Scribing, particularly in Emergency Medicine (EM), has been something of a phenomenon during the past decade. Scribes are typically employed by third party vendors such as Scribe America as well as directly by provider groups. Scribe America has experienced phenomenal growth and now employs over 2500 scribes; physician group CEP America employs over 600 scribes for their ED and Hospitalist Practices. What accounts for the scribe boom, and how do we measure the impact of scribes on the Acute Care Continuum?
A Very Brief History
Scribes appear throughout ancient history as “record keepers” who copied legal texts and other documents. Scribes also appear many times in Scripture. They were influential in government and religious circles until the printing press essentially killed the demand for scribes. Flash forward to the 1970s, when a study in the Annals of Emergency Medicine found that scribes who “shadow physicians” and act as “human tape recorders” improved ED efficiency. However, between the 1970s and early 2000s, scribes were rare. An oncology practice where I consulted in the 1990s used scribes, but I saw very few of them in emergency medicine until recently.
What accounts for the phenomenal increase during the last decade? The dramatic, government-incented increase in the use of electronic health records (EHRs) created the need. EDs in post-EHR implementation often experience a significant decrease in productivity as providers struggle to interact with systems that are not always user friendly. So, ironically, advances in technology resulted in a rebirth of one of the world’s oldest professions–scribes, of course. (What were you thinking?)
Scribe Impact on the Continuum of Acute Care
Anecdotal evidence indicates that scribes improve the quality of providers’ work experience. There is also evidence that scribes, by allowing providers more clinical time and less administrative burden, improve ED throughput and thereby reduce ED overcrowding. Validating this anecdotal evidence, concrete metrics show the impact of scribes on acute care:
- Relative Value Units (RVU) per Visit/Hour Shift
As the use of scribes improves documentation, RVUs typically increase. RVUs also increase because of the increased clinical time that the provider now has available to see patients.
- RVUs Lost by Deficient Charting
Chart deficiencies, such as incomplete history, physical, and medical decision making elements, often result in ED services being coded at lower levels than clinically indicated. For example, four elements of a History of Present Illness (HPI) are required to code the highest ED Levels (99284-5). Having fewer than four elements documented can result in down-coding a clinically justified 99285 to a 992853
- Unbillable/Incomplete Charts
Charts missing key elements, such as a physical exam, or the signature of the attending, or a teaching physician attestation are returned for completion. Well trained scribes significantly reduce the number of returned charts by identifying missing elements and reminding providers to complete the chart. Of course, the best scribe cannot induce a signature from a provider who didn’t complete all of his or her charts before the end of shift. (Physicians, PLEASE sign those charts and do your attestations).
In addition to impacting key metrics, scribes have taken on expanded roles in physician practices, such as making phone calls and tracking down labs. As the role of scribes evolves, there is the potential for them to move into areas such as EHR implementation assistance and point of service coding. Scribing has been with us for 3,000 years; and has been booming in the past ten years. Scribes appear to be here to stay–in one form or another.