To Hire, or Not to Hire, a Scribe

Illustration: Lee Sauer

A few weeks ago, I wrote about how EHRs have drastically changed the way that we deliver healthcare. From 2004 to 2015, practice EHR use shot from 20.8% - 86.9%.¹ Many thought that the EHR implementation would allow for better access to data, better communication, and improved workflows. All of these occurred in other industries that adopted automation and computerized systems. But that's not what happened in healthcare.

Instead, EHRs have added to the burden of documentation. Rather than allowing providers to spend more time with patients, EHRs require that they spend more time in front of a screen, entering data. In fact, a 2017 time study found that of 471 primary care doctors, the average provider spent about 3.08 hours with patients and 3.17 hours in front of a computer.² I'm sure many members would agree with these numbers or feel they are even higher.

All of us understand the burden providers feel with the demands of EHR documentation, which often impedes providers from functioning at the top of their licenses or being fully engaged with the patient. The added administrative burden has increased feelings of burnout, and resulted in some physicians leaving the practice instead of learning a new system.

Given physician shortages, especially in cardiology, we can't afford to lose experienced clinicians due to the demands of an EHR. As one physician in a 2014 New York Times article put it: “Making physicians into secretaries is not a winning proposition.”³

To offset the dissatisfaction and clerical burden, many physicians have turned to the use of scribes. Because we are often asked about whether scribes are the right solution, I'd like to share some of the advantages and disadvantages of using them, based on what I've seen in practices, as well as read in the literature.

First, let's define the role of a scribe.

What a Scribe is and does?

A scribe is a non-provider who enters the details and notes of a patient’s clinic encounter into the EHR in real time, while the physician examines and focuses on the patient. Scribes are not licensed professionals and they are not allowed to act independently. According to The Joint Commission, scribes only operate at the direction of the practitioner for whom they are scribing. They may only document what they see and hear from the provider. Basically a scribe is a “human dictaphone” who enters the data that a physician provides during the patient visit.
The number of EHR scribes is growing fast. In 2015, the American College of Medical Scribe Specialists stated that there were 20,000 scribes in the U.S., and that number was expected to grow to 100,000 by 2020.⁴

Most scribes do not have a degree nor a medical background. They may or may not have coursework or certification training - both of which are available in many community colleges and paramedical training programs. Generally speaking, the cost of a scribe is $20-$25 per hour.

Often scribes are hired and trained by the practice, or home grown from existing staff within the practice. Other times, practices employ scribes through a staffing agency such as ScribeAmerica, PhysAssist, or PhysiciansAngels, a virtual scribing company that provides off-site scribes who listen to the patient encounter through a HIPAA-compliant platform. If your practice is located in a city with a medical school, you may also have the opportunity to recruit medical students as scribes.

There are certain documentation requirements for scribes, such as the scribe attesting to the fact that he or she acted as a scribe for the physician during the encounter. Be sure you understand the guidelines and limits. And as with any clinical note, the physician must review the scribe's work for accuracy and completeness and sign off.

Advantages of using Scribes.

Some of the most common positives of using an EHR scribe are:

1. Reduced physician burnout. Simply put, scribes allow physicians to spend less time at the keyboard and more time with the patient. Those who use them report a dramatic increase in face time because the entire visit can be devoted to the patient. No more turning and typing. Patients love it. From my conversations with members, the main reason many are considering scribes is to address physician burnout.
2. Increased physician satisfaction. The fact that scribes can directly reduce burnout typically results in an overall improvement in physician satisfaction.
3. Increased patient satisfaction. Scribes give providers more time with the patient, improving patient relationships and satisfaction. A study in the Journal of Urology showed that patient satisfaction was 93% in an ambulatory setting when a scribe was present, versus 87% when one was not.⁵
4. Improved physician efficiency and more time for medical decision-making. Because physicians can focus on what the patient is telling them they have more time to arrive at a diagnosis and treatment plan. At MedAxiom, we are always talking about physicians working at the top of their licenses. The use of a scribe is a way to achieve this because scribes allow physicians to focus on complex medical decision-making rather than clerical work.
5. Improved documentation and charge capture. Scribes are solely focused on documenting what the physician and patient are saying. That enables them to obtain a better medical, family, and social history, and a more complete review of systems - which can improve documentation. And because scribes are deliberate and comprehensive when entering data, overall charges improved.⁶
6. Increased physician productivity. Because physicians are freed from paperwork, they have more time to see additional patients. One study showed that physician productivity increased 10% when scribes were used.⁷ In my conversations with administrators, many have been able to add one to five office visit slots per provider with the use of a scribe. This improved productivity can have a positive impact on ROI.
7. Opportunity to teach future clinicians. If the scribe is a medical school or advanced practitioner student, you're providing real-life clinic experience, terminology training, and an opportunity for them to observe physicians making medical decisions. In essence, you're helping to train the next generation of clinicians.

