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May 2019

Does use of a Scribe in the Emergency Department Increase Productivity and Improve Patient Flow... Yes, But...

Does use of a scribe to document in an electronic health record (EHR) increase an ER physician’s productivity?  Do scribes improve ED physician’s satisfaction with their profession?  Do scribes help improve ED patient flow? Well, overall yes, scribes improve productivity, but not necessarily for all ED physicians.

I am a pediatric ER physician and my pediatric emergency department (ED) has a scribe program.  Use of scribes was "free" until 3 years ago when our organization decided to stop paying for scribes.  A compromise was made, though, with ED physicians--we could individually decide to continue using scribes, but would have to pay half the cost.  All but 2 of 28 ER physicians decided to continue using scribes.  The cost is essentially covered by seeing a couple additional patients each shift.  Clearly the majority of us feel scribes improve wRVU production by more than that.  And since ED physician productivity is one of the main factors within the ED patient flow diagram, increased productivity correlates with fewer bottlenecks and overall improved ED patient flow. One colleague told me he sees a 20% decrease in productivity when he does not use a scribe, but the degree of impact varies from physician to physician in our group.  Part of the increased productivity has to do with tasks a scribe can do other than EHR scribing, like fetching this or that.  And in some cases, it looks like scribes help physicians cherry-pick lucrative patient cases---don't get me started on that one (I finally figured out why I never got to see the known appy patients that got transferred in).

All of our most highly productive ER physicians use scribes.  In addition to being naturally gifted "fast" physicians, they spend less time on documentation during their shift.  Most of their notes are in draft form at the end of the day.  Some will spend 45-60+ minutes editing and signing notes after their last patient, but most will go home and complete the notes 1-2 days later.  I think scribes are particularly valuable to those faster-types of physicians, both for productivity and for physician satisfaction.  Scribes allow them to maintain a fast pace with less work to do after their shift to complete charts.  

I am one of the two exceptions who chose not to pay for a scribe.  Both of us take a methodical approach to seeing patients, hence neither of us are in the high productivity range, but neither of us saw our productivity drop.  In fact, I eventually found that I could see more patients without a scribe.  Most of my notes are completed and signed when the patient is discharged, and typically the rest of my notes are completed within 30 minutes after seeing my last patient.   My method of working requires me to spend a lot more time documenting during my shift as compared to "fast" physicians, unless its crazy busy when documentation simply has to go out the window for the sake of getting patients seen and properly cared for. 

Why would some physicians like myself be faster without a scribe?  This would be a great subject to study.  In my individual case I feel it has to do with how my mind processes information and my method of working.    

First, I am 59 years-old, and the framework for my thought processing in previous decades was built around formulating a plan as I wrote out my ED note on paper.  When EHR and scribes came along, I found it difficult to process information and formulate a plan while verbalizing information to a scribe, so I ended up using a small notepad to write brief notes to help me "think" as I spoke to the scribe. I apparently need to see the words to help me plan. With voice recognition I can see my words going onto the screen, similar to when I saw them going on paper, and I thus find myself better able to process information and formulate a plan simultaneously.  Second, although I'm older and not as efficient using a keyboard as my younger colleagues, I'm tech savvy.  After eliminating use of scribes I found ways to leverage voice recognition and certain personalization tools in our Epic EHR.  Using our voice-recognition tool I created HPIs, MDMs, critical care templates and discharge instructions with built-in [macros].  I also created voice commands to dictate frequently used smartphrases that can be built in Epic.  Whenever I found my hands leaving the mouse and dictation device to reach for the keyboard, I would make note of that and later on think about ways to eliminate the need for a keyboard in that particular situation using voice recognition or personalization tools within the Epic EHR.  For frequent point-and-click actions (i.e. Save, Enter, Order, Open My Note....) I programmed buttons on the dictation device which significantly reduced mouse clicks.  Thus, I now spend most of my day with one hand on the dictation device and the other on the mouse, and happily see more patients without a scribe.

So in our group nearly all of the ED physicians subjectively feel scribes improve their productivity and, as a result, improve ED patient flow.  Even when the organization reduced reimbursement for the scribe service to 50%, nearly all chose to pay for their scribe service.  At least one ED physician sees a 20% decrease in productivity without a scribe, but the degree of impact varies from physician to physician..  And finally, the two ED physicians who decided not to pay for a scribe were able to maintain, or even increase, their productivity.