Published in the May 2018 issue of Today’s Hospitalist
AS HIS administrative responsibilities ballooned, California hospitalist Sanjay Muttreja, MD, knew that something had to give. What ended up suffering was his clinical documentation. ”My H&Ps were not complete, and sometimes I didn’t even finish,” he recalls. “I would be so tired that I would say, ‘I will come back and finish up my H&Ps later.’ But then I was off-shift and I would forget.”
Meanwhile, hospital leadership at Inland Valley Medical Center and Rancho Springs Medical Center knew he was working his tail off both as a clinician and as medical director for a dozen Envision Physician Services (formerly EmCare) hospitalist groups throughout southern California. “They wanted to help me,” so the ED director offered to “share a scribe” with him.
Now, Dr. Muttreja has his own scribe, one specifically trained in hospital medicine work. “I see more patients than I would before, and lifestyle has improved for me 100% because I go home on time,” he says. “Scribes are here to stay.”
“Lifestyle has improved for me 100% because I go home on time.”
~ Sanjay Muttreja, MD
Envision Physician Services
While the data are still being analyzed, Dr. Muttreja adds that having a scribe appears to have contributed to a hike in the hospitals’ case mix index (CMI), as well as better reporting on quality measures and an increase in on-time record completions.
He hopes to make the case for adding three more hospital medicine scribes next year. And he notes that half his hospitalist colleagues are “asking when can they get their own scribe.”
But the other half aren’t. While the buzz around using scribes in hospital medicine is loud, support is far from universal. Some practices conclude that these nonclinical documentation assistants—who typically shadow doctors and enter notes into an EHR—are worth the between $20 and $30 an hour that they cost. But others come to the opposite conclusion or stay on the fence. (Scribes generally earn half that amount, while the other half goes to the staffing company that recruits, trains and supervises them.)
Even supporters of the model think hosp italists should proceed with caution. Michael Corvini, MD, group vice president of Team- Health’s Southeast operations, served as medical director of a medical scribe company before joining TeamHealth last year. He says that data on scribe performance are lacking.
“The big picture is that the utility of scribes in hospital medicine is nuanced,” says Dr. Corvini. “While I feel there is great potential in the model, I don’t think we have a final answer yet.”
Using medical scribes, he points out, can allow physicians to spend more time with patients and less time with an EHR. And “scribes can document the bulk of information collected during an admission history and physical,” suggesting a potential niche for pairing scribes and admitting physicians during times of high-admission volume.
“Not all scribes are created and trained equally.”
~ Michael Corvini, MD
But Dr. Corvini wonders how much help scribes can offer when documenting a rounding hospitalist’s daily progress note, where the majority of the documentation focuses on medical decision-making and requires direct physician input. He also notes that “not all scribes are created and trained equally” nor can they all reproduce what they hear quickly and accurately. “That makes high-level training and quality control essential.”
Pilot trials and benefits
Dr. Muttreja also presents this perspective: Offering work to scribes, who usually are younger and planning to go on to be medical professionals, is doing them a big favor. It’s allowing them, he says, to get their “feet wet” and figure out if this is what they really want to do.
He’s seen them go either way after their stint as being scribes. “Some realize that this is definitely the field for them,” he points out. “Others become disillusioned, so they don’t have to spend all that time going through medical school.”
But some practices may shy away from using scribes because documentation is not their most pressing need. Or they may decide that money spent on scribes could go further on other staffing solutions, from medical assistants to nurse practitioners, depending on their patient population and their type of workload. (See “Alternative staffing models.“)
This spring, TeamHealth is piloting a scribe trial in one Texas facility. Among other questions, Dr. Corvini says he and his colleagues want to find out if using scribes “will increase productivity to the point where the cost is recovered.” (TeamHealth owns its own medical scribe company, PhysAssist Scribes, which staffs the EDs it operates.)
“I can see a role for scribes in a subset of practices that need extra support.”
~John Birkmeyer, MD
But such productivity and cost-saving conclusions aren’t a sure thing. In fact, the Tacoma, Wash.-based national organization Sound Physicians conducted a pilot study utilizing scribes for hospitalists last year. It decided to not pursue that model, although the company continues to use scribes in emergency medicine. For hospitalists, Sound Physicians is looking at other ways to optimize efficiency such as telemedicine and greater use of advanced practice clinicians.
Sound Physicians’ chief clinical officer John Birkmeyer, MD, ticks off the “non-trivial benefits” that teams derived from using scribes in that pilot study: a modest increase in physician satisfaction, a slight rise in productivity—including four more minutes spent at patients’ bedside during encounters—and a “small but measurable improvement in the completeness of documentation, which supported slightly more accurate coding levels for professional services.” Still, “the return on investment needs to be there to justify the added cost of incorporating scribes.”
