Published in the February 2014 issue of Today’s Hospitalist
A FEW YEARS AGO, the hospitalists at Saint Barnabas Medical Center in Livingston, N.J., found themselves struggling.
Their individual census wasn’t particularly high “between 12 and 14 patients a day “but their productivity was below par. Billing charges were being lost, primary care physicians were waiting days for discharge summaries, and the hospitalists felt they didn’t have enough time at the bedside with patients or to discuss cases with consultants.
At the same time, the demand for hospitalist services was on the rise, but the budget wouldn’t allow hiring any more doctors. To top it off, the physicians were still dealing with paper charts.
The 15-physician group, which is staffed by Inpatient Medical Associates (IMA), caught one break in June 2012 when the 600-bed hospital implemented an EMR. But in April of that year, the doctors had started a pilot project that proved to be a key solution: using scribes to help offload much of doctors’ documentation and clerical time.
“Our ER affiliate had been using scribes for more than 20 years, and the model worked very well for them,” says Alexander Strachan Jr., MD, MBA, IMA’s executive vice president. “We decided to pilot it.”
Within weeks of bringing in two scribes “unlicensed individuals who enter information into the EMR or chart at the direction of a physician or other licensed clinician “the group’s productivity jumped significantly.
Today, with five scribes, group members each see between 22 and 24 patients a day, reports Maninder Abraham, MD, IMA’s executive medical director and hospital medicine section chief at Saint Barnabas. “And both the hospitalists and the primary care physicians are a lot happier,” Dr. Abraham says.
As Dr. Abraham points out, the scribes don’t shadow the hospitalists into every patient room. “Two doctors share a scribe,” she explains, “so the scribes sit in one place and the physicians call or see them personally and give them notes.” Because the scribes aren’t following the doctors into patient rooms, their presence “has never been an issue with patients or families.”
Formally known as clinical information managers, scribes have been used in many ED models. The Joint Commission gives the use of scribes its blessing, but it states unequivocally that scribes may not act independently. Meanwhile, the Centers for Medicare and Medicaid Services requires that physicians review every aspect of scribes’ work and input, and document having done so.
Typically, scribes are nursing students or others taking a year before starting medical or physician assistant school. According to Dr. Abraham, EMTs are also drawn to the position, as are physicians studying for their USMLE exams or applying for residency, or candidates interested in hospital or health care administration. Data from the American College of Emergency Physicians indicate that the average ED physician spends between 30% and 40% of each shift on documentation, and that using scribes can increase ED physicians’ number of patient encounters by as much as 25%.
Dr. Strachan has seen a similar impact on hospitalists’ productivity, with doctors gaining back several hours a day that used to be devoted to documentation and to making sure transitions run more smoothly. He sees scribes as a solution to what he calls the “inelastic” structure of hospital medicine, with hospitalists doing most of the work required to move a patient through a hospitalization, including way too many clerical tasks. Augmenting hospitalist staffing with midlevel providers “and two midlevels work with the Saint Barnabas hospitalist group “still doesn’t “relieve the hospitalists of all the nonclinical work they have to do, ” Dr. Strachan says.
“Hospitalists are too expensive to be consumed doing paperwork,” he notes. In addition to transcribing H&Ps, progress notes and discharge summaries, the scribes at Saint Barnabas work one-on-one with hospitalists to ensure that documentation reflects the appropriate level of service performed and to assign billing codes.
Improving the bottom line
That, Dr. Abraham notes, has boosted the group’s bottom line and reduced billing delinquencies by 90%. Those gains are offset only slightly by staffing expenses, with a scribe’s salary costing only one-fifth of a hospitalist’s.
The scribes also perform other clerical functions: notifying primary care physicians about admissions and discharges, including faxing discharge summaries; placing phone calls to consultants; tracking medical records, medication lists and lab results; and assigning patients, including generating daily rounding lists. What scribes may not do is enter orders or perform anything hands-on with patients, including any lab work or set-up for procedures.
Just as important as the economic gains are the boost to physician efficiency and satisfaction.
“Our discharge summaries are turned around in less than 24 hours now vs. 72 hours before we started using scribes,” says Dr. Abraham, “and they’re much more detailed.” She credits that with the big increase seen in primary care satisfaction, which jumped from 67% in 2012 to 98% in June 2013.
It now takes hospitalists only five minutes to review the summaries the scribes produce, where doctors used to spend at least 45 minutes preparing each discharge summary for transcription. (The discharge summaries no longer have to go through the hospital’s transcription department.) Another big time-saver is having scribes track down lab and test results.
Downsides few, but problematic
Scribes need four weeks of training, in Saint Barnabas’ experience. That includes two weeks of off-site training in medical terminology and transcription, and two weeks of on-the-job training shadowing either a hospitalist or an experienced scribe.
For scribes, the job’s appeal is the broad experience they gain. “They love the work, and they’re very eager because it helps them learn,” Dr. Abraham observes. That on-the-job experience helps boost their resume and can be a leg-up for future medical students.
But that highlights the biggest downside of the model: Scribes tend to be short-timers, staying on average less than two years.
As a result, IMA, which now uses scribes in a second hospitalist program, is looking for another staffing solution. The idea would be to expand the pool of potential candidates to include other medical professionals such as experienced coders, who might be more inclined to stay in the job.
“We’re also trying to figure out if we could recruit different types of scribes to create a career ladder,” says Dr. Strachan. The company is deciding how best to attract candidates to serve multiple programs or to outsource scribes to programs that don’t want to staff such slots themselves, and create paths for scribes who want administration-level roles.
Hospitalist groups interested in the model should first make sure that hospital bylaws won’t be a problem. Saint Barnabas had to clear that hurdle.
“We had provisions already in place in our medical staff bylaws for credentialing nonclinical personnel,” Dr. Abraham points out. “We provided the hospital a copy of our training manual and our policies and procedures for scribes, and the hospital designated our scribe program as an approved scribe-training program.”
Bonnie Darves is a freelance health care writer based in Seattle.