Although there have been reported improvements in emergency department length of stay, this is due to the downstream effect on physician productivity.

Let’s examine some of the common issues encountered when setting up a scribe program.

1. Cost/Benefit – There is a case to be made for the financial benefit of having scribes. Here are a few ways that costs comparisons can be made.

  • Scribes improve physician efficiency. This has been proven (see article list below). This improvement in efficiency may result in improvements in physician productivity, i.e.- patients seen per hour. However, depending on the acuity being seen in the emergency department or clinic, this gain may not be realized. It would be easy to make the case utilizing patients per hour seen since that equates to a tangible revenue for cost comparison. More often what is seen is an improvement in physician job satisfaction and an improvement in patient satisfaction. Although theses are not as easy to translate into discrete dollar amounts, they certainly have a price. Additionally, there are emergency department studies that have shown a reduced LOS as a result of the efficiency gains. This also should be accounted for when making the financial case for scribes.
  • Many institutions lose up to 30% of their productivity with the transition to an electronic health record. Although those systems are improving, the focus on user efficiency is in its infancy. Scirbes have been shown to restore physician efficiency to levels seen prior to the implementation of electronic health records. However, scribes should not be expected to routinely exceed pre-EHR physician efficiency levels.
  • When used in a hospital setting, any gain seen in physician patients per hour is multiplied for the institution when facility charges are also taken into consideration.
  • Scribe salaries can be passed along as a charge to the individual physicians, a shared expense at the group level, or a cost that is included in a package for recruitment. In the approaching physician shortage, this is an attractive component of a complete offer.

2. Home Grown Or Contracted – Wether you are utilizing scribes in a clinic or a hospital setting, there are two options for the program: employ or contract. This decision should also come with a few considerations.

  • Contracted solutions provide a quicker start up and the convenience of not having to manage the work force. However, they are more expensive and termination of the contract includes noncompete clauses for all the scribes so all are lost at termination.
  • Employed scribes require several administrative hurdles such as recruitment, establishing a training program, assigning a supervisor and scheduler, and administering payroll. However, the individual hourly rates of the scribes can typically be set lower and large organizations may be able to absorb the administrative duties and costs. Smaller offices with smaller staffing requirements may also find this a better avenue to develop long term retention.

3. Job Description – There are some regulatory restrictions regarding the role of scribe.

  • The Joint Commission has made it very clear that scribes may not perform order entry. If you are in an environment where you have such oversight, this item is not negotiable.
  • The scribe job description should be clear that scribes are not avenues for the modification of poor physician behavior. Specifically, it is not a scribe’s duty to monitor physician behavior or serve as a corrective method for poor behavior. This is the duty of the medical director.
  • It should also be made clear that scribes cannot serve as communication “go-betweens” physicians and other staff. In the hospital setting, physician-nurse communication should not be supplanted by physician-scribe-nurse communication as this introduces significant room for human error. Scribes do not have the education or training to tackle such conversations.
  • CMS has accepted that scribes may independently document elements of the history that can be gathered from patient self reporting forms, or questionnaires. These include the past medical history, surgical history and social history. All other information is dictated by the physician to the scribe during or after the patient encounter.

4. Credentialling – For larger institutions and hospitals, credentialling scribes should be performed so as to allow them to access all the necessary portions of the patient electronic record required to perform their duties. This seems obvious, but it is important to remember that the scribe requires a significant level of unrestricted access to a patient chart.

5. Employee Pool – If you choose to create your own scribe program, give some thought to the type of qualifications you want in an applicant. Traditionally, college students who have an interest in medicine and even medical students have served as scribes. This creates a mutually beneficial scenario since the scribe has an interest in the medical care and has access to education from a physician as part of the job. However, it does also create significant turnover in the employee pool as school schedules change and students graduate.

6. Training – The ideal training program provides instruction on use of the electronic health record and then a significant orientation regarding the environment. Since the physician will rely on the scribe to effect efficiency, it is important that the training focus on all the aspects of the physician workflow. Otherwise, the physician will spend a significance amount of time educating a new hire.

7. Staffing – Consider what shifts will require scribes, how many hours per day and days per week you are seeking. Also be sure the physicians are in agreement regarding the option for a scribe. Some practices make it an optional service to have a scribe but at a cost to the physician. Others find it to be so impactful that all shifts are staffed with scribes regardless of physician preference.

8. Hourly rates – In a large organization with a contracted service, expect to pay hourly rates above minimum wage. In a solo office practice this may also be necessary to retain a high performing scribe.

9. Supervision / Reporting – Be sure there is a clear supervisor responsible for the scribe pool. This person should have final approval of hires, oversee the training program, and deal with any human resource issues that arise. Individual physicians in a group practice are typically not given this role as expectations can vary. It is helpful for the supervisor to insure that all the physicians have the same expectation of the scribes and for the supervisor to intervene when conflicts arise. Typically this becomes a part-time administrative role for one of the physicians. If a contract service is utilized, this role is not necessary.

If you have interest in surveying the literature on scribes, a brief list of relevant articles touching on several specialties is available here:  Scribe Article List

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