Disadvantages of using Scribes.

Of course, we can't just view the use of scribes through rose-colored glasses. Here are some things that can dissuade physicians from using them:

1. Cost. The biggest negative we hear about scribes is the added expense of bringing on an additional resource. This is especially frustrating for physicians who were expecting the EHR to make them more efficient, not less. In addition to the expense itself, there is often conflict about who should bear the cost of the scribe - the practice or the hospital system.
2. Burden of liability. As noted above, the physician reviews and signs off on the scribe's notes. But the burden of accuracy is still on the physician, should the documentation be questioned in the future.
3. Burden of onboarding and training. Many scribes arrive with little clinical knowledge. Physicians must train them in terminology, conditions they treat, and procedures they do. That can take several weeks to several months. That said, this is a temporary disadvantage and most physicians report that investing the time up front is worth the payoff.
4. Reduced physician competency with the EHR. When physicians grow to rely on scribes, it can lessen their ability to use the system, which may have negative effects as EHR and other technology changes and evolves.
5. Patient privacy. This is rare, but still a potential issue. Some patients may feel uncomfortable with the scribe in the room. The physician introducing the scribe and validating the importance of his or her role can overcome this. But patients do have the right to ask the scribe to step out at any time.

We recently sent a short survey on our listserv about scribes, asking whether members use them, who pays for them, and the impact. Although the number of responses from who use scribes was small (11), the top three insights were clear:

1. Scribes are primarily used in the outpatient setting.
2. The provider is paying for the scribe out of his or her own compensation.
3. Scribes improve documentation and give the physician more work-life balance.

So, should you hire a scribe for your practice? To answer that you must weigh the advantages and disadvantages I've laid out here, consider physician needs and culture, and evaluate the overall ROI. And while numbers are important, don't lose sight of the positive impact scribes can have on the hard to quantify advantages such as reducing physician burnout, improving documentation, and increasing physician and patient satisfaction.

¹Office-based Physician Electronic Health Record Adoption, Health IT Dashboard, 2015, https://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php

²Electronic Health Record Logs indicate The Physicians Split Time Evenly between Seeing Patients and Desktop Medicine, Tai-Seale, M., Olson, C.W., et. al., Health Affairs, April 2017, https://www.ncbi.nlm.nih.gov/pubmed/28373331

³A Busy Doctor's Right Hand, Ever Ready to Type, June 2014, Hafnter, K, January 12, 2014, New York Times, https://www.nytimes.com/2014/01/14/health/a-busy-doctors-right-hand-ever-ready-to-type.html

⁴Medical Scribe Industry Thrives, Bryan, M., May 12, 2015, Marketplace, https://www.marketplace.org/2015/05/12/health-care/medical-scribe-industry-thrives

⁵Scribes in an Ambulatory Urology Practice: Patient and Physician Satisfaction, Simi Koshy, Paul J. Feustel, Michael Hong, and Barry A. Kogan, June 2010, Journal of Urology, https://www.jurology.com/article/S0022-5347(10)03017-X/pdf

⁶EHRs-A Catalyst for Medical Scribe Use, Phil C. Solomon, Spring 2017, MiraMed Focus, https://www.miramedgs.com/insights/60-focus/past-issues/summer-2017/698-ehrs-a-catalyst-for-medical-scribe-use

⁷EHRs-A Catalyst for Medical Scribe Use, Phil C. Solomon, Spring 2017, MiraMed Focus, https://www.miramedgs.com/insights/60-focus/past-issues/summer-2017/698-ehrs-a-catalyst-for-medical-scribe-use