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SCRIBES AND THE EHR
DREAM OR DISASTER?
ROBERT ROBINSON, MD
ASSISTANT PROFESSOR OF CLINICAL MEDICINE
• Efficiency
• Effectiveness
• Work flow
• Learning curve
• Performance
• Patient satisfaction
• Documentation needs
• Complexity
• Capability
• Reliability
• Functionality
• Flexibility
CHALLENGES WITH EHRS
HEALTHCARE
PROVIDER ISSUES
• Complex medical documentation
– Insurance
– Legal
– Patient Safety
• Declining reimbursement
• Documentation time is unreimbursed
“A scribe is one who follows the doctor
around and writes word for word, what
the doctor says as he’s examining the
patient – a sort of human tape
recorder.”
SCRIBES DEFINED
• Scribe must
document
– Physician’s presence
– Their role as a scribe
– Their credentials
• (Degree, Title)
– Signature
• Physician must
document
– Accuracy of document
– Work actually
performed by
physician
– Signature
DOCUMENTATION REQUIREMENTS
SCRIBE LITERATURE: CASE REPORTS
ED Manag 2009 Oct;21(10):117-8
– 10% increase in billable charges
– 6.45% increase in number of patients seen
– $600,000 in savings in first year
Retinal Physician 2011 Mar:3-9
- 25-100% increase in number of patients seen
Optometric Manag 2011 June:30
- $75,000 increase in annual revenue per scribe
- Collections per patient were $300/encounter
PHYSICIAN PRODUCTIVITY
Acad Emerg Med 2010 May;17(5):490-4
– 13 ED physicians x 18 months
• Compared shifts with scribes to shifts without scribes
– Increase per 12 hour shift
• 9.6 additional patients p < 0.005
• 28.8 additional wRVUs p < 0.005
Hospital absorbed the cost of the scribes
JOB SATISFACTION
J Urol 2010 Jul;184(1):258-62
– 5 physicians x 10 months
• Clinic days randomly assigned to have a scribe
– Improved physician job satisfaction
• 69% with scribes versus 19% without scribes p = <0.001
– No effect on patient satisfaction (trend towards positive)
Medical Students acted as Scribes
• Costs
• Quality
• Efficiency
• Learning curve
• Patient satisfaction
• HCP satisfaction
• Medical Legal Issues
– Is there balance in
what is documented
• Patient comments?
• Other comments?
– Accountability
• Can scribes be sued?
• Who has supervisory
responsibility?
CHALLENGES WITH SCRIBES
COST ANALYSIS
Hourly
Wage
Annual
Wages +
Benefits
Net Profit
(Added Revenue Minus
Wages, Benefits)
ROI
$10 $25,192 $11,470 46%
$15 $37,788 -$1,126 -3%
$20 $50,384 -$13,722 -27%
Estimate: $36,662 revenue increase with addition of 1 Scribe
Based on
10% increase in revenue in a single study ED Manag 2009 Oct;21(10):117-8
Median Collections of $366,622 for Internal Medicine MGMA 2011
Benefits are 34% of wages (BLS Employer Cost Report June 2011)
40 scribe hours/week, working 47 weeks/year
WORKFLOW ANALYSIS
History +
Exam
Document
Review +
Charge
Total Encounter Time
20 Min
7.5 Minutes
Possibly reduce by
50% with scribe?
