This Medical Scribe Can Be Yours for the Low, Low Price of Two New Patients a Day!
I would like some feedback on the whole “medical scribe” thing. I have always had an issue with it. It’s nothing personal against the people doing it. It’s just weird. Weird that there is another person in that room or in another room listening (I guess privacy doesn’t really matter that much?). Weird that we add new people to this bloated system to pay for in order to justify bogus metrics and documentation. Instead of fixing that issue we create a whole new profession. This article by the AMA says is that:
Based on 2015 data from the Centers for Medicare and Medicaid Services and the National Ambulatory Medical Care Survey, the study aimed to determine the number of visits needed to make a scribe program profitable. The study found that the mean cost of implementing a scribe program was $47,594 for the first year.
To make the scribe program profitable after one year, physicians from all specialties had to see two new or three returning patients each day. This was calculated with the assumption that physicians and other health professionals would work 220 eight-hour clinic days per year and that scribe shifts mirrored that schedule.
Do you see how this is rationalized? Only two new patients a day or three returning patients each day. Ummm, that’s a lot to add and that is just to break even. I just don’t get it. Why is seeing more patients a day better? Yes, someone is typing for you but you are more emotionally and mentally drained from seeing those extra patients.
The article says doctors shouldn’t be the ones paying for it but who does? If you are still a private fee-for-service doctor then you cannot afford this. If you are working for a hospital then I guarantee you are going to be told to see those extra patients.
But maybe I am wrong? Do you have a scribe? Or do you have an opinion about this? I would love to hear it.
I am an academic orthopedic surgeon. I use a scribe (virtual scribe). They are paid for by the university but I am sure it comes out somehow out of our reimbursement. But I would still use them even if I had to pay for the service directly. For one, I am not typing and can actually look at the patient while they are telling their story. I can use the time in the EMR to look up studies, place orders, while listening to the patient (or ask the scribe to do that). For instance, the scribe can locate the needed faxed study report and transcribe the results into the note – this saves a huge amount of time. Over time, the scribe knows the common diagnoses and treatment plans so well that I don’t even dictate them anymore: I just discuss with the patient on their level and the assessment and plan is in the note in “medical speak” and I just sign it.
So overall, it makes each visit more efficient and saves me a lot of time after clinic. Yes, it does allow me to see more patients but I see that as a good thing, since I am still done at the same time and have less post-clinic EMR work.
Hi, Doug. First off, let me congratulate you for the blog: the content is excellent and seems you have made a real success moving from ‘Doug only’ to a team approach. Saw your query re Medical Scribes and though I’d comment. I’m a psychiatrist and have never used a Medical Scribe in the sense that I think you (and the medical industry) use the term. Even so I do have some thoughts and related experience:
At a meta level, seems you already have your mind made up on the topic . . . but maybe open a crack therefore your openness to the thoughts of others. From both a practical and ‘practice satisfaction’ perspective a doc should be open to being creative in considering practice models including staffing. At one level, it can be largely a calculation re cost/benefit but, like you, I know there is more to it than that: privacy, another person to have to deal with, patient perception, etc. At another level, it is not that different from ‘Should I hire a nurse, tech, etc.”
I think the concept of Scribe is too narrow. A physician should hire any ancillary person that improves the practice experience and parameters. As a solo private physician, at different times, I’ve used what I call a ‘historian’, a ‘virtual assistant’ (VA), and my transcriptionist functions beyond simple typing to add value to me, my practice and the patients I see.
Historian: Much of my practice for a few years has focused on patient evaluation, diagnostics and a work product consisting of a 8–10 page polished, complete, full formal Psychiatric Evaluation to be used by an employer, for disability, rehabilitation or the courts. I love seeing patients and spending quality time with them averaging 90 minutes per instance; for me personally/professionally what I hate is dictation and office management tasks. I review documents before and/or after the session but while I am with the patient I am examining them via interview, testing, mental status, etc. and taking extensive hand written notes into a template in the process. Later, I dictate for 15–30 minutes the using my notes as a guide to generate the initial report draft.
I found that I could have a Historian sit in and take all the notes while I fully focused on the patient which allowed me a better connection and to pick up more important subtleties: blushing, body language, unusual use of language, etc. Then the Historian would dictate the historical part of the exam and I would only have to dictate the conclusionary portion: diagnostic section and summary and recommendations. I tried to double down on this concept but without success:
Tried to capture all or most of the history by having the patient register on a web site and fill in sections on their own history. I’d print that out, review it and use it as a guide to elaborate or explore during the session in the office. Failed because the patient base was so heterogeneous re computer skills, typing and willingness to fully comply.
