Use of Medical Scribes in the Ambulatory office Setting

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Financial and Economic Aspects

There are uncorroborated reports of increased practice reimbursements from scribe use resulting from both increased productivity (patients per session) and higher per-patient fees from improved coding. The net effect on reimbursement must also consider the cost of having the scribe. There are suggested economic models but no referenced data that supports possible financial outcomes. (see Appendix A Grace 2007)

Because not every physician in a practice will desire a scribe or find a scribe useful, there are different options proposed for allocating the cost of the service. (Campbell 2012) One option is that the individual provider using the service employs the scribe. This presumes that providers using scribes directly benefit in terms of productivity towards their incomes and in decreasing their administrative burden. A second option would have the practice assume the responsibility for the cost in order to regulate what scribe service will be used, the hourly rate, and education and training requirements are needed for scribe candidates. The third alternative is a combination allowing the providers and the organization to share the expense of a scribe program because of the mutual benefits. The Vancouver Clinic’s COO, Tom Sanchez, reported that 18 of 194 physicians used medical scribes and that their return on investment was between 15% and 20%. (Sparling 2013)

Scribe program cost estimates were obtained from ScribeAmerica, the largest supplier of medical scribes in the U.S.. Program costs including clinical training, credentialing, corporate compliance, and insurance can be paid separately or rolled into the hourly rate of the scribe at a rate of $20-22 per hour. ScribeAmerica will coordinate schedules including substitutes for illness and will monitor scribe performance. There are no other out-sourced scribe service companies for the ambulatory environment in the Mid-Atlantic region. (C. Newman, personal communication, January 28, 2015)

Physician and Patient Satisfaction

There are two small studies of physician and patient satisfaction in ambulatory practices using scribes. One is a report from a urology practice and the other is from a cardiology clinic. (Koshy 2010, Bank 2013) In these reports there was substantial improvement in physician satisfaction and there were small gains in patient satisfaction. Increases in physician productivity could not be proved because of the small study size and limited duration of the trials. Authors admit to significant limitations in their studies where the physicians were willing volunteers.

By redirecting clerical tasks to a medical scribe, physicians can increase individual patient contact time, give more thought to complex cases, and schedule additional patients in their work day. Provider moral is improved and patients perceive the increased attention. Communication with patients is important to determine their wishes about having the additional staff in the exam when discussing medical information. (Coffin 2012) Education for patients about the benefits of a medical scribe on the physician’s ability to focus on the patient may improve acceptance. A suggestion to assess patient satisfaction can be found in the cardiology clinic study. (Bank et al 2013) In a standard questionnaire, patient rated their visit interaction with the doctor and their overall satisfaction with the practice.

Recommendation

I propose that Capital Digestive Care perform a trial of scribe use with five physicians assessing physician satisfaction, patient satisfaction, productivity metrics, and expense projections. The available literature is not sufficient to decide if an independent, non-hospital based, subspecialty practice should implement a wide-spread medical scribe program. Although we might eventually hire and train our own full-time medical scribes, I propose we engage ScribeAmerica to supply scribes for this trial.

A temporary set of policies and procedures for a medical scribe program must be developed with the scribe vendor to satisfy documentation requirements within our own electronic health record prior to initiating the trial.

Notes should be assessed for compliance with requirements early in the program. Since the provider is ultimately responsible for the contents of the documentation, the final note should affirm the provider’s presence during the time the encounter and his/her verification of the accuracy of the medical information. The documentation should be assessed for coding requirements and code level accuracy by the CDC Quality Committee director who is a certified coder.

Assessment of success in achieving a scribe program’s goals can be performed after a limited amount of experience. Goals may include reductions in transcription costs, improvements in overall documentation, reduced turnaround time for EHR tasks, improved provider satisfaction, and increased patient satisfaction. Suggested survey instruments for physician and patient satisfaction are attached in Appendix B and C. Financial metrics captured during the proposed trial will include relative value units billed per hour, number of patients seen per hour, and number of incomplete notes at the end of the day.

Each physician in the trial will participate in 6 full-day scribe assisted sessions that will be compared with 6 full-day standard sessions. Some internal resources will be needed to tally satisfaction and financial metric scores. A proposal from ScribeAmerica to provide scribes for the trial is projected at $6,000.00.

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References

Bank, A. J., Obetz, C., Konrardy, A., Khan, A., Pillai, K.M., McKinly, B.J., Gage, R.M., Turnbull, M.A., & Kenney, W.O. (2013). Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. ClinicoEconomics and Outcomes Research: CEOR, 5, 399–406. doi:10.2147/CEOR.S49010

Campbell, L. L., Case, D., Crocker, J.E., Foster, M., Johnson, M.,… & Warner, D. (2012). Using Medical Scribes in a Physician Practice." J AHIMA 83 (11):64-69.

Coffin, J. S. (2012). Using Scribes to Enhance Efficiency and Productivity in the Office. Retrieved September 6, 2015, from http://www.dorlandhealth.com/dorland-health-articles

Gellert, G. A. (2015). The Rise of the Medical Scribe Industry Implications for the Advancement of Electronic Health Records. JAMA 313 (13):1315-1316.

Grace,