7.5 Minutes 5 Minutes
Possibly save 3.75 minutes/Patient
Possibly see 1 more patient/hour
• Physician Factors
– Improve skills
• Documentation
• Coding
• EHR use
– Utilize templates
• Documentation
prompters
• Improve efficiency and
proficiency
• EHR Factors
– Documentation needs
– Responsiveness
– Flexibility
– User Interface
– Mobility
– Training
– Speech to Text
software
ALTERNATIVES TO SCRIBES
• Scribes can aid documentation process
– High cost for little benefit
• Little published data to support use
• Scribes transcribe without Knowledge or
Context
– Poor substitute for high quality health care provider documentation
• Unclear risks
• Lower cost alternatives exist
– Education, Speech to Text software
SUMMARY
• References
– ED Manag 2009 Oct;21(10):117-8
– Acad Emerg Med 2010 May;17(5):490-4
– J Urol 2010 Jul;184(1):258-62
REFERENCES

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The impact of Scribes on EHR users

  • 1. SCRIBES AND THE EHR DREAM OR DISASTER? ROBERT ROBINSON, MD ASSISTANT PROFESSOR OF CLINICAL MEDICINE
  • 2. • Efficiency • Effectiveness • Work flow • Learning curve • Performance • Patient satisfaction • Documentation needs • Complexity • Capability • Reliability • Functionality • Flexibility CHALLENGES WITH EHRS
  • 3. HEALTHCARE PROVIDER ISSUES • Complex medical documentation – Insurance – Legal – Patient Safety • Declining reimbursement • Documentation time is unreimbursed
  • 4. “A scribe is one who follows the doctor around and writes word for word, what the doctor says as he’s examining the patient – a sort of human tape recorder.” SCRIBES DEFINED
  • 5. • Scribe must document – Physician’s presence – Their role as a scribe – Their credentials • (Degree, Title) – Signature • Physician must document – Accuracy of document – Work actually performed by physician – Signature DOCUMENTATION REQUIREMENTS
  • 6. SCRIBE LITERATURE: CASE REPORTS ED Manag 2009 Oct;21(10):117-8 – 10% increase in billable charges – 6.45% increase in number of patients seen – $600,000 in savings in first year Retinal Physician 2011 Mar:3-9 - 25-100% increase in number of patients seen Optometric Manag 2011 June:30 - $75,000 increase in annual revenue per scribe - Collections per patient were $300/encounter
  • 7. PHYSICIAN PRODUCTIVITY Acad Emerg Med 2010 May;17(5):490-4 – 13 ED physicians x 18 months • Compared shifts with scribes to shifts without scribes – Increase per 12 hour shift • 9.6 additional patients p < 0.005 • 28.8 additional wRVUs p < 0.005 Hospital absorbed the cost of the scribes
  • 8. JOB SATISFACTION J Urol 2010 Jul;184(1):258-62 – 5 physicians x 10 months • Clinic days randomly assigned to have a scribe – Improved physician job satisfaction • 69% with scribes versus 19% without scribes p = <0.001 – No effect on patient satisfaction (trend towards positive) Medical Students acted as Scribes
  • 9. • Costs • Quality • Efficiency • Learning curve • Patient satisfaction • HCP satisfaction • Medical Legal Issues – Is there balance in what is documented • Patient comments? • Other comments? – Accountability • Can scribes be sued? • Who has supervisory responsibility? CHALLENGES WITH SCRIBES
  • 10. COST ANALYSIS Hourly Wage Annual Wages + Benefits Net Profit (Added Revenue Minus Wages, Benefits) ROI $10 $25,192 $11,470 46% $15 $37,788 -$1,126 -3% $20 $50,384 -$13,722 -27% Estimate: $36,662 revenue increase with addition of 1 Scribe Based on 10% increase in revenue in a single study ED Manag 2009 Oct;21(10):117-8 Median Collections of $366,622 for Internal Medicine MGMA 2011 Benefits are 34% of wages (BLS Employer Cost Report June 2011) 40 scribe hours/week, working 47 weeks/year
  • 11. WORKFLOW ANALYSIS History + Exam Document Review + Charge Total Encounter Time 20 Min 7.5 Minutes Possibly reduce by 50% with scribe? 7.5 Minutes 5 Minutes Possibly save 3.75 minutes/Patient Possibly see 1 more patient/hour
  • 12. • Physician Factors – Improve skills • Documentation • Coding • EHR use – Utilize templates • Documentation prompters • Improve efficiency and proficiency • EHR Factors – Documentation needs – Responsiveness – Flexibility – User Interface – Mobility – Training – Speech to Text software ALTERNATIVES TO SCRIBES
  • 13. • Scribes can aid documentation process – High cost for little benefit • Little published data to support use • Scribes transcribe without Knowledge or Context – Poor substitute for high quality health care provider documentation • Unclear risks • Lower cost alternatives exist – Education, Speech to Text software SUMMARY
  • 14. • References – ED Manag 2009 Oct;21(10):117-8 – Acad Emerg Med 2010 May;17(5):490-4 – J Urol 2010 Jul;184(1):258-62 REFERENCES