Implementing a Scribe Program – Setting up for Success

Implementing a Scribe Program –

Setting up for Success

Exploratory Paper

Samantha Beatty, FACMPE

August 24, 2016

This paper is being submitted in partial fulfillment of the requirements of Fellowship in

the American College of Medical Practice Executives American College of Medical Practice Executives Professional Paper

Exploratory Paper

Implementing a Scribe Program – Setting up for Success

The increasing use of electronic medical records (EMR) during the clinical encounter brings not only benefits but also barriers that may affect the doctor-patient relationship and increase the work burden of the physician (Koshy, S., Feustel, P. J., Hong, M., & Kogan, B. A.,

2010). The adoption of EMR is becoming a widespread reality and may bring benefits including more efficient and effective patient encounters, better continuity of care between specialties, and improvement in data quality, readability, availability and information exchange. An EMR can also increase the opportunity to improve healthcare through better adherence to protocol guidelines, decreased medical errors, and improved data monitoring and aggregation (Shachak,

A., & Reis, S., 2009). However, as clinicians and patients are increasingly experiencing the computer as a barrier during the clinical visit, groups are beginning to look at a variety of solutions to improve the clinician-patient relationship; leaving clinicians free to focus on establishing better rapport and communication with patients.

One solution medical practices are exploring is the use of medical scribes. This paper is based on a literature search, personal experience, and several interviews of other practice leaders, with the goals of reviewing the evolution of scribes in the medical practice setting and determining how to implement a scribe program and set it up for success. While this paper primarily focuses on the keys steps to implementing medical scribes, it also explores several scribe personnel options including pre-med students, medical assistants, and virtual scribes. A review of the pros and cons to consider when determining whether to employ scribes or contract with an independent scribe company is also included. The target audience is practice administrators and physician owners who are considering medical scribes as a possible solution to

increase clinician productivity, satisfaction, revenue, and patient satisfaction while decreasing

documentation time.

History of Scribes – Emergency Departments

Based on literature review, the first documented use of medical scribes occurred in 1975

in the Emergency Department (ED) at St. Mary’s Hospital in Reno, Nevada. According to Allred

and Ewer (1983), the hospital ED was experiencing an increase in patient volume as well as the

number of patient records that were being completed later in the shift. By implementing scribes,

they stated, “In five years, it has proven to be a cost-effective means of providing a prompt,

accurate medical record.” In this early study, Allred and Ewer (1983) described the non-nurse

scribe as someone with a “knowledge of basic medical terminology and anatomy and good

penmanship” and they found “pre-medical and pre-nursing students especially well motivated.”

As time progressed, other hospital ED’s began evaluating and using a scribe solution,

although in most cases, the primary reason stated for implementation had to do with increasing

throughput. Very few of these hospitals performed documented studies or outcomes, which

limits the research and evidence around the effectiveness of scribes. One specific assessment took

place more recently in the Department of Emergency Medicine at a University of Florida Health

hospital. This assessment aimed to improve both throughput and clinician satisfaction by

implementing scribes and set very clear outcome measures to evaluate their success. In this

research article, Allen, Banapoor, Weeks, and Payton (2014) were able to demonstrate that

“through evaluation of pre-scribe and post-scribe implementation, the post-scribe time period

reflects many throughput improvements not present before scribes began.” They also

demonstrated, “100% of clinicians indicating scribes were a valuable addition to the department

and 90% of clinicians stating scribes increased their workplace satisfaction and quality of life.

(See Appendix A: Throughput Measures Assessed and Clinician Survey Questions from (Allen et al., 2014) to see the throughput measures and a list of survey questions they used for evaluation.)

Outpatient Medical Practices: Definition of a Scribe and Types of Personnel

The movement to using scribes in outpatient medical practices is first documented in

2010, and has increased dramatically over the last several years. According to The Joint

Commission, a scribe is an unlicensed person hired to enter information into the EMR or chart at

the direction of a clinician (physician or practitioner). It is important to note that The Joint

Commission’s stand is that the scribe does not and may not act independently but can document

the previously determined clinician’s dictation and/or activities (Shultz, C. G., & Holmstrom, H.

L., 2015). Typical activities of a scribe include chart preparation, pulling forward relevant information or data from previous visits, collaborating with and cueing the clinician during the patient encounter, taking dictation, editing notes, and order entry for clinician review and signature. According to a personal interview with a multi-specialty practice’s medical director,

“One of the greatest benefits of having a scribe, is the detailed visit summary that patients receive at the end of their visit. All of the key points from the encounter are noted, as well as any changes to medications, and instructions for them to follow. They also have easy reference to any orders or referrals generated during the visit (Sparling, 2015).”

There are different types of personnel utilized as scribes in the outpatient setting.

