Scribes slash EMR burden

Urologists who view electronic medical record documentation as a burden are turning to scribes. Scribes, many say, relieve them of that burden, freeing urologists and other providers to focus on patient care.

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But scribes cost money-money that’s on top of what urology practices have already spent on EMRs.

Urologists tend to view working with scribes in a mostly positive light, while noting a few negative aspects. Some have developed best practices on working with scribes and shared them with Urology Times.

First, a look at the data on scribes

Studies examining the use of scribes in medical practice have been, for the most part, positive.

A PubMed search yielded one study of scribe use in urology. EMR scribes increase urologist satisfaction and don’t lessen urology practice patient satisfaction, according to the study, published in the Journal of Urology (2010; 184:258-62).

The study’s authors assigned EMR scribes to five academic urologists, then surveyed patients and physicians to determine acceptance and satisfaction. They found that patients had slightly higher satisfaction rates when scribes were present, at 93% versus 87%. But it was the physicians who were most dramatically impacted. Nearly 70% of urologists surveyed were satisfied with office hours when they had a scribe, versus almost 20% of those who were without a scribe.

A more recent urology-focused article, published in Urology Practice (2015; 2:101–5), found that medical scribes in an academic setting could increase patient flow and reduce the burden on providers by reducing computer charting. The model described in the study “is only financially prudent if the increased expenses are offset by additional revenue from increased patient visits,” the authors wrote.

Another study, published in ClinicoEconomicsand Outcomes Research (2015; 7:489-95), looked at scribes’ yearly impact on physician productivity and revenue in a cardiology clinic. It found physician productivity was about 10% higher among those who used scribes. The use of scribes generated an additional annual revenue of $1,372,694 at a cost of $98,588, according to the authors.

The Journal of the American Board of Family Medicine published a review in 2015 on medical scribe use, identifying five studies, including the 2010 urology study. The authors found that although the number of studies was small, the research collectively suggests medical scribes improve “clinician satisfaction, productivity, time-related efficiencies, revenue, and patient-clinician interactions.” But more studies are needed, they concluded.

Next: On the frontlines of care

On the frontlines of care

Dr. StorkBrian Stork, MD, a urologist practicing at West Shore Urology in Muskegon, MI, said he found it was becoming increasingly stressful to listen to and maintain eye contact with his patients while simultaneously entering their information into the EMR.

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“I thought there had to be a way I could practice better, and serve my patients and the community in a way that would be quite frankly more fun than sitting at a keyboard, talking to the patient and typing,” he said.

Dr. Stork told Urology Times that he solved that problem more than a year ago by hiring a scribe.

“Nursel, our certified medical scribe, and I walk into the exam room together. She sits at the computer monitor and basically transcribes to the best of her ability, while I’m talking to the patient. I don’t touch the computer at all when I’m in the room,” Dr. Stork said. “I feel like I can actually really listen to a patient without having to worry about what box I’m going to click to make the office visit billable.”

Muskegon, MI urologist Brian Stork, MD, works closely with his scribe, Nursel Dogan. Dr. Stork says Dogan, who has a background in accounting, is another set of eyes looking at billing. (Photo courtesy of Brian Stork, MD)In addition to doing the documentation, Dr. Stork said his scribe, who has a background in accounting, is another set of eyes looking at billing, to make sure it’s correct.

“Because of her accounting background, when I am out of the office or in surgery, she helps us in the business office,” Dr. Stork said.

Dr. KoganBarry A. Kogan, MD, chief of urology at Albany Medical Center in Albany, NY, is glad to have the help of a scribe.

Dr. Kogan, who was among the authors of the 2010 Journal of Urology study looking at scribes in urology, said he is not a great multitasker.

“I think my face would be in the computer screen much of the patient visit, and my typing would be a mess,” Dr. Kogan said.

The scribe facilitates a better physician and patient interaction and dramatically reduces the burden of EMR documentation.

“I merely review, make a few small edits (if more than that, I need to do additional training of the scribe), and sign the note,” he said. The only disadvantages, according to Dr. Kogan, are cost and the time and energy required to train a scribe.

