Are scribes really worth it? It's a question that has likely come up for many a hospital administrator. Now a study gauging the cost/benefit ratio of medical scribes has been completed. The landmark project, which actually was titled "Are Scribes Worth It?," concluded that scribe programs can greatly assist higher acuity emergency departments that are struggling with long patient stays, a high percent of patients leaving without treatment and challenging electronic medical record systems. Some medical scribe programs, according to the study, actually more than pay for themselves.
The study was produced by Tanveer Gaibi, MD, medical director for Northwest Hospital in Randallstown, Md., Michael Hochberg, MD, medical director for Saint Peter's University Hospital in New Brunswick, N.J., Daria Starosta, MD, EmCare director of practice improvement, and Mark Switaj, MBA, an EmCare client administrator.
"We wanted to determine whether medical scribes are truly worth the investment," says Dr. Starosta. "We focused on determining improvements in overall productivity and quality in the emergency departments and the financial return on investment of medical scribes."
A medical scribe is an unlicensed person hired to enter information into an electronic medical record or chart at the direction of a physician or practitioner. Scribes do not and may not act independently, but can document the previously determined physician's or practitioner's dictation and/or activities.
"We used a collaborative team to determine the effectiveness of scribes," says Dr. Gaibi. "Our group not only included two site medical directors and an EmCare practice improvement pair, but the scribe leadership from ScribeAmerica, a national medical scribe staffing company."
To determine the value of scribes, the oversight group weighed the cost of scribes' salaries against the returned value, with special emphasis on marked improvements in:
• Patients per hour
• Relative value unit capture
• Number of billable patients
• Reduction in hours of coverage
• Number of down-coded charts
• Pulse oximetry and rhythm strip capture
• Length of stay for patients
• Door-to-doctor times
"Our return was calculated by assigning financial values to improvements in certain key metrics," explains Dr. Hochberg. "We measured increases in patients per hour, billable volumes, RVUs per patient and ancillary interpretations. We also looked at decreases in down-coded charts, education, non-billables and EmCare provider coverage. We weighed all of this against the cost of two scribes at two emergency departments."
The two emergency departments studied were Northwest Hospital in Randallston, Md., and Saint Peter's University Hospital in New Brunswick, N.J. Northwest sees an annual ED volume of 65,000 patients. It uses the Cerner EMR system and has an ED staff of emergency physicians, mid-level providers and "fast track" physicians. Northwest's ED began using scribes in April 2012.
Saint Peter's annual ED volume is 68,000 patients, utilizes the McKesson EMR system and staffs emergency physicians, pediatricians, mid-level providers and "fast track" physicians. Scribes began working in the Saint Peter's ED in February 2012.
Both EDs used the metrics prior to scribe staffing as the baseline. After implementing scribes, the Northwest Hospital saw improvements across the board:
• 7.64 percent improvement in patients per hour in the ED
• 72.5 percent improvement in down-coded charts
• 67.3 percent improvement in critical care
• 41 percent improvement in pulse oximetry
• 72.1 percent improvement in rhythm strip percentage
• 36.2 percent improvement in patient Length of Stay
• 22.3 percent improvement in the average Door-to-Doctor time
Saint Peter's University ED also saw measurable improvements in every measured parameter:
• 8.52 percent improvement in average patients per hour
• 5.87 percent improvement in average RVU. per patient
• 14.82 percent improvement in average RVU. per hour
• 87.2 percent improvement in down-coded charts
• 100.35 percent improvement in pulse oximetry
• 15.85 percent improvement in length of stay for adult patients
• 26.40 percent improvement in length of stay for pediatric patients
• 40.12 percent improvement in door-to-doctor times for adult patients
• 41.54 percent improvement for door-to-doctor times for pediatric patients
The way ROI was determined was based on a few factors. Every site is different in terms of the amount of physician and mid-level provider coverage, and the level of scribe coverage introduced can vary. On top of that, mid-levels are paid different rates at different sites.
But here's the breakdown in this study: It costs the studied organizations an average of about $20 an hour for a scribe. A physician is paid an estimate of about $180 hour. Scribes can also be measured at about 20 percent of the productivity of a physician.
"We found that the biggest driver for an R.O.I. is reduction in physician coverage," said Mr. Switaj. "For every physician hour we cut, we can offer about nine scribe hours to keep everything budget-neutral. In fact, given that a scribe can be valued at about 20 percent of the productivity of a physician, 20 percent of $180 per hour equals $36, but a scribe costs us $20/hr, so we can, if done right, immediately recognize value. In all practicality, though, we simply cut physician/mid-level coverage to the point where what we save in provider payroll dollars we spend in scribe coverage. So, if we want nine scribe hours, we cut one physician hour. Then, because the scribe allows the physician to be even more productive and documentation was stronger, we saw the return on our investment as noted. So, a one percent improvement in RVUs at our hospital produced $16,000 annual pickup, a one percent improvement in productivity resulted in $32,000 annual pickup, a one percent pickup in number of billable patients resulted in $11,500 annual pickup, a one percent pickup in rhythm strips documentation capture resulted in $2,600 annual pickup, and a one percent pickup in 'pulse ox' documentation capture resulted in a $144 pickup."
"Our conclusion is that scribe programs probably won't fix an ED that is really broken," says Dr. Hochberg. "But EDs that are looking to reduce length of stay, are struggling with a high percent of left without being seen rates or are experiencing challenges with their EMRs could really benefit from hiring scribes. Scribe implementation can even pay for itself."
Russ Harris, MD, serves as CEO for EmCare's North Division, which encompasses 19 states of the northeastern U.S. Dr. Harris received his medical degree from Temple University School of Medicine and his master's degree in medical management from Tulane University. He is a retired captain of the U.S. Navy, having earned two Navy Achievement Medals.
Mark Switaj is a division client administrator for the north division of EmCare, a leading provider of physician practice management services. He helps oversee management of more than a dozen hospitals and has introduced and demonstrated the efficacy of introducing ED medical scribes at several hospital locations. Prior to joining EmCare, Mr. Switaj served as director of business development for EmCare's sister company, American Medical Response. He also worked as a manager of business development, account executive and an emergency medical technician for AMR. Switaj earned his MBA. from Georgetown University and a BS in business from Boston College.
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