Options include medical or nursing students, medical assistants (MA), registered or licensed- practical nurses (RN or LPN), and those without clinical training that are administrative personnel trained specifically in the skills and function of a scribe, such as transcriptionists. In the majority of the documented research and personal interviews conducted over this past year, the two primary types of personnel functioning as scribes are medical students and MAs.

Medical Scribes

Medical scribes can be hired as direct employees of a medical practice, or contractually

hired through an independent scribe company. Those hired through a contract with an

independent company are most often pre-med or medical students who are able to work with a

clinician for an average of one to two years. They come to the practice with training around the

medical scribe role, general medical terminology, and strong typing and documentation skills. In

some instances, they may already have EMR specific training. Scribes in the outpatient medical

practice require focused recruitment and selection, and customized training materials specific to a

practice’s specialty and individual clinician. According to Hiller (2016), “The partnership with

an independent company can ease the burden on the practice to recruit and train medical scribes,

as well as developing a transition plan when scribe turnover occurs.”

For practices that choose to hire and train their own pre-med or medical students as

scribes, there are several important factors to consider. One factor is understanding the length of

time a scribe can commit to working with a clinician. Having a defined period of time and setting

appropriate expectations up front can set the scribe and clinician up for success. Second, the need

for documented training processes as well as clinician preferences and workflows is critically

important. When there is scribe turnover, having everything documented makes the transition

period smoother from one scribe to the next. The third factor is to ensure the practice evaluates

the appropriate salary range for the medical scribe so they are competitive with salaries offered

by independent scribe companies. One multi-specialty practice’s director stated, “Turnover and

competitive market salaries were our biggest challenges. The clinicians have become very reliant

on their scribe, and describe the day as painful when the scribe is not there. Having a pool of

scribes to draw from is a strategy we are considering, but we need to be willing to pay a higher salary than is currently offered to make this possible (Shields, 2015).”

In a recent text poll by the Medical Group Management Association (MGMA), called

MGMA Stat, members were asked to answer the question, “Does your group employ scribes or

rely on external scribe resources?” Twenty-five percent of respondents selected “employ”

compared with just over ten percent responding “external” and sixty-five percent responding with

either “no scribes, not applicable, or not sure.” This data suggests that there is more collective

experience with employing scribes in a medical practice, however, there is still much to be learned from both models.

Medical Assistants as Scribes

Hiring a medical assistant (MA) as a scribe is another possible personnel option. While no evidence of published research in this particular area was found, in roundtable discussions of practice administrators with this model of scribe staffing, there were several consistent themes.

Situations where the MA was successful included a highly motivated MA and clinician team, where both the clinician and the MA were willing to invest time one-on-one before and after patient visits. MAs in this scenario were said to feel valued and strongly committed to the care team and retention rates were accordingly high. Another factor described as helpful, but not a requirement of success, was a higher MA to clinician ratio. The higher ratio allowed there to be a team of MAs that would room patients, and manage phone calls, prescription refills, and other team-oriented tasks more in keeping with a traditional MA role, while the MA-scribe worked directly with the clinician. There was no consensus across specialties related to the exact ratio, however, in a roundtable discussion with six different practices, it ranged from 1.3 – 1.8 MAs per clinician. There was one practice that did not increase the MA to clinician ratio and simply added scribing to the MA job description. This practice did not have enough experience with the model to have a clear sense of whether it would be successful in the long term. The early benefit they experienced was strong patient relationships with the MA and clinician team. The greatest challenge they faced was increased wait times for either the clinician or the patient in between

visits, due to the need for the MA to first complete the scribing duties before rooming the next

patient.

Virtual Scribes

A virtual scribe is one that is available to connect electronically through various video-

technology solutions and is not physically present during the patient encounter. As it is early in

its adoption there is no research on this subject, however, it is an option to consider in rural areas

where recruitment is challenging. Several independent scribe companies are now offering this

option.

Key Steps to Implementing a Scribe Program

Understand the practice or individual clinician goals and desired results

Through numerous interviews and the review of all relevant research, six areas of desired improvement emerge as constant themes:

1. Improved clinician satisfaction

2. Improved efficiency and productivity

3. Increased revenue; by increasing number of visits seen, increased coding as a result of

improved documentation (a “higher octane visit”), or both

4. Decreased documentation time for clinicians and staff

5. Improved quality and consistency in charting in the EMR

6. Maintained or improved patient satisfaction

Understanding a practice’s goals and desired results prior to implementing a scribe program is the first key step, as the review of research demonstrates that scribes are not an automatic solution for all clinicians. Scribes are not a “one size fits all” approach, nor will every

clinician benefit from utilizing one. For this reason, it is important to determine specific desired

results in each of the above listed areas, and more considerations for practice leaders to think

through are explored later in this paper.

