A 2017 Medscape survey indicated that nearly half (49 percent) of orthopaedic surgeons feel burned out. The top three causes cited?

1. too many bureaucratic tasks
2. increasing computerization of practice
3. too many hours at work

If you’re looking to reduce the number of hours and tasks spent on bureaucracy and electronic data entry, as well as reclaim some quality of life at work, consider hiring a scribe. Scribes enable physicians to focus on patients and get out of the office sooner. The efficiencies they produce can increase the number of patients on the clinic and surgery schedule, covering the cost of the scribe and then some.

A life changer

“I started using a scribe about a year ago,” said Mark Floyd, MD, a sports medicine and general orthopaedic surgeon at the Harbin Clinic in Rome, Ga. “I built my practice to about 40 or more patients a day and was staying until 7 or 8 p.m. to finish notes. Several colleagues used scribes, and I didn’t see them staying late. That was enticing.”

Dr. Floyd is one of six orthopaedists at his clinic, a multispecialty group that uses ScribeAmerica, a national provider of medical scribes. Dr. Floyd has two children, a 6- and 4-year old, and getting home late meant missing out on dinner and other family activities. Now that he has a scribe, Dr. Floyd leaves shortly after the last clinic visit.

“For me, it’s about work-life balance,” he said. “The kids will only be young once, and I want to be part of that.”

Chad Patton, MD, MS, director of the Center for Spine Surgery at Anne Arundel Medical Center in Annapolis, Md., said using a scribe has changed his life: “At the end of the day, I have more time and energy, which makes me happier overall.”

Dr. Patton hired a scribe after spending a year using voice-to-text dictation software following implementation of electronic health records (EHRs). Even with voice-to-text dictation software, it was taking Dr. Patton up to 1.5 hours to finish his documentation after the last patient left.

Dr. Patton contacted the head of the scribe program in his hospital’s emergency department, who offered a scribe to work with him on a one-day trial basis. “Using the scribe made an immediate difference,” he said. “I realized that I had changed the way I practice by adapting to the EHR, but with the scribe, I could reengage with the patient.” As a result, his documentation process time has plummeted to 15 to 20 minutes per day.

Research supports the experience of Drs. Floyd and Patton. A pilot program conducted by dermatologists at Boston’s Brigham and Women’s Hospital showed significant reductions in time spent on documentation and physician burnout when scribes were used after EHR implementation. The scribes enhanced physician efficiency, improved patient access, and increased clinical revenue, which resulted in a reduction of the physicians’ average time spent on EHR work in half. Across 695 post-scribe visits, physician documentation time significantly decreased, averaging three minutes per patient.

The role of the scribe

A scribe is a nonlicensed, nonprovider who enters the details and notes of a patient’s clinic encounter into the EHR in real time, while the physician examines and focuses on the patient. Further, scribes do not require a medical background to be effective.

“Scribes don’t interact with the patient,” explained Margaret M. Maley, BSN, MS, a consultant with KarenZupko & Associates, Inc. (KZA). “They are only allowed to document what they see or hear from the provider. They are not independent, and they operate only at the direction of the practitioner for whom they are scribing.”

Half of the scribes at Abilene Bone & Joint Clinic in Abilene, Texas, are athletic trainers. The six-surgeon practice has an outreach program that provides 19 high schools with football and basketball trainers.

“We were able to hire many of them as scribes when the practice switched to an EHR [system] 7 years ago,” said Spence Southall, PT, practice manager at Abilene Bone & Joint Clinic. “Many of our physicians typed with one finger,” Mr. Southall continued. “We didn’t want them to stare at the computer. We wanted them to interact with patients and practice orthopaedic medicine.”

The two lead physicians in the practice have had their scribes the longest, and Mr. Southall said they would never trade them. “One doctor calls his scribe a ‘quarterback.’” Currently in the practice, every physician has a scribe and every mid-level employee who works independently has a scribe. “They’re indispensable,” said Mr. Southall.

Ms. Maley said there remains a big misconception among physicians that “scribing” is what a physician assistant or nurse practitioner does when adding to the note. “In most cases, what they are really doing,” she clarified, “is a patient assessment.” Ms. Maley warned that using a mid-level provider as a scribe vastly underutilizes him or her as a professional and as a revenue generator. “Using a highly paid, medically trained professional to essentially take dictation and organize medical documents is bad business. Don’t do it.”

How it works

Workflow varies by practice, but generally, a scribe shadows the physician as he or she sees patients. Most scribes are physically present in the exam room with the physician, quietly pecking away on the keyboard and asking the occasional clarifying question while the physician focuses on the patient encounter.

Dr. Floyd’s scribe has an always-open laptop set up on a rolling desk, which she wheels from one room to another. Like a court recorder, the scribe types while he talks. “What she types may not be verbatim, but she captures the essence of the conversation,” he said.

Dr. Floyd developed templates and uses key phrases with his scribe to speed data entry. “When I say, ‘medial meniscus tear,’ she types in a code that pulls up the template and makes additions. When I say, ‘right knee arthritis, injection, physical therapy,’ she is so familiar with this that when we walk out of the exam room she already has it ready for review. Sometimes I need to edit; sometimes I don’t. Then I sign off.”

Mr. Southall described a similar process, adding, “When our physicians are done with clinic, they are done for the day. They do some dictation, but it goes straight into the chart. Very rarely do they stay late to compile notes.” The practice’s scribes support the physicians in other ways: Over the years the role has morphed to include tasks such as obtaining authorizations for MRI and surgery and managing the surgery schedule. Scribes also help refill prescriptions and room patients and recently have begun participating in coding. “We’ve sent all of our scribes to the coding courses cosponsored by AAOS and KZA,” added Mr. Southall.