Tried to record the whole session and have my transcriptionist write most of the report, especially the routine, history and such. Failed because some patients were not comfortable with recording but mainly because the sequence of data gathering in the session and recording was too discontinuous for the transcriptionist to easily follow.
Virtual Assistant: This is the area in which I’ve had the most success. You can hire a VA online at a very low rate but you have to shop around to find a good match re skills, costs, performance and personality. I’ve used one in the Philippines and one in the US (Georgia); both have been excellent. Long story on this topic but, in short: Sometimes I’ve had my transcriptionist also be my VA; other times the functions are separate but always remote. I’ve never actually seen any of my past VAs!
The VA does all my scheduling, billing, triages all my calls, and does ‘other tasks as assigned’. For me, in a solo private practice setting for the type of work I do, this is all done in approximately one third time for the VA or for about $50/day + bonuses for outstanding work and ‘special projects’. I average 2 exams/day at an average of $850 each and could do 3 so I think that is about 3% of my gross. BTW, I have VERY low overhead . . . you would be surprised . . . maybe shocked (no employees, never pay rent, etc.) . . . but that is another story .
Transcriptionist: When I first started practice I was paying $5.00/page; once I went remote it dropped to $1.00/page; once I went global and integrated it into the VA role it dropped to $0.50/page. Excellent quality, 24hr turn around and documents encrypted both ways. Love it! Over time my transcriptionist(s) develop and sense of my reports including both content and structure –> increased efficiency. We use a LOT of templates, codes, macros, text expansion, etc. so I don’t have to dictate so much and reduce typos at the same time.
What I have done over time would not work for everyone or even most but the end result has been a very high level of function in what I do: lucrative, satisfying, high patient and referral satisfaction, and a very polished work product. Each to his/her own. Build your own practice environment over time using creativity and what works. Think of it as your own ‘medical bonsai tree’ . That may include a Medical Scribe or not. The best stuff is ‘outside the box’!
Does anyone see the Ponzi scheme in this. How many new patients can be added indefinitely? I “retired” and have helped friends when overloaded. I use the hospital EHR. I do work for insurance companies so I have no overhead (beyond a license and CME). I can work when I want. No MIPS.
Why stop at hiring scribes? Why not buy some cuneiform tablets at the bazaar in downtown Nineveh?
If nothing else, the need for scribes proves that EVERY line used to push EMRs, by the vendors and our medical societies, was a complete and total lie.
Don’t forget that the number of extra patients one needs to see is entirely dependent on one’s negotiated fee schedules and one’s overhead. If you don’t have the luxury of highway robbery fees like the authors, it’s going to be a lot more than two or three patients daily..
Forgive me for my second comment today. Have all of you learned to don the many hats now required of a solo practice practitioner (as our healthcare industry continues to grow)….our dying breed? I can think of coding and compliance officer, HIPAA officer, OSHA officer, accounts payable officer, IT officer…..it is hard enough to pay for a practice manager/administrator and how much responsibility can you give them?
Can’t wait for retirement…..
Gary,
Like you I did it all from 1984 until I finally caved in and sold my practice for financial reasons in 2010 and retired in 2014. I’m still finding reminders of my work years in boxes which I happily toss or shred (if any patient references, SS numbers, etc.) NOT to mention dreaming about every night. Every…freakin’…night. Bless you and others for hanging in there and enjoy retirement when you get there…
I left a group practice to retire last July. At 64 the COBRA insurance was too enticing. I still hold it against Obama for ramming EHR down our throats. Didn’t do a thing to improve care. I did it all, office, hospital and call. Became a burden with all the administrative useless, busy work that has been forced upon us. I foresee when med students “get” that primary care is the worst specialty to go into and rightfully forsake it. It wasn’t always that way. I started in January 1988 after 5 and a half years of residency as I started out in something else. I was very comfortable with critical care. Liked it the first 20 or so years but when the government got involved with forced EHR, it was miserable. Thankfully I could see the light at the end of the tunnel, saved up a nice nest egg and didn’t experience a suicidal despair like some do. Was able to hang on until I could walk away. I left one year earlier than I planned so I wasn’t too far off. So, so much happier now. I have nearly no medical related nightmares. Once the Covid thing is under control, my 26 year old autistic spectrum son and I will be able to take some trips and outings. He’s doing real well. (I lost my spouse in 2019 due to Radon induced lung cancer. We didn’t know about it and she never smoked in her life. House is abated now and barely detectable. What a way to find out about it.)