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At Dr. Kogan’s practice, the scribe’s primary role is to type into the EMR. The scribe prepares notes before the patient arrives. For example, for new patients, the scribe might add x-ray and culture reports to the results section of the note, he said. And for follow-up patients, the scribe summarizes data from the previous note and copies results of previous studies and procedures. The scribe accompanies Dr. Kogan into the room and records the patient’s history and physical findings that he points out. The scribe records the discussion of Dr. Kogan’s plan for the patient and the diagnosis.

“Of course, they cannot make any independent judgments,” Dr. Kogan said.

Next: Increasing efficiency

Dr. BaumNeil Baum, MD, professor of clinical urology at Tulane University School of Medicine, New Orleans, uses a scribe. He believes scribes increase the doctor’s efficiency 20% to 30%.

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Dr. Baum told Urology Times he makes use of the “sandwich technique,” in which he meets the patient first for up to 90 seconds and has a general dialogue that doesn’t include the urologic complaint.

“It’s more to greet them and let them see who I am. Then, I tell them the scribe, Jennifer, will come in and ask them a few questions,” Dr. Baum said. “While the scribe is taking the history of the present illness, past medical history, and review of symptoms, I can see two to three additional patients.”

He then goes back in with the scribe to do the physical exam, communicating his findings while the scribe does the documentation. Dr. Baum tells the scribe what to write about the plan of care outside the room, then goes back in to talk about it with the patient.

“It works so well. I’m able to see at least one additional patient per hour as a result of having a scribe. If you can see two additional patients a day, you will have more than paid the cost of the scribe,” Dr. Baum said.

Dr. SuskindAnne M. Suskind, MD, MS, assistant professor of urology at University of California, San Francisco, says she loves her scribe.

“She is with me in all of my clinics. I do two full days of clinic a week, so we spend quite a bit of time together. She’ll follow me into a room during an interview. I’ll introduce her to the patient. And she’s kind of like a fly on the wall,” Dr. Suskind said. “She just really allows me to forget about the documentation while with the patient.”

To prepare patients for the added person in the room, Dr. Suskind enters the room first, as her scribe waits in the doorway. Dr. Suskind introduces herself, then introduces her scribe, Ashley Li, BS, explaining that Li is there to help with documentation “so I can focus on you [the patient],” Dr. Suskind said.

In almost all cases, having her scribe in the room is a nonissue for patients, according to Dr. Suskind. She does not, however, have her scribe in the room during patient exams.

“I do female pelvic medicine and reconstructive surgery. So, once I finish the interview with the patient, I’ll ask the patient to change for a pelvic exam. I’ll leave the room and come back by myself to perform the exam without my scribe,” Dr. Suskind said. “That’s just what I’ve decided is best for me. I’ll then come out of the patient room and I’ll fill in the details of the exam with my scribe, then, we’ll go back in the room together to complete the encounter. I sense that patients appreciate the privacy that this offers them.”

In addition to doing most of the EMR documentation for Dr. Suskind, her scribe is a good resource for residents coming through the department.

“She really knows my flow and what I do for patients and how the system works,” Dr. Suskind said. “The residents ask her questions all the time about how I do things, and it saves some of my time to be able to focus on the residents and their educational experience.” (Also see, “A scribe’s view: ‘Committed to delivering efficient care.' ")

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Michael Murphy, MD, co-founder and CEO of ScribeAmerica, which staffs 78 hospitals in 13 states with scribes in urology, said one client had added daily patients to his clinic schedule and reached 100% same-day chart signing since using scribes.

“Another site has four providers using scribes and their volumes increased 4%, 10%, 24%, and 26%, respectively. This resulted in additional $16,000 per month in revenue,” Dr. Murphy said.

Next: Potential drawbacks

Potential drawbacks

Dr. MurphyThere is no license required to become a medical scribe. The job description, according to ScribeAmerica, is a person who helps the provider with data gathering and real-time EMR documentation. And while the profession does not require certification or training to educate scribes on medical terminology, privacy law, and more, scribes hired through companies like ScribeAmerica receive training. In the case of ScribeAmerica, it’s 120 initial hours and continuing scribe education. And there is a certification through the American College of Medical Scribe Specialists, although the college’s website does not list urology among the specialties certified.