Identify which clinicians will benefit the most

The second key step in implementing a scribe program is to evaluate and understand

which clinicians will benefit the most. There are some identifiers that are more obvious than

others when a practice leader begins this evaluative process. One is to note which clinicians

spend significant time in between patients or at the end of the day documenting their visits.

Second is to observe which ones struggle to be efficient in the EMR. It is risky to assume,

however, that all clinicians who struggle in these areas will benefit from implementing a scribe.

In one practice, a clinician that spent two or three hours at the end of a busy clinic day

believed they would improve their satisfaction and documentation time by implementing a scribe.

When the scribe was hired, trained, and began working with the clinician, it became clear the desired results would not be forthcoming. The practice administrator talked with the individual clinician and identified the need to be open to other changes. These changes included adapting

their workflow during patient visits, and verbally calling out key findings during the exam, as

well as being willing to provide ongoing feedback to the scribe on how documentation should be

recorded throughout the visit. The scribe needed to learn the clinician’s preferences, and the

clinician was the best teacher for the task. In this situation, the clinician was open to doing work

differently, and adjusted quite successfully. In other situations, clinicians have become frustrated

and dissatisfied, because they wanted the documentation to flow a very specific way, utilizing

their own individual prose (Hiller, 2016). If clinicians are unwilling or unable to spend adequate

time training and giving feedback to their scribe, their results will be limited.

Express clear expectations for clinicians

Communicating with clinicians in advance of implementing a scribe program will help

the individual understand what to expect from having a scribe, and what will be expected or

needed from them. The clinician will need to know the process for hiring a scribe and how they will be involved, as well as a timeline for training and full implementation. This timeline will vary depending on the goals and needs of the clinician, and whether the practice has decided to employ or contract scribes.

According to Sparling 2015, there is strong value in having clinicians fully proficient on the applicable EMR system prior to implementing a scribe. This proficiency ensures that on days without a scribe the clinician can still document appropriately, albeit a bit “painfully”. In multiple practices, a guideline of six to twelve months of documenting in a specific EMR was utilized to define the length of time for new clinicians to be considered proficient. This typically aligns with the amount of time required to build a practice with the capacity that a scribe is warranted financially as well.

Groups that share best practices for implementation with their clinicians also set themselves up for success. Best practices may include workflows for how chart preparation will occur, where the scribe will stand in the exam room, whether the clinician will take a laptop or access the EMR while with the patient, and how patient instructions will be completed and delivered. The document in Appendix B: Sample Clinician Scribe Service Agreement provides an example of one practice’s tool to identify best practices and other expectations for review with the clinician prior to scribe implementation (Hiller, 2016). This particular practice partners with an independent scribe company.

Another key point to address in advance is how the clinician or practice will pay for the scribe. There are different methods to consider, with the basic question being whether the

individual clinician or the practice will pay for the additional cost of the scribe. This decision

will depend on a variety of factors such as whether the practice employs clinicians or if they are

owners, what goals the practice has for implementing scribes, and what type of clinician

compensation model exists. It is also possible with this method to evaluate and create agreement

with the clinician about the percentage of cost they will pay. An alternative method to consider is

to calculate how many additional visits per day the clinician must see to cover the cost of the

scribe, and add that number of visits to their daily schedule. One practice determined that the

cost of the scribe could be recouped with two to three additional patient visits per day. That

practice chose to pay the cost of the scribe, and require the clinician to add one hour of patient

contact time to each clinic day to produce the additional visits and revenue (Sanchez, T.,

Sparling, M., 2013). This works well in an environment where clinicians are employed by the

group. Methods of paying for the scribe vary greatly from one practice to another, and ultimately

need to support the goals that the practice has for implementing a scribe program.

Engender team communication and partnership

Team communication, whether you choose to employ or contract scribes, is essential to

maximizing the program. Crim (2016) states, “Scribes have become a part of our patient care

team.” Imagine that the scribe, the MA, and the clinician each form a leg on a tripod, all working

together to support and care for the patient throughout their visit. In order for this care team to

work smoothly, each role must clearly understand who is performing each task during the visit.

Identifying tasks that the scribe can take on to free up MA and clinician time is key. For instance, shifting chart preparation to the scribe allows the MA to have more time preparing for the day, taking vitals at the beginning of the visit, and assisting in procedures and other clinical tasks that require MA training. Additionally, having the scribe record exam findings and instructions during the patient visit, allows the clinician to interact on a more personal level with the patient as they do not need to interact with the computer or EMR much if at all while in the exam room.

Outcomes: Determine measures for success in advance of implementation and measure pre- and post-implementation

The final, and likely the most important step in implementing a successful scribe program is to determine the measures for success as well as a baseline for each measure pre-scribe. Once a baseline is determined, the practice can measure results at three and six month post-scribe intervals to determine the overall effectiveness for the individual clinician or practice as a whole.

