Scribes Overview/White Paper

Allen L. Hsiao,

Background & Literature

The advent of the EMR has been a double-edged sword for physicians and other clinicians. There are
clear invaluable advantages that the EMR enables: decision support, a foundation to support population
health, easy convenient access to comprehensive patient information, as well as simple and
sophisticated analytics utilizing the now digitized data. However, capturing this critical data via the
currently available user interfaces by keyboard and mouse is time consuming. The EMR can also “force”
users to document, indicate, order, and other tasks good for regulatory, quality, billing, compliance, and
other needs (“Meaningful Use,” PQRS, MACRA, etc.), but detrimental to workflow and the quick patient
visit. Scope of practice limitations, and less-than-strict legacy adherence to those limitations, are also
almost always highlighted and remedied by installation of robust EMRs. Unfortunately, such tasks are,
more often than not, shifted solely onto physicians to accomplish. Coupled with increasing financial
pressures requiring physicians to see more patients in shorter time periods, this perfect storm is
contributing to physician burnout. [1-6] As a result, instead of embracing the EMR as a modern
indispensable tool of healthcare, many physicians understandably instead view it as an ever-tightening
noose.

Users very facile with computers, and others aided by technologies such as speech recognition, are able
to leverage EMR tools to meet the increased demands. However, many physicians are still unable to
meet both the increased patient loads and new EMR without spending significant after-hours effort. In
recent years, interest and utilization of scribes has been growing at a rapid rate; scribes can at least
partially decant the extra burden impressed upon physicians by market and regulatory forces, hard-
wired by the EMR.[7-9] While still somewhat nascent, the literature has begun to show very promising
results ranging from decreased length of stay to increased productivity in the number of patients seen,
and increased physician satisfaction and decreased time spent after hours.

Given nature of scribe utilization, it is unfortunately unfeasible to have blinded, randomized control-type
studies. Instead, most studies are observational, mostly comparing pre and post-intervention metrics.
From a review such literature, two studies did note increases in productivity up to 6.45%.[10, 11] Other
studies have also shown that most patients are comfortable with scribes when properly introduced to
the concept.[12-14] However, the cost to appropriately (within actual clinical setting, with customized
training to specific areas of healthcare) train a scribe is significant (around $6000) but has a quick return
on investment financially, as well as very high physician satisfaction with marked impact in after hours
spent documenting. [13,15]

Downsides noted in the literature include the concern that scribes will prevent physicians from
becoming experienced and well trained in utilization of the EMR.[16] On the other hand, if physicians
have been appropriately trained and have been using the system without scribes for a prolonged period
of time, and yet are still spending too much time after hours, that concern may be misplaced. Also,
newer technologies are being leveraged to allow for more economical and less intrusive, “virtual
scribes” where scribes logged into the same EMR system participate by voice-over-internet-protocol
(VOIP) speakerphone in real-time, but do not need to be in the exam room. [17]
While physician becoming overly-reliant on scribes (whether virtual or in person) is a reasonable
concern, when compared head-to-head, scribes have been noted to produce higher quality notes.[18]
Additionally, marked decreased (36% less) time spent by physicians documenting in the EMR with a
measured RVU increase up to 5.5% (likely due to better documentation) was noted in two studies;
however, decrease ED LOS was not detected as hoped for.[19, 20]

In the ambulatory environment, one cardiology clinic study found that the 10 out of 25 cardiologists
who chose to use scribes saw 9.6% more patients per hour yet spent 2.5 (+/- 0.9) fewer hours
documenting due to scribes (See Fig 1). The increased 9.6% number of patients seen resulted in $1.3
million extra in revenue and corresponding increase RVUs compared to an outlay of $98,000 to employ
the scribes. Coding at the highest levels was also higher in the scribe group vs the non-scribe group
which resulted in an additional $24K in revenue.    [21]
 

Fig 1. Decreased Time Spent by Physician in EMR (Previsit, Visit, and Postvisit) on Scribe Days
Reproduced from Bank, A.J. and R.M. Gage, Annual impact of scribes on physician productivity and revenue in a
cardiology clinic. Clinicoecon Outcomes Res, 2015. 7: p. 489-95.

Lastly, there was a recent meta-analysis on scribe literature by Heaton et al with findings consistent with
the findings of the review of the recent literature summarized above. Heaton and colleagues identified
210 articles about scribes, was able to obtain the full text for 70 of them, and then narrowed those
down to 17 higher quality ones that assessed outcomes of interest (throughput, revenue,
provider/patient satisfaction). Their findings:
·         5 studies looked at throughput/LOS, basically no difference measured in meta-analysis.
·         4 studies measured patients per hour, average 0.17 more patients/hour with scribes.
 ·         4 studies examined financial impact of scribes, but because of varying methodologies meta-
analysis of them could not be done. However, increase of 0.21 to 0.29 RVU per patient were
described in two studies, and $44-$52 increase in charges per visit were measured when scribes
were used.  
·         8 studies examined satisfaction of providers and/or patients, but because of different
methodologies meta-analysis could not be done. Improved provider satisfaction, decreased
stress, higher quality teaching were described when scribes were used. No change in patient
satisfaction was found in one study (cardiology clinic), but improved in two (one in a urology
clinic setting, another in an ED).[23]
 