A boost to physician satisfaction
Sound Physicians isn’t discarding the model completely, however. As Dr. Birkmeyer says, “I can see a role for scribes in a subset of practices that need extra support.” In situations where programs may be having problems staffing, for instance, scribes may provide some relief and help clinicians avoid burnout.
And although both empirical and anecdotal evidence are mixed on whether using scribes boosts hospitalist productivity enough to offset their costs, one outcome few dispute is provider satisfaction. Once they try them, almost “everybody likes having scribes,” says Eric Edwards, MD, medical director of the division of hospital medicine at the University of North Carolina’s Hillsborough Hospital. There, scribes work alongside hospitalists during the weekday noon-9 p.m. swing shift.
“Doctors find the shifts a lot more palatable when they’re working with scribes,” Dr. Edwards says. But proving their worth otherwise has been harder. “We have looked at things like how quickly patients get out of the ER and whether hospitalists are billing at a higher level with scribes, and we haven’t been able to show any kind of statistically significant benefit.”
“The doctor can say, ‘Hey, remind me to check that CT scan at 2 o’clock.’ “
~ Jeffry Kreamer, DO
Best Practices Inpatient Care
In other facilities, however, scribes are credited with improving hospital reimbursement. One study published in the May/ June 2015 issue of Physician Leadership Journal concluded that adding medical scribes to hospitalist shifts increased the CMI at two suburban Chicago community hospitals by nearly 0.3. Each change of 0.1 translated to “an approximate gain of $4,500 per patient to the hospital on Medicare patients,” explains study coauthor Jeffry Kreamer, DO, chair of Best Practices Inpatient Care. The 50-doctor hospitalist group staffs five Advocate Health Care hospitals in suburban Chicago.
According to Cassy Panter, director of hospital scribe services for the Ft. Lauderdale, Fla.-based national scribe staffing company ScribeAmerica, hospitalist scribes, at least those her company staffs, often serve as “an extension of the hospital’s CDI teams.” They attend regular clinical documentation improvement meetings and act as intermediaries when CDI staff needs answers and clarifications from physicians.
She recommends that hospitalists use scribes for more than just documentation, something that distinguishes them from ED scribes. (See “Don’t hire an ED scribe.”) “Their scope expands into anything that is nonclinical, like doing courtesy messaging to primary doctors that a patient has been admitted or scheduling follow-up appointments,” Ms. Panter says. Many hospitalist groups have renamed their scribes “care team assistants” or “physician care assistants”(PCAs) as a result.
At some hospitals, scribes also do courtesy rounds, re-visiting patients to ask if they have any additional questions for their doctor. While scribes cannot legally provide any clinical care or touch patients, they can give nurses a heads-up about physician orders. They can also check results and relay messages.
“I would absolutely pay $10 an hour to have my own clerk with me on my rounds.”
~ Amanda Green, MD
Paris Regional Medical Center
Scribes can also keep a hospitalist’s running “to-do list,” a task Dr. Kreamer says he finds particularly useful to make sure results don’t fall through the cracks. “The doctor can say, ‘Hey, remind me to check that CT scan at 2 o’clock’ or ‘Keep an eye out for such-and-such a test and tell me when it comes back.’ When you do that, you realize the mental bandwidth that those tasks use up.”
Less locum use and overtime
Some programs also find that employing scribes is an effective hospitalist recruiting tool.
Before hiring its PCAs, the hospitalist group at Washington Hospital in suburban Pittsburgh was calling in locums every time the census surged and hospitalists each had to see more than 20 patients. Because the practice was understaffed, that was happening “six to eight days each month” and “costing us a lot of money,” says Nathan Goldfein, MD, senior vice president of hospital medicine operations for Envision Physician Services.
Since adding PCAs last spring, both locum use and overtime have dropped to zero and hiring has become easier. “For the first time in four years, we are fully staffed,” says Dr. Goldfein. For him, “the business case is easy” to make in short-staffed, growing programs like his own.
Where the business case is harder to make, he explains, is in groups that are fully staffed or where employing hospitalists spend significant time in intensive care units or doing procedures. Such situations produce less work for nonclinical clerks like scribes.
Even at Washington Hospital, Dr. Goldfein points out, scribes work only during the day rounding shifts; the night shifts are not busy enough. Plus, hospitalists who have decent computer skills or advanced EMRs may not need them. And they are usually not a good option for smaller hospitals that need providers who can double as clinicians or in remote communities that lack a pool of pre-med college students looking for work.