According to Hiller (2016), measuring at these intervals allows the practice to adjust and make improvements along the way.

As stated in the first key step of implementing a scribe program, Understand the practice or individual clinician goals and desired results, six areas of desired improvement emerge as constant themes:

1. Improving clinician satisfaction. As a practice evaluates improvement, the first step is to assess the individual clinician’s current satisfaction and what factors are causing them to be less satisfied. This baseline data is critical in order to determine improvement post-scribe implementation. The most common tool practice leaders utilize is a clinician survey with a specific set of questions to evaluate improvement. The survey questions may be administered in a variety of ways, including email, personal interview with recorded responses, or a structured survey tool. Regardless of the survey method, utilizing a numerical rating can assist with quantifying the results in addition to qualitative comments from clinicians. For example, if a clinician were asked the question, “What is your individual stress level related to chart documentation during a clinic day?” the responses would vary greatly and provide a practice leader purely qualitative results. During roundtable discussion and personal interviews, practice leaders consistently shared that the analysis of clinician satisfaction is difficult to quantify because questions utilized were qualitative in nature, and often not documented prior to the scribe program being in place. By adjusting the above question slightly and asking the following

question both pre- and post-scribe, there is the ability to capture results in a quantitative manner:

“Utilizing a scale of 1-10, where 1 is no stress and 10 is extreme stress, how would you rate your

individual stress level related to chart documentation during a clinic day?” Additionally,

including a free text area on the survey for clinicians to provide qualitative comments related to

their satisfaction allows leaders to evaluate effectiveness in a comprehensive way. For practices

that administer a formal clinician satisfaction survey, adding questions related to ease of

documentation or stress level related to documentation provides another option for evaluating individual clinician’s satisfaction with quantitative data.

2. Improving clinician efficiency and productivity. When evaluating success in these areas, it is important to know the metrics a practice will use to determine improvements, and then measure the same way for both pre- and post-scribe implementation. Following is a list of questions and some possible answers provided by practices that are currently utilizing scribes, to assist a practice leader when considering scribes for improvements in efficiency and productivity:

1. Does the practice utilize the number of patient visits/encounters, or the work relative

value unit (wRVU) to determine productivity? Depending on the specialty, a group

can select either metric to evaluate productivity; the important factor is staying

consistent with the measure pre- and post-scribe. For example, in a surgical practice

one administrator found patient visits/encounters to be the more effective measure

overall, as it prevented surgeons from being incentivized to add only high wRVU

procedures. In several primary care practices, leaders found it useful to look at both

metrics consistently. In OBGYN practices it was said to be challenging to compare

generalists with gynecology only clinicians depending on the call structure and how

deliveries are handled within the obstetric portion of the practice. All of these factors

should be considered for the practice’s specialty and specific compensation model

when determining how the practice will evaluate productivity changes as it relates to

implementing scribes in the clinic.

2. Will patient visits/encounters or wRVUs be measured hourly, daily, weekly, or

monthly? Once the practice has determined how they will measure productivity, the

next consideration is what unit of measure will be utilized to evaluate improvement

post-scribe. One practice found that daily counts were most helpful over time to

evaluate and see how many patient visits to add each day. This approach also guided

the practice as to what type of visits to add, as they measured both encounters and

wRVUs daily. In another practice, clinicians preferred to see encounters per hour so

they could evaluate the possibility of reducing length of appointment time verses

adding additional encounters to the end of the day.

3. Given the practice specialty, is the clinician in the office daily, or do they have days

in surgery or at the hospital? How will this impact measuring productivity related to

scribe implementation? In primary care practices, this is almost a non-issue.

Clinicians tend to be in the office a set number of days per week with regular and

predictable schedules. In OBGYN practices there is typically great variability in

scheduling scribes which adds a level of complexity to creating maximum efficiency.

These clinicians are sometimes called mid-day to do surgeries, or deliver babies.

Determining how to utilize the scribe during these one to two hour blocks of time in

the middle of the day becomes an important consideration. For surgical practices that

have set surgery blocks for the clinician such as orthopedics, this is far less of an

issue and easier to plan in advance. Understanding the practice complexities related

to scheduling scribes will assist leaders in setting a program up for success from the

beginning.

4. To determine efficiency for patient visits, will a practice evaluate based on time spent

with the clinician, or overall visit cycle time? This goal can depend on metrics such

as patient satisfaction, and the desire to improve the overall visit cycle time for a

patient verses simple improvements related to the time spent with the clinician. If the

practice goals are more related to keeping the clinician on time, and other areas of the

visit are flowing smoothly, then measuring this aspect of the visit is an effective

measure. If a practice is not measuring any portion of visit cycle time, it is valuable

to get a baseline in each area, such as time to check in, time spent rooming a patient,

time with a clinician, and time for ancillary tests if appropriate. With the baseline

measures calculated, the practice will be able to measure the same metrics post-scribe

to see where the scribe is having the most impact on efficiency.

