Physician burnout caused by the documentation burdens inherent to electronic health records EHRs has become a big problem. Fortunately, scribes are proving themselves to be the cure. Unlike technology exclusive approaches, such as CAPD, front-end speech, or other physician centric document creation methods, scribes, and especially virtual scribes who are able to strategically incorporate some of those emerging technology options, are able to reduce physician burnout, increase patient satisfaction, improve document quality, and as an added bonus, notably increased per-provider revenue generation.
A recent study by the University of Wisconsin and the American Medical Association AMA showed that physicians work an average of 11.4 hours per day when on duty, with 5.9 of those hours spent directly engaged with their EHR. Such unreasonable time balances directly lead to:
- Physician burnout caused by the conflict between patient focus time and documentation time
- Marginalized patient satisfaction scores due to physician’s focus on EHR reporting requirements
- Poor report quality caused by minimal speech rec proofreading or other time saving shortcuts
- Risk to patient care and potential allowable encounter revenue caused by poor document quality
On the other hand, scribe supported business practices, deliver:
- Increased patient interaction during encounters gained by eliminating in-visit EHR distractions
- Reduced total time spent with each patient due to elimination of in-visit EHR data entry efforts
- Increased daily visits per provider enabled by time saved per patient and EHR support from scribe
- Improved document quality by eliminating documentation shortcuts while adding richer data
- Improved revenue per encounter through better HCC reporting and other claim influencing data
When scribes began to grow in popularity, the argument against them was that they were the type of resources used to generate documents before transcription, so it was a step back in time, not a step forward. The difference however, is that unlike transcriptionists who are inherently limited to generating narrative reports from recorded dictations after a visit, today’s scribes take on a considerably wider scope of real-time encounter support and EHR documentation responsibilities, such as preparing orders and scripts for physician approval. They also complete pre-visit chart reviews to save the physician time and ensure comprehensive documentation with each visit, confirming HCC acknowledgements and other potential ongoing care and/or revenue influencing details.
Challenge – EHR Impact on Physician Time and Document Quality
Following the shift to EHRs, numerous studies calculated the added time required to document each patient. Less attention was paid to the measurable financial impact that added time had on the income of physicians or the total revenue generated per physician for their employers. One COO confided that he had uncomfortable discussions with a few long time physicians who estimated their personal annual income loss directly attributed to their forced reduction in patient load resulting from increased documentation time at $80-$100 K. Their only option was to hire more physicians and support staff. The EHR objective to ensure report quality and deliver instantaneous availability was to have physicians complete the documentation themselves. It looked great on paper, but in practice, required physicians to take on the role of glorified data entry clerks, distracting them from their primary purpose of patient care. Of course, EHR vendors and other technology players developed a wide array of productivity improvement tools, which unfortunately just added more to the cost of the overall solution and more often than not, added additional points of potential quality failure, if for example, front end speech documents or cut and paste sections from pervious reports were not proofread prior to signature.
Of course, cut and paste content and automated blocks of inserted text, which typically served liability protection concerns more than ongoing care, added to report volumes (note bloat) but delivered zero value for encounter specific conditions. All they did was make resulting documents difficult to comprehend without improving physician efficiency or positively impacting patient care or financial outcomes. Any real solution must relieve physicians from data entry and ensure all meaningful patient care and financial outcome influencing content (such as HCC details) are included for each encounter.
Solution – Scribe Impact on Physician Time and Document Quality
Independent studies confirm that scribes enable increased patient visits per day by 20% or more, although it can vary by specialty, while simultaneously improving RVU’s anywhere from 15% to as much as 50%, depending on pre-scribe practice results. Direct per-encounter patient contact time typically reduces by about 20% while true direct patient interaction time (without multi-tasking/distractions with computer data entry) approximately double, contributing to improved patient satisfaction scores.
From a business model’s perspective, the cost of scribes is covered with the addition of one or two additional scheduled patients per day, again depending on specialty, while for many specialties it is not uncommon to comfortably settle in at four to six additional patients per day following a few weeks ramp up period when the doctor and scribe learn to work together seamlessly as a team.
Onsite Versus Remote Versus Fully Speech Recognition Facilitated Scribing Solutions
Most onsite scribes are med students earning income while enhancing their education. Consequently, their typical employment tenure is roughly equivalent to an academic year of nine months. Given the upfront time to get them trained and thoroughly integrated with a given physician, employee turn-over and unsupported gaps between scribes is a constant battle for onsite scribing businesses.
In contrast, remote scribing businesses show a better balance between med students and former transcriptionists or other HIM related staff. This balance significantly improves the average scribe tenure and enables a deeper organizational bench of support, where multiple scribes are used to support each physician client at different percentages of time so if/when one leave, others are already up to speed and the chronic onsite model unsupported gaps are eliminated. The remote model also eliminates geographical barriers in areas where a steady stream of interested med students are scarce.
A more recent entry into the market is fully speech recognition facilitated scribing solutions. As with any such leap of applied technology, the controlled environment demos are quite impressive. At the same time, the difference between a human supported approach versus a pure technology solution today, is the ability of staff to be consistently proactive, conform to individual physician’s communication styles, and effectively minimize EHR record review and edit time. Just as with the introduction of EHRs ten years ago, it looks great on paper and demos well, but has not yet proven itself to deliver the full physician time and document quality advantages of live or remote scribes.
Organizations who rely solely on physician created documentation or those who supplement those efforts with traditional medical transcription will see significant physician quality of life, patient satisfaction, document quality, and revenue per provider gains with a scribe program. In addition to KPI improvements, some organizations have reported business revenue increases of $1 M or more over program costs per 20 scribes deployed across a variety of specialties.
There will always be a shifting balance between the contributions of technology and human effort to create and process medical records, yet the cost-effectiveness and efficiency of the human contributions and their individual impact on quality must also be considered. In today’s environment, there is no one size that fits all. All physicians have different levels of comfort and preference with the technology tools at their disposal. Scribes seamlessly optimize the clinical documentation process while delivering measurably superior quality for ongoing patient care and financial results. It’s time the industry gave physicians help instead of more responsibility. It’s simply good business.
Dale Kivi, MBA
Senior Director of Communications, AQuity