The Many (Many) Benefits of Virtual Medical Scribes
Afser Shariff, M.D.
Founder & Chief Medical Officer, Physicians Angels, Inc.
I am a busy ENT surgeon in Toledo, Ohio. We use a good EMR that is specialized for our practice. But even the best EMRs still take time to enter data. That time spent typing and pointing and clicking is what many doctors horribly underestimate.
The definition of a scribe varies, depending on whom you ask these days. Some transcription companies are marketing themselves as “scribe” companies. And some scribe companies are really doing transcription.
Scribing is not listening to a doctor dictate a note and typing it. It is interpreting the physician patient interaction and converting it into a concise document with relevant information, along with appropriate coding, to send to the coders/billers, while also creating the letter to the referring doctor and doing any associated tasks. We find that some doctors never become comfortable using a scribe at the scribe’s full capacity. The doctors end up dictating to their scribe – which is still faster than doing it themselves – but is never as fast as empowering the scribe to document the encounter.
Virtual Medical Scribes Cost/Benefit Analysis
A true cost-benefit analysis is an area that doctors and hospital executives struggle to understand when it comes to using scribes. First, it helps to understand what the most expensive recurring cost in healthcare is for labor: doctors, physician assistants, and nurse practitioners.
According to data we have collected for our own internal studies – which were subsequently confirmed by Michael E. Porter and Thomas H. Lee in a Harvard Business Review article titled, “The Strategy That Will Fix Healthcare” – a doctor’s cost per minute runs up to $4 minute. This drops to $1 per minute for NPs/PAs. So, to speak of cost-benefit ratios, we first have to know what is the cost for a medical facility’s doctor per minute of work. Hold in mind the thought of $240 per hour: the cost of 1 hour of a doctor’s time.
Would you pay $240 per hour to have someone type and click information into an electronic medical record? Of course not. So then why would you take your most expensive group of employees and make them into data entry staff?
And what happens during the time that the doctors are typing? If they type in front of a patient, that is akin to texting during a conversation.
Studies report that patients perceive doctors, who are typing while they are talking, as not listening to them. If the doctor types their notes after the encounter, then the next patient has to wait longer to be seen (lowering patient satisfaction scores) – or less patients are being scheduled, which means less revenue (confirmed by multiple studies), unless each patient is billed more (also confirmed – EMR’s allow upcoding, but no real improvement in patient care or health outcomes).
So the current status quo with EMRs is thus: Expensive EMR deployments, doctor’s time poorly utilized, less patients seen, more expensive patient encounters, longer wait times to be seen, increasing patient dissatisfaction, and higher physician burnout.
Breaking Down the Data and the Day
The minimum amount of time that it takes a physician to process his or her portion of the patient encounter in an EMR is 4 minutes, with most charting taking 12 minutes, and complex patient cases taking up to 20 minutes. So at $4 per minute, a physician can cost $16 to $80 per minute just to type up a single patient encounter.
The cost of a Physicians Angels’ Virtual Medical Scribes cost $14 per hour. Onsite scribes are more expensive ($18 to $26 per hour, and have several drawbacks associated with absenteeism, turnover, and overhead costs). The average doctor using a scribe can easily see one more patient per hour. This means that seeing just one new patient covers the cost of a scribe and saves the doctor over 2 hours of typing each clinic day.
The average doctor can then either take the time savings and have more time for other activities (research, publishing, management), or they can see more patients in the same number of hours. Considering the halo effect of each extra patient encounter, this translates into extra lab tests, radiologic studies, or surgeries. Not only the small clinic, but the big health systems stand to gain a tremendous amount of ancillary revenue from using medical scribes.
By fractionating and specializing work, a combination of doctor/scribe can be more productive than a doctor alone. This is Adam Smith’s division of labor argument that many in healthcare don’t fully understand or trust yet. Many clinic directors and hospital directors only see another person being hired as a liability, not realizing that the EMR is no different from a CT scan or EKG machine. The EMR is a data acquisition device. You don’t see the radiologist or cardiologist operating the CT or EKG. They have technicians, thus allowing their mental energies to be devoted to the interpretation of data and management of the patient. A medical scribe is an EMR technician, in other words.
Some doctors claim they already use a scribe. In fact, they have assigned an existing medical assistant or nurse to “scribe” for them. This is something my ENT group tried, and it was a costly mess. Pulling a staff person off of existing responsibilities and patient care, and then asking them to work as a scribe means that other work piles up. Having a patient care provider, like an MA or nurse, work as an EMR data entry clerk is not a productive use of their training or time neither.
What healthcare groups nationwide deploying EMRs have experienced, without fail, is a reduction in the number of patients seen per office day, along with an increase in wait time. The cause is doctors acting as EMR data entry clerks for large portions of the day, instead of seeing patients.