5. What other metrics will the practice measure to determine efficiency and productivity

(such as chart preparation accuracy and time, or room turnover time)? For practices

with goals around accurate and timely chart preparation, this metric is also important

to consider. One practice found that MAs were spending an average of nine minutes

per patient chart to prepare for the days visits. When the scribes took on this task,

they were able to reduce that time to four minutes per patient chart, with no negative

impact on quality based on chart audits conducted by supervisors. This practice was

able to start MAs thirty minutes later each day as a result, which reduced payroll

expenses due to overtime.

There are many questions to consider when determining how to measure improvement in clinician efficiency and productivity, and the above list is a sample to help practice leaders begin to think through this complex question as it relates to their practice specifically.

3. Increased revenue. By increasing the number of patients seen, and the increase in coding as a result of improved documentation (a “higher octane visit”), or both, most clinics implementing scribes see an increase in revenue. In one specific case, a five-clinician primary care practice was looking to improve patient visits, access, and satisfaction, as well as decreasing the amount of

time spent on the computer. While this individual practice improved each of the goal areas, they

also saw a positive impact on revenue. By shortening appointment times for most visit types, and

improving chart documentation quality, the practice saw the following results:

Pre-Scribe Post-Scribe

Charges: $285,841 Charges: $398,031 (39% increase)

Visits: 2,918 Visits: 3,759 (29% increase)

Avg. Charge/Visit: $97.99 Avg. Charge/Visit: $105.89 (8% increase)

According to Arena (2015), the founding physician of the practice had previously reduced his number of days in the office from five to four as the chart documentation was proving too onerous a task for him. After implementing a scribe into his practice, he chose to move back to five days in the office, which contributed to the increase in visits and revenue generated. Lest we get overly focused on the finances, it is notable that this senior clinician cited one of his reasons for returning to practice five days a week was that he was “having FUN again!” He had become disenchanted with the amount of time he had been spending with the computer, so the addition of the scribe improved his sense of professional satisfaction with his daily routine, and his finances.

Another documented prospective study in a Cardiology clinic saw improvements in revenue as a function of increased patient volume (Bank, Alan J, et al, 2013). In this study, both the number of patients seen per hour, and the wRVUs generated per hour increased.

Most other documented studies did not include specific revenue impacts. In the primary care example above, it is notable that increasing revenue was not an initial goal for the practice.

In addressing other goals, the practice was able to see a positive impact to revenue. It is possible to measure revenue both pre- and post-scribe retrospectively and is a good measure for practices to evaluate, even if it is not a stated goal for implementing a scribe program. In situations where one of the desired outcomes includes the practice or clinician increasing revenue, a key factor for

15 success is to ensure the clinician or practice is busy with strong patient demand. Making a clinician more efficient and able to see more patients can certainly have positive financial outcomes, but only if there is the patient demand to fill their newly expanded schedule.

4. Reducing documentation time for clinicians and staff. This particular measurement requires individual clinicians and staff to manually track their documentation time, making it one of the most difficult to measure quantitatively. Methods utilized to track this metric include paper time logs, digital timers, and various mobile applications designed to track time. According to

Shields (2015), clinicians were so happy to reduce their documentation time and not have to stay late into the evening, or take work home with them. Hiller (2016) stated, “Several clinicians have reduced their documentation time at the end of the day by more than 50%. It was difficult to quantify because clinicians often forgot to track the time utilizing a timer or mobile application.”

Not surprisingly, when reviewing qualitative comments, there also appears to be a strong link between clinician satisfaction and reduced documentation time.

5. Improved quality and consistency of charting in the EMR. This area is observed with mostly medium to large group practices. Improved quality and consistency of charting can be accomplished by standardizing the training scribes receive on the front end, and creating standard preferences for key exam findings as well as diagnosis or problem-based charting. Again, determining what metrics a practice desires to improve is key. One specialty practice focused the scribe on creating a standard document at the end of each consult visit that recorded diagnosis, key findings, orders, and test results that could easily be sent back to the referring provider to ensure continuity of care in a reliable, standard format. This practice received positive feedback from several primary care groups that were delighted to have the information and follow up. In other groups, creating standard templates for smoking cessation counseling that clinicians were doing during the visit allowed scribes to document in a way that met a variety of quality metric goals for the practice. The clinicians were doing this work pre-scribe, but not documenting it in a

reportable way. Post-scribe they had a clear process that was consistently followed and could

more clearly see the impact they were having on patients and their behavior modification around

smoking cessation. This kind of data acts as a professional satisfier for clinicians who previously

have not had feedback systems to easily evaluate their own progress.