Hi Kurt, Glad things are looking up for you! As a volunteer physician I just received a Pfizer vaccine, so I feel like a little burden is lifted from me! Just wanted to comment about EHR…I didn’t get a desktop until 2004! I was a slow adopter of EHR, part of the sale to the hospital. It’s funny that I myself didn’t mind it so much. I found that in hand-written notes I was constantly omitting details that could have upped my charges, just for lack of time. The best thing about EHR is that the bad handwriting is automatically eliminated. It seems that I always had partners who, aside from being fine human beings, had crappy handwriting! Now my volunteer free clinic is planning to get EHR, so we’ll see if my opinion changes since I haven’t used one in 6 years!
Nobody rammed EMRs down our throats. Physicians volunteered for them, even with the complete lack of evidence to support the claims made for them.
Those of us who have stayed with paper charts are more convinced every day that we’ve made the right decision.
:We have met the enemy and he is us.”
Kurt – I’ve heard medical students refer to their rotations as Family Practice Hell or Family Practice Purgatory. Can’t say as I blame them. I tell them, when I get students, that if they are going to do Family Medicine, they should at least find a fellowship of some sort. Whatever interests them. Otherwise they are nurse practitioners in the eyes of administrators.
I recently closed my solo practice and am now employed part time. A big reason was exactly what you say. I liked being my own boss but the administrative burden just became too much. In addition to what you mention I would add HR director and MACRA/MIPS specialist. I actually enjoyed the IT stuff though.
I am also in a rural area. I also do not agree with packing your exam room (I don’t know about you, but as an ophthalmologist my rooms are standardized at 8×12 and if you add in patient, whoever accompanies patient, doctor, doctor’s tech, wheelchair or walker, it does get kind of claustrophobic). Also I wonder about the safety of so many people in this COVID era being jammed into my small intimate rooms. Maybe I can get government money to remodel my office?
At the present time of declining reimbursement, I am happy if I can squeeze in a few extra visits just to maintain my income!!!! And then there is the extra person I need to hire to deal with these never-ending chart review requests which we get from most every insurance company……and then there is the extra person I need to hire to clean the office because it is so hard to get any cleaning work out of the regular staff.
These are just nails in the coffin for solo practices.
Thank you for allowing me the opportunity to vent.
I was first introduced to the concept of medical scribes when I flew to a university town to review an urgent-care computer program in 1988. This urgent care was using med students as scribes (unpaid, I assume). Well, I never used scribes. My exam rooms were crowded enough in pre-pandemic days with children, parents, BFFs, spouses, gay lovers, neighbors, etc. (Privacy? HA!) It seems to me that with the advent of EMR, Dragon Naturally Speaking, etc., that scribes would be superfluous even if affordable (and only a hospital-owned practice would be able to afford them, like they justify having their hallways full of useless vice-presidents).
As an office based physician I don’t like the idea of a scribe. Having additional people in the room changes the dynamic and in longitudinal care effects the trust that has been built over time. I’m afraid I don’t like precepting students for that same reason. I have worked in ER’s and think it would work better there as the communication is mainly for acute, more straightforward problems.
In a rural setting it’s not a simple thing to find people that can function as scribes, and frankly someone sharp enough to be a good scribe probably will move on to something else. And of course somebody has to pay them.
They are useless. They are snitches. Did you forget to ask about the patient’s grandfather’s shoe size – but you wrote 10 1/2 down anyway? That’s a crime against the, the, well, it’s fraud. They are also the ADVOCATES for the patient, so if a patient asks for more pain medicine, and complains that you didn’t give it last time, well, up goes the confidential report, and the scribe reassures them that they will get their, which one? Oxycodone? Sure.
A fine concept with a terrible name is “rent-seeking.” This scribe is paid, right? The money comes from somewhere. Does the scribe actually add to the income of the… the… whatever it is you work for? If so, we’d have seen scribes 50 years ago, when everything was quill-on-paper. But no. They take a chunk of change without improving “production.” And whose chunk do they get? It’s paid for by the two “extra patients” that you see but they have somehow “added” to your work quota!
“The Healthcare Industry” has been a bonanza since it got its name. So much money is coming in, jobs can be made out of nothing. And that’s what politics is – making jobs! Notice that the administrators and other rent-seekers at the big academic industries have had their COVID shots – both of them! Because distributing them out to the peasants is too hard a job. They aren’t afraid to use COVID vaccination as a lever. Watch for more of this.