Scribes don’t have to be physically present in the exam room to be effective. Virtual scribing and office staffing solutions company Physicians Angels offers a HIPAA-compliant platform through which a scribe in India listens to the patient encounter and documents just as a physically present scribe would. The virtual scribe is connected using a secure IP address, and the scribes are skilled at navigating dozens of EHR platforms.

Lauren Kaiser, PHR, SHRM-CP, director of human resources at the 20-physician group Tri-State Orthopaedics in Evansville, Ind., said the virtual scribe solution works well and meets the practice’s unique needs.

When Tim Hamby, MD, of Tri-State Orthopaedics, reached a point where his clinic was seeing an average 70 patients a day, three days a week, he sought a better quality of life. But Ms. Kaiser said the practice had trouble finding the right person in-house or locally. The role’s description didn’t meet the minimum number of hours per week that were required by some scribe services. Physicians Angels offered a flexible solution, and the results have been very positive.

Complications included the audio-over-internet sound quality and international accent, and although neither was a deal breaker, onboarding did take longer than with an in-person scribe.

The wait was worth it, said Ms. Kaiser. “The virtual scribe has been invaluable. Dr. Hamby has three children and is very involved in coaching their sports teams. Now that he doesn’t have to dictate all those charts, he’s done when he walks out the door.”

Financial return

When a practice considers adding a position, it’s important to evaluate whether the benefit or improved productivity can cover the cost.

“For scribes, the answer has always been yes,” Mr. Southall said. “If you [can add] two or three more surgeries a month, it covers the [cost of the] scribe. And then everything on top of that increases your income. To any physician who says he or she can’t afford one, I say, I don’t know how you cannot afford one.”

Table 1 provides average costs of hiring a scribe, and Table 2 provides a sample financial model for calculating return on investment (ROI). Use your estimated volumes to determine whether a scribe is a prudent investment.

Dr. Patton, too, sees benefits. He has increased the number of patients he sees in clinic by about 24 percent. “That has made the scribe cost neutral, if not a net benefit from a revenue standpoint,” he said.

Good advice

If you’re considering a scribe, there are plenty of lessons to be learned from colleagues.

First, most advocates of scribes stress the importance of training and onboarding. Abilene Bone & Joint Center has new scribes follow a one-month orientation and training program that includes shadowing the physician and formal EHR training. “[After training], it still takes about six months for our scribes to flourish and feel comfortable,” Mr. Southall said.

Although a new scribe doesn’t need an orthopaedic or clinical background to be successful, once hired, make sure they have a thorough command of orthopaedic terminology, specifically the conditions you treat. If that awareness is missing, the American Academy of Professional Coders offers online bundled Anatomy + Terminology courses for $695 to $1,040,
depending on whether your practice is a member. You might also consider sending your new scribe to online courses offered by The American College of Medical Scribe Specialists, online universities such as William Paterson University’s WPConnect, or a local program.

Make sure your EHR templates are detailed and up to date. When Tri-State Orthopaedics hired its first scribes, the physicians had not set up individualized templates in the EHR. “That’s something we would do differently,” Ms. Kaiser admitted. “I think it would have been easier if we had created the templates upfront.”

Document the use of a scribe correctly. “The scribe must attest in each record that he or she is documenting on the provider’s behalf and acting as the scribe,” Ms. Maley explained, adding that the guidance for scribe attestation comes from The Joint Commission, not the Centers for Medicare & Medicaid Services. “If the scribe is an athletic trainer or other licensed professional, make sure [he or she] resists the temptation to add information from their own evaluation to the medical record when acting as a scribe.”

Finally, optimize your investment. Sharing a scribe is common, especially in a group practice. “If two physicians have an opposite surgery schedule, they can share a scribe because they aren’t in the office at the same time,” Ms. Maley suggested.

For instance, Dr. Floyd’s scribe works part time for his practice and covers a neurosurgeon’s clinic when Dr. Floyd is in the operating room (OR). Mr. Southall’s group tasks its scribes with obtaining preauthorizations and referrals when the surgeons for whom they work are at the hospital or in the OR.

“EHRs have contributed to the rising rates of physician burnout. While perhaps not for everyone, I believe that scribes help improve our well-being,” said Dr. Patton, who is on a physician well-being committee at Anne Arundel Medical Center. “Add to that the financial ROI, improved quality of life, and a return to the joy of practicing medicine—that’s a significant return. But you have to try it in your workflow to decide if it’s right for you.”

Cheryl Toth, MBA, is a business writer with KZA.

References:

1. Peckham C: Medscape Orthopedist Lifestyle Report 2017: Race and ethnicity, bias and burnout. Available at: https://www.medscape.com/features/slideshow/lifestyle/2017/orthopedics#page=2
2. EHR Scribes Cut Physician Documentation Time in Half, Study Says, Staff Writer, AMA Wire, December 21, 2017. https://wire.ama-assn.org/practice-management/ehr-scribes-cut-physician-documentation-time-half-study-says
3. Glassdoor.com, Medical Scribe Salaries, N=1,861. As of July 9, 2018. https://www.glassdoor.com/Salaries/medical-scribe-salary-SRCH_KO0,14.htm
4. Indeed.com, Medical Scribe Salaries in the U.S., N=2,531. As of July 10, 2018. https://www.indeed.com/salaries/Medical-Scribe-Salaries
5. 2018 Medicare non-facility allowable is $74.14. Assume approximately $26 reimbursement for one additional service.