6. Maintain or improve patient satisfaction. Many practices utilize a structured patient

satisfaction survey, which can be an effective, quantifiable way to ensure patients are not

negatively impacted by the implementation of scribes, and to measure their overall satisfaction

both pre- and post-scribe. Another valuable tool is to utilize a point-of-service survey for patients to complete after the scribe implementation occurs. This survey should be short and concise, with one to three questions specific to the scribes. (See Appendix C: Sample Point-of-Service

Patient Survey to see an example of one practice’s survey used for evaluation.) In all of the literature review and interviews completed, there was not one example of overall negative patient satisfaction. In a few instances, individual patients made a request to not have a scribe present for all or a portion of their visit. In these circumstances, practices and individual clinicians have the flexibility to ask a scribe to leave the exam room for portions of the visit as applicable. Positive patient comments related to scribes have increased significantly in practices that were interviewed, and included themes around clinicians “looking them in the eyes” and not being

“focused on a computer” during the visit. One practice shared a direct quote from a patient that stated, “My visit was incredible. The doctor was warm, thorough, and kind. I especially

appreciated the scribe so that the doctor’s attention was fully directed to me, his patient. Kudos to you for investing in your patients and doctors. It is making a big difference.” In this specific example, the patient visit was a standard fifteen minute appointment. The practice leader had data demonstrating that the actual amount of time this particular clinician spent with patients on average has decreased since implementing a scribe. Patients’ comments, however, indicate they perceive their time with the clinician to be longer, or higher quality time. This shift in the

17 dynamic of the visit and patients’ perception of it has great possibilities for practices, and should not be underestimated.

Conclusion

In conclusion, as scribes have evolved from the early days of Julius Caesar, who was reputed to have seven scribes who followed him around taking dictation (Greenblatt, 2011), to the

ED, and now to the outpatient medical practice environment, there is still much to learn about how to implement a successful scribe program.

One systematic literature review was recently conducted by Shultz and Holmstrom

(2015), with the purpose of summarizing the literature investigating the effect of medical scribes on health care productivity, quality, and outcomes. In this review, the conclusion stated,

“Available evidence suggests medical scribes may improve clinician satisfaction, productivity, time-related efficiencies, revenue, and patient-clinician interactions. Because the number of studies is small, and because each study suffered important limitations, confidence in the reliability of the evidence is significantly constrained (Shultz, C. G., & Holmstrom, H. L., 2015).

While early research may not statistically demonstrate the effectiveness of scribes given the limited number of studies, the qualitative evidence gathered during numerous interviews must be considered. When scribes are thoughtfully implemented and key steps are followed, there is a clear case for scribes as a positive change for practices that are attempting to improve clinician and patient satisfaction, productivity, efficiency and revenue, or simply reduce documentation time for clinicians and staff. While it is not a solution for every situation or clinician, there are clear situations where scribes--implemented well--are extremely effective.

A practice must consider whether to employ or contract scribes, and whether a medical

student, MA, or other administrative personnel will best meet the needs for the clinician, the practice, and the specialty. When implementing scribes, the five key steps to guide success are:

1. Understand the practice or individual clinician goals and desired results

2. Identify which clinicians will benefit the most

3. Express clear expectations for clinicians

4. Engender team communication and partnership

5. Determine measures for success in advance of implementation and measure pre- and

post-implementation

While existing evidence on the use of medical scribes remains limited and more research is needed to expand our overall knowledge and understanding of how practices can benefit from the use of scribes, it is clear that following these key steps will assist practices in identifying challenges early and setting things up for the greatest likelihood of success.

Appendix A: Throughput Measures Assessed and Clinician Survey Questions from

(Allen, B., Banapoor, B., Weeks, E. C., & Payton, T, 2014)

Throughput Measures Assessed

(1) door to triage time: the time elapsed from when the patient arrives in the ED until the patient is triaged; (2) door to room time: the time elapsed from when the patient arrives in the ED until the patient arrives in the room; (3) door to provider time: the time elapsed from when the patient arrives in the ED until the provider (physician) signs on to the patient’s chart; (4) door to disposition time: the time elapsed from when the patient arrives in the ED until the provider decides the patient’s disposition; (5) door to exit time: the time elapsed from when the patient arrives in the ED until the patient exits the ED; (6) provider to disposition time: the time elapsed from when the provider (physician) signs on to the patient’s chart until the provider decides the patient’s disposition; (7) disposition to exit time: the time elapsed from when the provider decides the patient’s disposition until the patient exits the ED; (8)The number of patients who left without being seen.

Survey questions.