Instead of hiring medical scribes, the response in healthcare has been to hire more doctors, NPs, PAs, and extend office hours. Medical groups have increased their most expensive labor costs to see the same number of patients they saw pre-EMR. They can achieve the same results with a low cost virtual medical scribe, instead.
We have to keep in mind that the EMR is the ultimate aggregator of data for doctors to use. But by asking doctors to be their own data entry clerks expends their energy incorrectly. It also results in doctors developing poor data entry behaviors, reducing the quality of the patient data – which threatens the ultimate quality and purpose of the EMR, not to mention the patient’s care.
Physician and Patient Satisfaction
Recent, independent research and publications are confirming that physicians are happier with medical scribes. We have on hand emails and letters from doctors who have been able to rejoin their families for dinners or spend evenings and weekends with their kids, instead of typing or dictating charts. This was my personal experience as well. I got my family back when I started using virtual scribes.
KPMG authored a global study in 2012 on physician burnout. One of the leading sources of burnout was documentation burdens. Countries like the United States, which have created documentation burdens on doctors, have accelerated the burnout rate. Medical scribes have been shown to decrease burnout.
As for patient satisfaction, research has shown that scores are higher with medical scribes, and in particular, with virtual scribes. Most patient exam rooms are small. Patients also fear being judged. Putting another person in the exam room with the doctor and patient can make it claustrophobic. The virtual scribes take up no space, and are invisible – “out of sight, out of mind” to the patient. The virtual Medical scribe allows the doctor and patient to maintain their traditional dynamic. Because the virtual scribe can only hear what is being said (we do not allow video/webcams with our virtual scribe service), the doctors are forced to verbalize their thoughts and communicate better with their patients. The side effect is that patients report that the doctors explained more to them, making them more satisfied with their visit. In contrast, when doctors do their own EMR data entry or dictate, they don’t verbalize to patients as much, keeping much information in their head or silent.
Virtual Medical Scribes – Logistics & Benefits
After trying onsite medical scribes in my clinic, we went with virtual Medical scribes. Virtual Medical scribes were more cost-effective and allowed specialization. On days I did not need my virtual scribe, I could share him or her scribe with other ENT practices across the country, lowering our costs and keeping skill sets high
Physicians Angels specializes our virtual scribes into ENT, Orthopedics, Urgent Care, Internal Medicine, Plastic Surgery, and other specialties. ENT is our largest specialty, and we have the largest ENT scribe pool in the world.
Medical practices with multiple locations can move scribes from one site to another based on work demands during the day without loss of time due to scribe travel. If one scribe is sick or on leave, we have a large pool of scribes to jump in and take over. Compared to many groups with in-house or onsite scribes, when an onsite scribe is sick or leaves, the down time before a replacement is trained can take 3 to 6 months. We have many groups that have transitioned from in-house scribes to our virtual scribe service, as a result of the benefits of using our virtual scribe model.
Additionally, we can shift scribes from one facility to another to manage fluctuating work flows. Large healthcare systems can rapidly shift workforce allocations from outpatient facilities and even support inpatient care documentation facilitating doctors and nurses to care for patients.
What is required for virtual scribes in terms of technology? A strong broadband connection, good internal IT infrastructure, and people willing to commit the time to refine their unique relationship with their virtual scribe team to reach optimal efficiency.
At the end of the day we provide a well-trained virtual scribe who is willing to work hard to make things work. It will take some time, as it would take any new person joining an organization. The good get better; the better get exceptional. Our experience has been that practices with good processes and productive doctors seeking better productivity do extremely well with virtual scribes.
By developing employees dedicated to a career path as scribes, hospitals and practices receive consistency without the turnover associated with temporary onsite scribes. At Physicians Angels, we had to build semester-long training programs for each specialty, creating a pool of employees that can quickly learn a new doctor’s style. We have an ongoing lifelong education and mentoring program for our scribes that is unique in the industry. When hospitals/practices try to replicate our process (none have been successful, to our knowledge), they realize how expensive and time intensive it is to build and maintain a small let alone large pool of scribes. We encourage doctors to share their lecture sets or internal training programs with us so that we can customize their scribe service even more tightly to their work flow.
Virtual scribes work out of HIPAA-compliant facilities with biometric scanners and cameras to ensure no data breaches. The security at our virtual scribe facilities is greater than or equal to what is present at hospitals. We do not allow our virtual scribes to carry papers, cellphones, or media storage devices into or out of our facilities. The USB ports are disabled on the virtual scribes’ computers. All communications and data shared is encrypted at 256-bit AES. Scribes undergo a background check and regular performance reviews and audits. For this reason, we do not employ virtual scribes that work out of homes.
The scribe market overall is growing fast. Within 10 years, we expect that there will be at least 30,000 scribes, across all specialties, needed in the United State. If we consider that EMR problems are not unique to the U.S. but worldwide, we can expect to see this industry grow internationally in the coming decade.