Medical Scribes: Red Ink or Revenue-sustainable Innovation?

Summer 2014 was an anniversary I prefer to minimize. The year marked my 40-year rite of passage since medical school graduation. If nothing else, the only constant of medical practice over that intervening interval has been change, change, and at times, drastic change. 

I began my career on archaic footing, awaiting cutting-edge technologies taken for granted today—CT scanning, bone marrow and solid organ transplantation (even faces today!), interventional cardiology, MRIs, statins, and a host of pharmaceuticals that now cure hepatitis C and other infectious diseases. There were no “hospitalists” back then, or admissions caps—a time I refer to as “B.C.,” “Before Caps.” 

More recently, and possibly least welcome by some physicians, the electronic medical record (EMR) has become de rigueur. Whether mature (aka older) docs like me are receptive, efficient, and professional in data entry and retrieval, or more typically, none of the above. As a result of cataclysmic changes over forty years, there are now novel medical neologisms, populated by terms that require elaboration. Recently, a new professional role caught my attention in this regard—that of medical scribes.

 My introduction to this newfangled medical position came by way of the Wall Street Journal in which the writer offered this crisp description:¹

Medical scribes are typically students with a college degree who are planning to go into the healthcare profession. They perform multiple tasks under physician supervision including reviewing a patient's medical record, writing a note summarizing previous clinic visits and hospitalizations, finding and copying relevant test results, documenting the physician's findings and treatment recommendations about a patient's problems, typing instructions to the patient, entering billing codes, and scheduling future visits, among other things.

Could it be that medical scribes are an efficient and cost-effective solution for what has evolved into palpable physician dissatisfaction with EMR management? I certainly wanted to know, and I suspect that you do too. 

Before answering that question, let’s look at data that addresses the contributions and potential economic impact of the new medical elite:  the author of the Wall Street Journal article is a cardiologist. He compared patient visits to his group’s practice—accompanied and not accompanied by scribes.^1,2 My first (and wholly uneducated) assumption was that scribes were 50% physician time-savers and 50% liabilities in regard to revenue generation. 

Bank’s study, however, showed that when a scribe was used, physician productivity (measured as patients seen per hour) increased more than 50%. The more important detail (despite my cynical prima facie opinion), though, was a marked increase in revenue. Time spent in direct interaction with the patient (that is, without the doctor staring at the computer screen) increased as well. Total time dedicated to each visit overall, however, decreased as a result of enhanced efficiency. With a scribe “in the house,” Bank sees 30% more patients per hour than his scribe-less colleagues. And, there’s a value-add: As a result of the scribe-enhanced efficiency, Bank now has increased openings for scheduling patients in a more timely fashion. Less data entry, more lunch, more family time… these are other benefits that may make scribes a viable—and valuable—solution. 

In Dr Bank’s words 

Everybody wins with this system. The patients win. They are seen on time, access to their physician is increased, and they get more attention at each visit. The physician wins by performing less paperwork, finishing work on time, and spending more time doing what he or she is trained to do. Productivity and compensation are increased,whether in a fee-for-service or accountable-care environment. The cost of care for each patient goes down because the tasks currently being done by physicians are being transferred to scribes, lower-cost individuals who earn $10 to $25 an hour.”¹

In the systematic study by Bank, patient satisfaction was measured as well, leading to a very positive conclusion:  

Based on written and verbal comments, patients’ reactions were either neutral toward or liked the scribe system. Many commented to clinic staff about the benefit of having the physician’s full attention without distraction from the computer. Clinic staff noted that patient flow improved when using scribes (despite increased numbers of patients being seen), and a number of patients commented that they were being seen in a more timely fashion.”² Costs generated by the scribe system were low. Direct costs for the entire study, including scribe salary/benefits and payments to the company that leased the scribes to us (for training, scheduling, credentialing, etc.), were only $2050. The cost of $25 per hour is comparable to the cost of transcription.² 

One cardiology practice endorses scribes. Where does the leave the rest of us? 

Turns out, Bank is not alone in his affirmation. There have been other, diverse clinical venues testing the feasibility of medical scribes. Emergency medicine, unlike other primary care practices (no appointments), seems to lend itself well to the scribe model. One emergency medicine study demonstrated that the primary endpoints of patients seen per hour and relative value units (RVUs)/hour improved significantly with scribes.³ These authors put those improvements into dollars and cents: Based on the 2008 Medicare RVU reimbursement rate of $38 for one RVU, a scribe being utilized to full capacity, resulted in an additional 2.4 RVUs/hour generated, which could result in an additional 91 billed dollars per hour.³ 

The results of this study also demonstrated that the utilization of scribes similarly increased physician productivity by 47 to 59% at an emergency practice—as disparate as possible from cardiology. The Vancouver Clinic in Washington,¹ providing an interface with primary care, likewise suggested medical scribes improved clinical documentation and allowed doctors to see more patients.⁴ 

Limiting inquiry regarding medical scribes to the information discussed thus far would be a mistake. The scribe question deserves additional unraveling. Let us look at less measurable, but very important professional details. Doctor-patient communication is a multifaceted, frequently ineffable, and rich interaction.² What transpires in that connection impacts not only patient satisfaction, but also medication adherence, conflict resolution, and clinical outcomes.² Does physician pre-occupation with data entry adversely affect the important content of these encounters? It has been demonstrated previously that EMRs lessen psychosocial discussion, curtail the patient’s agenda, and change the organic flow and style of doctor-patient communication.² 

Any innovation that simultaneously increases doctor-patient quality time (time completely free of any other distractions) without disturbing what has become a fragile economic matrix for American medicine is to be applauded. Bank and his coauthors summarized the available facts in expectation of further studies and refinements in the medical scribe model, as detailed below:

Physician services make up 21% of health expenditures in the United States. In addition, physicians are highly compensated individuals who are being asked to do more with declining reimbursement. Any change that improves physician productivity and efficiency (without impairing quality or physician or patient satisfaction) should have significant financial benefits for both physicians and for the healthcare system as a whole. In the current fee-for-service environment, if each physician in our clinic saw 2 additional follow-up patients daily (9% increase in productivity), the direct and indirect cardiovascular revenue generation would be approximately $5.4 million. Since we have a significant backlog of patients waiting to be seen in our clinic, this revenue would accrue because patients could be seen in a more timely fashion and receive appropriate care, not as a result of seeing patients more frequently or performing excessive testing. Improved productivity would allow the same number of physicians to manage a larger patient pool (hence more dollars in the pool) or a reduced number of physicians to manage the same patient pool. In either event, the cost of care per patient is reduced.²

A final answer to the implementation of medical scribes still eludes me, and perhaps you too. On paper, however, the concept holds water for me. I suspect, that you, many of our readers know immeasurably more about the subject than me. I encourage you to jump into the conversation with both feet. To scribe or not to scribe promises to be an enlightening and pragmatic dialogue that will affect all of our futures.

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.

REFERENCES: 

1. Bank Alan J. In praise of medical scribes: an old-fashion remedy for the ills of electronic record-keeping. The Wall Street Journal. April 6, 2014. 

2. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406.

3. Arya R, Salovich DM, Ohman-Strickland P, and Merlin MA. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17(5):490-494. 

4. Sparling M, and Sanchez T. Scribes in clinical practice. A means of improving provider efficiency and satisfaction. Presented at The Vancouver Clinic; 2012; Vancouver BC, Canada.