(1) Do you think scribes are a valuable addition to this department? (2) From a shift stand point, have you seen an increase in work production/work flow while working with a scribe? (3) Before scribes, how many hours following your shift did you spend charting? (4)With a scribe, how many hours following your shift did you spend charting? (5) Does the use of a scribe increase the amount of time you spend with patients? (6) Do you enjoy working with a scribe? (7) Overall, does the use of scribes increase your workplace satisfaction? (8) Does the use of a scribe increase your quality of life? (9) Does the use of a scribe increase your level of focus at work? (10) Does the use of a scribe decrease your level of stress at work? (11) Does the use of a scribe decrease your level of stress at home? (12)Will the use of scribes extend your career as a physician/PA/NP? (13) Does the use of a scribe help you remember to ask the patient questions that you otherwise might have forgotten to ask? (14) Please discuss your thoughts about the use of scribes in RAZ (15) Please discuss your thoughts about the use of scribes in Core (16) Please discuss your thoughts about the use of scribes in the Trauma Bay (17) Please discuss your thoughts of the Scribe Program as a whole

Appendix B: Sample Clinician Scribe Service Agreement

[Practice Name] is looking for ways to improve patient and clinician experience, as well as efficiency and revenue. One of the options we have been exploring is the use of medical scribes. This document outlines the expected outcomes of a scribe program, best practices for implementation, and the terms for securing a scribe to support your practice goals.

Expected Outcomes of a Scribe Program

 Time Savings: Regardless of the volume of patients seen each day, scribes can reduce your documentation time by an average of 50%. Most often clinicians can complete all documentation within one hour of seeing the last patient, and many routine visits are completed at the end of each visit and not saved for the end of the day.  Documentation Quality: Some clinicians under code their charts because they are unable to fully document all of the care that occurs in the appointment. With a scribe this information is fully captured often resulting in a higher level of reimbursement.  Training: Training is addressed collaboratively by [Practice Name] and [Scribe Vendor]. [Scribe Vendor] provides 80 hours of classroom training prior to bringing the scribe on site. Once the scribe is onsite, they are paired with an experienced medical scribe trainer. NOTE: Timing for training is highly dependent on clinician FTE and time in the clinic. Scribes that work 4-5 days/week with a clinician will come up to speed much more quickly than those that have 1-3 days/week with a clinician in the clinic setting. In some instances 2 scribes will be trained per clinician for cross-coverage.  Expected Medical Scribe Recruitment and Retention: Medical scribes are generally pre- med students, and will be recruited to work 1-2 years, with the average length of service being 15-21 months. Training plans include overlapping the existing scribe with a new incoming scribe to minimize disruption in the transition period for the clinician.  Provide Feedback to Medical Scribe: It is important for clinicians to review each note and provide feedback to the scribe regarding elements to delete/edit/add in order to improve documentation quality. This ensures that documentation is thorough and reflective of individual preferences. This is more intensive during the training period and eases with time.  Patient Volume: Most clinicians can ramp their patient volume after the first 2 months of implementing a scribe program. Our data suggests that the scribe program becomes profitable by seeing an average of 2 additional patients (99213) per clinic day.  Patient Satisfaction: Our patient satisfaction surveys indicate maintained or increased patient satisfaction due to patients receiving the full attention of the clinician and being seen in a timelier manner. We have also seen a decrease in the length of time a patient spends in our office overall.  Clinician Satisfaction: Clinicians report greater satisfaction when scribes are used because they have someone in the room documenting the details of the exam, HPI, patient instructions, orders entered and signed, medication entry (which is signed by the clinician at the end of the visit), and obtaining relevant imaging and lab reports. This allows the clinician to have more “real” face time with patients without having to multi- task.  Increased Revenue: By seeing 2 additional billable visits per clinic day clinicians can increase revenue to cover the cost of the scribe for their practice.

Best Practices for Implementation

1. Chart Prep: The scribe is responsible for preparing all patient charts for the day. At [Practice Name] this requires the scribe to arrive early enough to prepare charts for the clinician they are scribing for; allowing the support staff to focus on other important aspects of patient care. 2. Patient Room Communication: Medical Assistant (MA) or LPN communicates the patient name and location to the clinician and scribe in the patient chart on the summary line. 3. Patient Handoff: After rooming the patient, MA or LPN connects briefly with the clinician and scribe, before they enter the room to report out (ideally, using SBAR-R). 4. Real-Time Documentation: All documentation in the room is performed by the scribe. 5. Use of Computer during Patient Visits: The scribe is responsible for all use of the computer(s) during the visit, including pulling up images for the clinician to review as requested. Best practice is for the clinician to not bring their computer into the exam room. 6. Scribe Location during Appointment: The scribe remains in the exam room during the physical exam, documenting the findings as dictated. In rare, sensitive situations, the scribe may be asked to step out, and the clinician dictates the findings at the end of the visit. 7. Patient Instructions: The scribe completes the after-visit summary by the end of the visit, printing once the clinician has reviewed and dictated any changes to the patient record. 8. Post-Visit Discussion: The clinician and scribe spend time daily to discuss each visit to address questions or additional details to add. 9. Completing Charts: While some charts can be completed during the visit, other, more- detailed charts may require additional time later in the day to complete. This will require scribes remain for as long as it takes to complete charts after the last visit. The medical scribe will enter the chart edits as directed by the clinician prior to sign-off. 10. Administrative Duties: The medical scribe can perform specific administrative duties to maximize their value during slow periods of the day. [Practice Name] has developed a list of such duties. 11. Time Keeping: The scribe will assist the clinician in working within the allotted time scheduled for each appointment.