Given the increased pressures physicians face and the positive impact of scribes described in the
literature, it’s perhaps not surprising then that experts at HIMSS this year predicted that the number of
scribes will be exploding over the next few years: there will likely be one scribe for every seven
physicians by 2022.[24]

Local Experience & Types of Scribes

At Yale New Haven Health and the Community, we have had some limited experience with scribes in
different areas, and our experiences reflect the three different options that are currently available:

1. Aysnchronous, Off-Line Scribes

One gyn-onc specialist at Smilow utilized a service provided by Perfect Transcription that was a hybrid
between transcription and scribe. The physician records their dictation on a digital recorder and
transmits the voice file to the vendor where a transcriptionist transcribes the recording and either
provides a Word file or can also log into the EMR and copy the content into the appropriate electronic
note. As it is asynchronous, it is limited only to documentation; transcriptionist cannot pend orders nor
respond to alerts or decision support.

Leading vendor offers the service at 10.9 cents per 55 character line and an additional cost to insert it
into the EMR documentation template.

2. In-Person Scribes
At Bridgeport Hospital, mostly in the ED, in-person scribes have been utilized for some time, pre-dating
the Epic EHR. For many years, the scribe program was a home-grown one where ED leadership trained
and certified their own scribes, often drawing from local talent and healthcare science students. These
in-person scribes shadow physicians as they see patients, documenting based on verbal and visual
responses into the EHR in real-time while the physician evaluates and treats the patient. Based on verbal
commands and spoken statements, scribes can also “tee-up” orders for signature and activation by the
physician as well as enter ICD-10 codes and complete referral letters. Documentation and orders are
then reviewed by the physician for accuracy and then signed during the patient visit before moving on
to the next patient. Orders are not active until signed by physician, hence scribes are truly acting only as
“scribes” and not as physician extenders.

In the BH ED, scribes are pooled, but in other environments and practices, scribes are assigned to
physicians and over time learn their preferences and idiosyncrasies. Due to frequent turnover and effort
needed to train replacements and administer the program, it was discontinued this year in favor of
outsourcing from Scribe America.

GH ED leveraged the experience from BH ED and recently also began the use of in-person scribes during
peak days/hours (M/Tu/F/Sat/Sun 7a-2a) and have had a very positive experience so far. While they did
not see an increase in number of patients seen per provider, there has been measured improvement of
revenue due to improved documentation (increased level of service and critical care documentation)
that is enough to offset the cost of the scribes. Provider satisfaction greatly increased (>95%) as well as
patient satisfaction for one MD in particular who had low ratings pre-scribe. Chart completion by end of
shift is also no longer a problem since introduction of scribes.

In person scribe costs range from $20-$22/hr, volume discounting is available with a decrease of
$0.20/hr for every 25 FTEs employed with floor around $18-20/hr

3. Virtual Scribes
A newer option, briefly described above in the literature review, are virtual scribes who participate in
real-time in the same EMR, but are not physically present in the exam room or hospital. These remote
scribes typically participate by VOIP speakerphone, either freestanding device or using the integrated
speaker and microphone of the clinical computer. Virtual scribes can document and complete structured
item review in-real time while listening to the physician, and can also pend orders. They cannot by
nature of the technology respond to physical cues, but are also less obtrusive and may be accepted
better by patients as more privacy is preserved. Virtual scribes are typically about 10-20% cheaper than
in-person scribes.

Some of our local community providers are utilizing this service and find it is extremely productive, even
“life changing.” Dr. Agnes Czibulka (current president of the New Haven County Medical Association)
tried both in-person and virtual scribes and feels virtual scribes are ideal, noting that she has been easily
able to pay for the scribes by seeing two more patients a day, yet no longer has hours of documentation
that she used to do after hours and on weekends. She believes almost all doctors should consider using
them as they can greatly decrease the feeling of burnout many physicians struggle with today.

Virtual Scribes services range from $14/hr to $20/hr with volume discounting available to bring down
costs to $12-18/hr depending on the vendor.

Summary
From the preponderance of literature currently available, as well as our limited local experience, it
appears scribes can at minimum greatly improve physician satisfaction by significantly improving the
number of after-hours, and overall time, spent performing documentation. This is significant given the
recent uptick in the number of physicians reporting feelings of burn-out within our System.

There is also good evidence that the use of scribes should in most circumstances be at least budget
neutral when accounting for increased revenue from increased efficiency (resulting in net more patients
seen per day as well), but may even enhance revenue due to improved quality of documentation, as well
as the potential to allow physicians to see more patients a day due to increased efficiency realized by
use of scribes. This is also an important consideration as it directly translates to increased access to care
for our patients and patient satisfaction. If less direct costs, such as the cost to recruit new physician to
replace one that has left to do decreased job satisfaction/burnout, as well as lost revenue during
recruitment time period, cost of virtual scribes may be well worth it.

References
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