Amanda Green, MD, has experienced that recruiting problem first-hand. Several years ago, when her hospitalist group at the 180-bed Paris Regional Medical Center in Paris, Texas, was under different management, she had a scribe to work with. But when that management company left, so did the scribes, and the new managers were not sold on the model.
Trying to recruit a good quality scribe has proved to be just about impossible.
Thinking back, Dr. Green says she “definitely” thinks good scribes made her more productive. Patients also appreciated the fact that she spent more time talking with them about her assessment and care plan while the scribe was busy typing. “It definitely improved the experience.”
On the other hand, inexperienced scribes and high turnover sometimes “added time to the end of my day,” as she would have to double-check or even rewrite the day’s notes before she could sign them. But comparing life with and without scribes, Dr. Green concludes, “I would absolutely pay $10 an hour to have my own clerk, who is scribe-like, with me on my rounds”—even out of her own pocket.
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
“I’ve found hospitalist providers prefer to work with a brand-new scribe as opposed to one with experience in the ED,” says Cassy Panter, ScribeAmerica’s director of hospital scribe services and a former ED and hospitalist scribe herself. “In fact, I don’t allow ScribeAmerica’s scribes to do both.”
Moreover, she explains, the work demanded and the skills needed are so different that she looks for completely dissimilar backgrounds when initially hiring. Although both need some university education and an interest in medicine, the perfect hires for inpatient medical scribe posts are young people with experience collaborating on research who may be in their gap year, preparing to apply to medical, physical therapy, physician assistant or nursing school.
By contrast, says Ms. Panter, “my go-to for hiring ER scribes is someone interested in medicine who used to work as a waitress or waiter. That’s because they can take information and get it down very quickly and remember and recall it.”
The shifts can differ as well. An ED scribe can be effective working shifts here and there. But Ms. Panter prefers to schedule hospitalist scribes on “back-to-back shifts so they get to know the patients.” It’s particularly effective to schedule one scribe to bridge the last day or two of one hospitalist’s week on and the first day of the hospitalist coming in after an off week. “Scribes can help fill you in on what was ordered yesterday, and it makes that first day back a lot easier.”
• Relinquish (some) control. It’s not unusual for doctors to think they can write a note faster and better than a scribe. “It’s true, but the reality is that it is not true,” says Nathan Goldfein, MD, senior vice president for hospital medicine at Envision Patient Services (formerly EmCare). “The reality is that physicians’ documentation is horrible.” That why “the CMI goes up” after scribes come in.
• Don’t dictate. Scribes are trained to listen to a doctor-patient interchange and record what was said during it. “It needs to be a conversation,” says Cassy Panter, ScribeAmerica’s director of hospital scribe services. “Spend a little extra time at the bedside on the plan of care, and the scribe will capture that in the note.”
• Verbalize as you work. Eric Edwards, MD, hospitalist director at University of North Carolina’s Hillsborough Hospital, says that hospitalists working with scribes should summarize back to the patient the history of present illness. “It’s good practice anyway,” Dr. Edwards says, “and it gives the patient the chance to correct anything the hospitalist heard incorrectly. It also gives the scribe a chance to make sure the documentation is accurate.”
• Be a coach and teacher first. “If you see a note that needs correcting, explain what you want it to say, then wait a couple of minutes while the scribe changes it,” says Jeffry Kreamer, DO, chair of Best Practices Inpatient Care, a private hospitalist group in suburban Chicago. “If you edit it yourself because that is more expedient, they will never get it. It’s like teaching someone to drive and the first time they do something wrong, you say, ‘I’ll drive; you watch.’ ”
Alternative staffing models
THE IDEA OF HIRING scribes “seems to percolate up periodically” at Virginia Mason Medical Center in Seattle. But the group chose instead to hire medical assistants who help with nonclinical work, including fielding post-discharge calls, processing requests for refills on chronic medications, helping assign admissions and tracking down medical records.
What those assistants don’t do, says Virginia Mason hospitalist Thérèse Franco, MD, is follow doctors and provide documentation. As for documentation, Dr. Franco says the hospitalists are more interested in innovative alternatives, like redesigning workflow, optimizing their EHR and incorporating voice recognition into documentation tasks.
“I think if we were hyper-focused on documentation, we wouldn’t have developed the talent that we do have in our two medical assistants,” she points out. “They really ease the burden of work for our team.”
Other situations where the scribe model may not be the best are practices that need people with more—not less—clinical ability.
“Overnights, for instance,” says Nathan Goldfein, MD, senior vice president of hospital medicine with Envision Physician Services, who also works some clinical ICU shifts in Alamogordo, N.M. “There are many cases where the overnight is busy and you could put a scribe in, but what is really killing the clinicians is the cross-coverage calls. You can be better off hiring an NP, who can deal with those and also do the occasional admit, rather than a scribe.”