Indirect costs are more subtle and related to risk management. It is important that scribes are educated in risk management strategies as part of their professional training. One can imagine how it might be dangerous for a scribe to document a child as “lethargic” based on what a parent describes, when the child may appear well on day 1, only to have the parent return on day 3 with a truly lethargic child.

While there have been no known cases of such discrepancy from misdocumentation by scribes to date, this is a potential risk that emergency physicians need to consider. Another indirect cost can be an actual slowing of physician workflow related to scribe incompetency. For example, a scribe who has difficulty composing a coherent HPI requires the physician to either revise or rewrite every HPI. Thorough scribe training and experience mostly mitigates this cost, but in some cases it may be necessary to terminate the scribe.

Monetary Benefits of a Scribe Program

There are several monetary benefits that can be categorized as either direct or indirect.

Direct benefits are those that directly increase revenue as a direct result of having scribes, including:

• Potential for increased patient volume throughput (e.g., instead of seeing 2.0 patients/hour, physicians might see 2.25 patients/hour). For example, at one hospital in Miami they were seeing 4,771 patients in November 2008 with an average ED length of stay of 381 minutes, prior to hiring scribes. After implementing a scribe program, by December 2010 they had jumped to a monthly volume of 6,700 patients with an average ED length of stay of 284 minutes, or a 25% reduction in time (Meyer).
• Increased RVU/patient (as a result of more robust documentation).
• Increased compliance with core measure documentation and the ensuing improvement in reimbursement as dictated by CMS for the coming years.
• For hospitals using EMRs, which will be most of them with the new national mandate, scribes document in real time and allow physicians to leave on time at the end of a shift.
• For hospitals with EMRs, it takes physicians approximately 30% longer to chart compared to paper charting (Meyer), but scribes can make EMR charting faster. Indirect benefits incurred by cost reductions as a result of having scribes include:
• Medical error reduction leading to decreased costs.
• Medical risk reduction through better documentation. For example, patients will get more thorough discharge instructions. There will be more frequent patient rechecks documented on the chart (since physicians often forget this crucial documentation step).

Nonmonetary Benefits

Many things that have value are not green. Much of the value brought by scribe programs is nonmonetary in nature. Scribe programs tend to increase physician workplace satisfaction by allowing physicians to spend more time on direct patient care and less on documentation and billing issues. They increase patient satisfaction by allowing physicians to have more time giving care and explaining diagnoses and plans of action in detail. Oftentimes, scribes will improve staff satisfaction by assuming tasks formerly reserved for nurses and technicians (e.g., tracking down lab values, informing physicians of updates on radiology results).

Case Study

In our suburban emergency department (approximate ED volume 60,000), we document using a leading EMR system and furnish our scribes with tablet laptops with wireless mice, which they carry with them, all of which requires technical support from time to time.