Best Practices
The Use of Scribes in the Emergency Department
As medical director of San Gabriel Valley Medical Center’s Emergency Department in San Gabriel, California, Rick Bukata, MD, employs a simple rule of thumb: quality, safety, revenue, efficiency, and morale increase whenever clinicians are doing work that’s “worthy of their degree.”
In keeping with this philosophy, Bukata strives to employ tools that allow the clinicians in his ED, which receives approximately 25,000 visits annually, to maximize the time they spend providing health care and minimize the time they spend doing tasks that don’t require their extensive training. As a result, Bukata is a champion of scribes. The term, scribe, evokes images of the centuries-old scholars who copied manuscripts in the days before the printing press, but in today’s health care setting it describes an individual who is trained to take notes, fill out charts, and assist physicians with various clerical tasks. Bukata admits that many hospital administrators have never heard of scribes — and that’s a shame, he says, because their utilization has proven to be cost effective while both improving physician and patient satisfaction.
What Does a Scribe Do?
The case for using scribes in the ED should begin with a discussion of what scribes do and what they do not do. Scribes accompany the physician as he/she examines and interviews patients and then records the physician’s observations and comments on either on paper or in an electronic medical record (EMR) depending on what the hospital uses. All information is recorded in the presence of a physician. In addition, they gather data for physician review (i.e., laboratory results, faxed radiology reports, medical records), coordinate communication between physicians and staff, make and answer telephone calls, provide patients with updates about waits and delays, and perform various other duties. They are, as Bukata puts it, a physician’s “third arm.”
What scribes do not do is make physical contact with or solicit information from patients, administer medication, relay verbal commands between physicians and nurses, or enter anything into a chart that has not been reviewed and approved by a physician. Physicians approve in advance every task performed by a scribe and take full responsibility, with their signature, for the information recorded in their patients’ charts.
Making The Case
Bukata says the most significant argument for the use of scribes is their ability to allow physicians to see more patients. To illustrate his point, he uses the hypothetical example of an ED that sees 2.7 patients per hour and bills — for the combined services of the hospital and the attending physician — $400 per patient. That works out to $1,080 per hour, or $18 per minute, in revenue. This scenario assumes that — as in most EDs — the attending physician is spending roughly 15 minutes of every hour charting for those 2.7 patients. Using a scribe to do this charting for the physician, Bukata observes, would free up these 15 minutes for the physician to see more patients, which would subsequently generate additional revenue for both the physician and hospital.
Hospitals have historically paid for dictation, but they are almost universally unwilling to pay for scribes despite evidence that they are a less expensive option for charting and provide a host of other benefits. This, says Bukata, is a major bone of contention between physicians and hospitals.
While still uncommon, the utilization of scribes in the ED has given birth to a niche industry of companies that recruit and train them. ScribeAmerica was created in 2003 to meet the needs of a number of California hospitals that were adopting EMRs as well as groups who were looking to increase their efficiency and productivity on paper-based systems. Scribes were used to generate physician buy-in for the transition from dictation to EMR, explains Chief Operating Officer Sarah Esquibel.
In addition to the financial opportunities they present, scribes are credited by proponents with providing other valuable, if less tangible, benefits. First, says Bukata, is the value for patients.“One of the recurring complaints of patients in the ED is that physicians don’t give them enough of their time, so without having to chart, physicians can use that extra time to be with their patients,” he says. This benefit is quantifiable: Esquibel says the Press Ganey patient satisfaction scores of physicians that use scribes have improved.
Another benefit, says Bukata, is “quality of life” for ED physicians. “Scribes help mitigate the daily stressors facing ED physicians,” he says. “Knowing they will have an assistant specifically devoted to them improves physician satisfaction and morale.”
So why are scribes used so infrequently? Chiefly because physicians are “very conservative by nature,” says Bukata. “They are reluctant to break from tradition and using a scribe is certainly not traditional. Most have no experience with their use and are not familiar with other physicians who have used them. Only the most entrepreneurial groups have given scribes a try, despite the fact that scribes can be taught relatively quickly and, in the unlikely event the experiment fails, there is little lost regarding time or cost.”
Who Makes a Good Scribe?
The majority of scribes are pre-med students recruited through college and university advising centers. Being a scribe is a demanding and rewarding. “When a scribe is new there is an abundance of new information and some physicians can be demanding,” says Bukata. “But it’s also lots of fun, because there’s an unlimited learning curve.”
“Pretty much anybody can be taught to be a scribe, so for me it’s not a question of education but rather one of motivation. You want somebody who has a lot of initiative. We can educate motivated people,” Bukata observes.
Rick Bukata, MD, Emergency Department Medical Director,San Gabriel Valley Medical Center, San Gabriel, California
Sarah Esquibel, COO, ScribeAmerica, Lancaster, California
