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About a year ago, the Executive Medical Committee of a hospital with which I am familiar met in order to prepare for a Joint Commission survey. Specifically, the committee wanted to formalize who can make entries into a patient’s chart. After the usual recommendations of physician assistants (PAs) and nurse practitioners (NPs) it was thought that the discussion was over. And then someone at the table mentioned scribes. Scribes?! they asked. No one at the meeting had ever heard of such a thing. Turns out the emergency physicians were using scribes to facilitate their charting and had been doing so for a number of years. After some explanation, and given the fact that it was a long established practice that was being used by EPs at other facilities, it was agreed that scribes could make entries into a patient’s chart as long as the doctor took full responsibility.

Just what were these scribes doing? They were assisting the physicians in charting as well as helping with a range of other tasks. What was the justification for this practice? It was simple: charting is extraordinarily expensive and EDs are generally very busy. The more time that doctors spend charting at computers and pulling up X-rays on a computerized image archiving system and doing computer order entry, the less time they can spend with patients. Seems pretty straightforward.

Is charting expensive? As long as there are patients waiting to be seen, you bet it is. Here is a real-life example. Say an ED sees 2.7 patients per hour. The revenue generated per patient (both physician and hospital components) is conservatively $400 a patient. If it takes 15 minutes out of every hour to do Medicare mandated charting on these patients then the math says that each minute of time spent in an hour is worth $18. So, for every minute that you chart and don’t see the next patient you lose $18 in opportunity costs. So charting is expensive primarily because it precludes physicians from seeing additional patients. Some hospital administrators flagellate themselves over the vast amount of money being laid out for transcription of dictated medical records and are driven to decrease these costs. At $0.13 a line, a 30-line ED record would cost a whopping $3.90. But even if it costs $5 it is trivial compared to the $18 your losing every minute you spend charting instead of seeing another patient. If dictation allows a physician to chart in half the time that is required by writing or, worse, using a computer, to document an H&P, medical decision making and treatment, then transcription is a bargain by any measure. In addition, transcription allows for the breadth of expression to more adequately describe the patient’s condition and response to treatment. Try that on a computerized system using pull down menus.

Get a Better H&P
A great benefit of scribes is that they can go ahead of the doctor and obtain certain essential elements of the history from each patient. They can get the past medical history, the medications, the allergies, the prior operations and perform a review of systems. Upon arrival of the physician, the scribe’s legible notes can facilitate a more focused approach by the physician with expansion of selected parts of the documentation. The scribe signs the chart as does the physician. The physician takes responsibility for the record. He/she has reviewed it, augmented it and clarified it.

One tactic that works well is to have scribes hold off on charting until the physician comes into the room and begins a summarization of the history of present illness. This allows the physician to separate the wheat from the chaff in the history and focus upon, and emphasize, the elements he/she thinks are the most important. Typically the physician would say something like, “OK Mrs. Jones, let me get this straight now. You’ve had four days of moderate abdominal pain in your right upper abdomen accompanied by some nausea but no vomiting...” This allows a focused summarization, which the scribe then takes down, rather than an unfocused history that a patient may give spontaneously.

Regarding the physical, the physician may say aloud his/her findings for the scribe to note (which assures the patient that the doctor is doing a very thorough job) and more sensitive findings (enlarged liver, appears older than stated age, etc.) can be given outside the room. The scribe can also check off any test orders when the doctor informs the patient. “Well, Mrs. Jones, you might say, I think we’ll need to get some tests. We’re going to order a gallbladder ultrasound to see if you have any stones, a blood count and a lipase test.” So now the patient knows what’s in store and the scribe has checked off the tests the doctor has indicated. Any medications are written by the doctor and the doctor signs the chart.

There is no sitting down in front of a computer outside the presence of the patient where a doctor has to enter his/her user name and password, find the patient from a pick list and then go onto the page for ordering blood tests and click off the lipase and CBC and then go to the page for the imaging tests and click off the GB ultrasound and then go to the drug page and order some IV ketorolac (after acknowledging no allergies to this medication, no history of renal failure and no history or GI bleeding). Others do it for him/her because it is understood that the doctor/nurse team is generating $18 a minute in revenue and the hospital cannot afford to have a doctor waste his/her time doing order entry,  no less generating a computerized history and physical with documentation of response to treatment, medical decision making and that a call to the PMD was made who agreed to see the patient for follow-up care at 10am the next day. Try that on a computerized system.

Like having a third arm
Scribes can facilitate physician work in a range of ways. They can check on the status of lab work that seems to be taking too long, pull up a patient’s X-rays on the imaging computer system (saving the necessity for the doctor to enter his/her user name and password), find the patient on the list and click open the X-rays. With a scribe doing this work, the physician merely has to walk over to the screen, check to see the patient name and review the films. Simple.

Who makes a good scribe?
College students who want to go to medical school make ideal scribes. They are smart, fast, eager to learn and they love being in the environment in which medical care is being provided. Plus, they love having it on their resume when they apply for medical school. EMTs who work for ambulance companies or in other settings are also good options. In emergency medicine there are at least eight companies that will hire and train scribes for physicians, all easy to find with a simple Google search.