Terms for Securing a Scribe to Support Practice Goals

To cover the full cost of the scribe program the following terms have been established for the individual clinician:

1. Paying for the scribe program:  [Practice Name] pays initial startup cost plus training time. After the training period (post 8 weeks of solo scribe time), the clinician will incur a standard monthly cost, with the remainder of the cost being allocated to the clinic to account for time spent on admin duties, etc. The standard rate is based on the clinician’s office FTE as follows: o Full time clinic (4 days per week) - $1,200 per month o 0.875 clinic FTE (3.5 days per week) - $1,050 per month

o 0.75 clinic FTE (3 days per week) - $900 per month o 0.625 clinic FTE (2.5 days per week) - $750 per month  By adding 2 visits per clinic day, the cost of the program will likely be offset via incentive payment 2. Provide feedback to the scribe on a daily basis as described in the Expected Outcomes section above. 3. Thoughtfully complete the Scribe provider’s assessments and periodic service reviews.

By signing this [Practice Name] Scribe Services Agreement, the clinician agrees to implement best practices and terms for securing a scribe to support practice goals.

Termination of Agreement

In the event the scribe program is not an adequate fit for your practice, please provide thirty days written notice to your practice manager regarding your decision to terminate your involvement in the program. Within those thirty days of notice, a plan will be developed with [Practice Name] and [Scribe Vendor] to redeploy your scribe elsewhere at the end of the thirty days (or sooner if that is desired and possible).

Clinician Signature: ______

Clinician Printed Name: ______

Signature Date: ______Effective Date: ______(Note - date post 8 weeks of solo scribing)

Appendix C: Sample Point-of-Service Patient Survey

Feedback on Today’s Visit

Your visit today included a medical scribe—a trained healthcare professional whose job it is to document important information in the computer while your provider talks with you. You can help us evaluate this program by answering a few questions.

1. Did having the medical scribe in the room make your experience better or worse?

2. Did you feel like you had more or less of your provider’s attention with the medical scribe in the room?

3. Do you feel like you spent more or less time waiting for your provider at today’s visit than you’re used to?

Other Comments:

Thank you for your feedback on the use of medical scribes. Please note you may still receive an invitation to complete an online survey regarding your overall satisfaction with today’s visit.

Bibliography

Allen, B., Banapoor, B., Weeks, E. C., & Payton, T. (2014). An Assessment of Emergency

Department Throughput and Provider Satisfaction after the Implementation of a Scribe

Program. Advances in Emergency Medicine, 1-7.

Allred, R. James et al. (1983). Improved Emergency Departemnt Patient Flow: Five Years of

Experience with a Scribe System. Annals of Emergency Medicine, 71-72.

Arena, J. (2015, May 6). Practice Consultant and President. (S. Beatty, Interviewer)

Bank, Alan J, et al. (2013). Impact of Scribes on Patient Interaction, Productivity, and Revenue in

a Cardiology Clinic: A Prospective Study. ClinicoEconomics and Outcomes Research,

399-406.

Crim, C. (2016, June 9). Physician. (S. Beatty, Interviewer)

Greenblatt, S. (2011). The Swerve: How the World Became Modern. W. W. Norton & Company.

Hiller, K. (2016, May 25). Senior Operations Manager. (S. Beatty, Interviewer)

Koshy, S., Feustel, P. J., Hong, M., & Kogan, B. A. (2010). Scribes in an Ambulatory Urology

Practice: Patient and Physician Satisfaction. The Journal of Urology, Volume 184, 258-

262.

Sanchez, T., Sparling, M. . (2013, March). Scribes in Clinical Practice. AMGA National

Conference, Orlando, FL, USA.

Shachak, A., & Reis, S. (2009). The Impact of Electronic Medical Records on Patient-Doctor

Communication During Consultation: A Narrative Literature Review. Journal of

Evaluation in Clinical Practice, Volume 15, 641-649.

Shields, S. (2015, May 20). Director of Operations. (S. Beatty, Interviewer)

Shultz, C. G., & Holmstrom, H. L. (2015). The Use of Medical Scribes in Health Care Settings: A

Systematic Review and Future Directions. The Journal of the American Board of Family

Medicine, Volume 28, 371-381.

Sparling , M. (2015, May 22). Medical Director - Physician. (S. Beatty, Interviewer)