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Scribes’ pay often comes out of physicians’ pockets.

The average pay for a scribe in a urology practice is $10 to $16 an hour, according to Dr. Murphy. Payscale.com lists the average pay for a medical scribe at about $12 an hour. The average medical scribe salary is $20,000, according to Glassdoor.com.

“I am sure this varies but we have paid $12 to $16 per hour, depending on the experience and expertise of the scribe,” Dr. Kogan said.

Another potential disadvantage of scribes is that they add one more person to the room, according to Dr. Stork.

“Sometimes, when I have a patient and a bunch of family members in a room and a scribe, there just isn’t enough room. And I’ll ask the scribe to step out and tell her later what to add,” he said.

Not everyone is a fan

Dr. AlbertsenPeter C. Albertsen, MD, who practices urology at UConn Health, Farmington, CT, said he doesn’t think using a scribe is cost-effective for his practice.

“Furthermore, what happens to these people when I am in the OR, on vacation, add patients for an extra session, am away at a meeting, etc.? Unless a scribe has other duties, I am not certain it makes sense financially,” Dr. Albertsen said. “I usually click the various boxes and phrases as I take my history and then type a summary note at the end. I often read as I am typing to reinforce points with patients and make sure they agree and understand the plan. I then hand them a copy of the masterplan as they leave the office.”

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Whether to hire a scribe is often a matter of physician preference, according to Dr. Stork. Dr. Stork’s partners, for example, have chosen not to have scribes.

“We’re all wired differently. I think that for physicians who really want to spend more time with their patients and don’t want to be spending a lot of hours after office hours, inputting all that data, a scribe is a really good option,” Dr. Stork said.

Next: Scribe hiring tips

Scribe hiring tips

Good qualities for a scribe include attention to detail, being interested and willing to learn, and having a nice demeanor, according to Dr. Suskind. Strong typing skills are a must, according to Dr. Stork.

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Dr. Baum said scribes in urology should be comfortable talking about sensitive sexual topics and notes that some people are culturally uncomfortable with watching exams or talking about such topics as sexual dysfunction or premature ejaculation. That can be a problem, he said, and urologists should address that topic in the interview before hiring a scribe.

Because many scribes are aspiring physicians and might leave their scribe jobs after a year or so to pursue their careers, it’s important for urologists to plan for a replacement. Dr. Baum said he hires the new scribe 2 weeks prior to when the current scribe is planning to leave the post, and has the current scribe train the new one.

“Within 2 weeks, they’re up to speed,” Dr. Baum said.

Dr. Kogan said there’s a drawback to hiring pre-med students as scribes.

“While they are bright and learn quickly, they rarely last a year. We train them but most often they get accepted to medical school and, if not, the job is not a good one for them long term,” Dr. Kogan said. “Emergency departments often use scribes, and we have found good scribes who want a change. They only require adjustment to urology diagnoses and to our individual preferences.”

Burnout prevention?

The burden of documentation is a known burnout factor in medicine. In an online article last year, Medical Economics reported on physician burnout solutions that indicated while medical technology is a part of the solution in health care, it’s also part of the problem. One of the solutions to the problem is to move doctors away from being data-entry clerks.

Dr. Suskind said University of California San Francisco is conducting a pilot looking at the use of medical scribes. While the pilot is ongoing, Dr. Suskind said her department has examined metrics for patient and provider satisfaction.

“Patient satisfaction is up, and provider satisfaction is off the charts,” Dr. Suskind said. “We can’t envision going backwards; it has been such an overwhelmingly positive experience. At the end of clinic, all the documentation is done. All I have to do is proofread my notes, make minor changes, and sign them.”

Dr. Stork, who is midway through his career as a urologist, said he agrees that EMR responsibilities are one of the top reasons for physician burnout. And having a scribe is one way to mitigate perceived problem, he said.

Urologists who find they can’t get patients in for 2 to 3 weeks because they’re so booked should consider hiring a scribe, Dr. Baum said. “A physician assistant can be expensive. A new associate can be very, very expensive to take on. A scribe helps the doctor to be exceedingly more efficient and productive,” Dr. Baum said.

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