Are Scribes Worth the Cost?
In a private practice setting it is clear that the doctor pays for the scribes, which can cost anywhere from $10 to $20 an hour depending on the circumstances. Scribes who work in EDs present a unique challenge. If the physicians in the ED are employees of the hospital, it is clear that the hospital will need to pay. But what if the EP is an independent contractor? In this situation, it would seem fair that the hospital pays 80% (they collect $400 a patient) and the physician pays 20% (given that a physician may collect $100 a patient). But splitting of the costs rarely occurs. Typically the contracting physicians bear the full cost. When this unfair arrangement occurs it is still easily feasible to justify the cost of a scribe being paid solely by the physicians.

Assuming each patient generates $100 in physician income, and assuming physicians are seeing 2.5 patients per hour, then to pay for a scribe for one hour at a cost of $20 requires that 0.2 additional patients be seen: not hard to defend at all. The cost for scribes is even easier to defend when physician satisfaction is taken into consideration. Simply put, they relieve hassles for physicians and make their lives easier.

Scribes: A New Trick for Old Dogs
Given that scribes make clear-cut economic sense for both physicians and hospitals, why are they so infrequently employed, especially in the hospital setting? Fundamentally, physicians are very conservative by nature. They are reluctant to break from tradition and using a scribe is certainly not traditional. Most have no experience with their use and are not familiar with other physicians who have used them. Sadly, only the most entrepreneurial groups have given scribes a try, despite the fact that scribes can be taught relatively quickly and, in the unlikely event the experiment fails, there is little lost regarding time or cost.

So what if you want to hire a scribe but your group says no? When this occurs, physicians should have the option of hiring their own personal scribes. When the physician shows up for work so does his/her scribe. The physician pays the scribe directly. Care should be taken when this occurs to follow all regulations regarding employees. In an era where physician payment is more and more based on productivity (RVUs) it is not hard at all to prove the value of a scribe.

Whose Scribe is it Anyway?
One final point about scribes in the hospital setting: It is ideal to have hospital-based scribes as hospital employees (rather than employees of independent contractor physicians) for a number of reasons. As hospital employees, scribes can be taught and authorized to enter test requests into hospital computer systems. Hospitals may be reluctant to allow this action by scribes who are physician employees. In addition, hospital-employed scribes can provide other services to physicians. They can assist at patient examinations and they can chaperone exams and assist with procedures. As employees of physicians, all of these extended tasks should be avoided and left to hospital employees to perform, and scribes should not be allowed to touch patients for any reason to limit medico-legal risks. Scribes will also need their TB tests and other items may be required by the hospital.

The Bottom Line
The goal should be to have physicians unencumbered and their work facilitated. Ideally the physician would be a free-floating intellect, not required to write, not required to sit in front of a computer, not required to do anything but interact with patients and staff. This would be ideal, but it is not particularly practical. Yet we should still strive to move in this direction. Instead, we are moving in just the opposite direction. So many hospitals encumber physicians by asking them to be data entry clerks, sitting at computers entering H&Ps, tests and drug orders and the like. On the premise that this system is better and safer, we are being drawn to a system that is neither. Sure we want rapid access to patient records and old EKGs and operative reports and medication lists. But there are other ways to get this essential information from computers without burdening physicians and sacrificing patient care. The key is to have the right people working at the right tasks – and that means empowering scribes and getting physicians off the computer!

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Interview with Joe Danna, MD
President of E Square Physician Scribe

On why he developed the scribe training program
“I had pretty selfish reasons. I realized that I was getting less and less time interacting directly with patients. Intuitively, I knew that a good part of the work we as physicians do outside of the patient encounter – two-thirds to be exact – was work that we could train someone else to do.”

On scribes as personal assistants, physician facilitators
“Most scribe programs have scribes simply documenting the history, but there’s so much more that they can do related to clinical information management. Labs, diagnostics, the whole ED course. I thought we could also train scribes to be true personal assistants to physicians. Our scribes help to organize their physician’s work, prompt and direct us as we get distracted. They help us stay on track so that we can move patients through efficiently. They prompt our critical thinking.”

On why scribe programs fail
“Places that try scribes and fail are the ones that don’t do the prep work. They don’t anticipate and address the barriers to success, such as administrative issues, nursing concerns, etc… Or once the class is done, they don’t mentor. It takes a good 90 days beyond the class for the scribe training to really ‘stick to the ribs’. And that’s where a lot of programs fail.”

On ‘career scribes’ vs. revolving door
“Scribes are a whole new career opportunity. That’s the way we build it. They’re on the front lines of medicine, hearing every story right along with us. They really do impact patient care. When we utilize them beyond typical scribe duties, they know that they’re impacting patient care. Our scribes tend to be long-term career players.”

On the long view of scribe partnerships
“In the ideal world, a scribe will stick with a single physician for years. Or you can recruit a scribe to work for two specific docs. Imagine working with someone for the next ten years who knows your practice, knows how you work and facilitates every aspect of that practice.”

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A note from a scribe (from Josh via epmonthly.com)
I currently work as a Scribe in the ED. The physicians I work with will usually introduce me on the initial encounter with the patient, so the patient acknowledges that I am there. The EP then begins the interview with the patient, jumping from onset of symptoms to associated symptoms, questioning the patients HPI, and doing their PE. While the EP performs these tasks, we scribes are trained to interpret the verbalized HPI and ROS to the chart. We also have the ability to chart the EP’s PE either in the room while being performed or verbalized to us after the exam. Depending on the type of charting system used in that particular ED, the scribe can have the HPI, ROS, and PE completed by the end of the interview. We then follow labs/rad to ensure efficiency in a timely manner. If one or the other falls behind, the scribe is responsible for notifying the appropriate people. The scribe is that extra help that is needed for the organized chaos of the emergency room.
 

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