Scribes & Neurology Teams

Scribes are valuable assistants in many medical practices, allowing physicians to unleash themselves from keyboard and screen to better interact directly with patients. Some physicians find the use of scribes also increases their efficiency, allowing them to reclaim time outside of clinic hours. A well-trained scribe can bolster physician and even patient satisfaction,¹ but does this translate to actual increase in dollars for your neurology practice?

Scope of Scribe Practice and Cost

Scribes can generate notes, enter data from discharge summaries and lab reports, and document the medical history as it is being gathered. Scribes can also enter orders to be reviewed and cosigned by the provider. It should be noted that The Joint Commission does not endorse having scribes enter the orders themselves using a clinician’s sign-in credentials. Based on discussions between the clinician or scribe and the patient during the visit, a scribe can document the entire assessment and plan to finish charting in real time, instead of the clinician having to finish charting after hours.

It is important to note that medical scribing is an unlicensed profession. Scribes typically only start with about 40 hours of training. Training options vary, and there is no standardized or nationally recognized certification. Training can be done on the job, online, or via in person courses, and vary considerably in terms of hours required and content. A scribe’s skills are limited to documentation in the electronic health record (EHR) during a clinical visit, and scribes are not able to perform direct clinical care such as taking medication histories or vital signs. Sometimes medical assistants, who have those skills and can interact directly with a patient while the clinician is not in the room, make less than scribes, which has led some to cross-train medical assistants to serve as scribes.

What does a scribe cost? Cost depends on where you practice and how you hire scribes. According to ZipRecruiter, the lowest hourly wage for a scribe in the US is $10.66 in North Carolina, and the highest is $16.16 in New York.² Agencies that provide medical scribes charge more, and hourly rates vary between $15 to $25 per hour. Specialty-trained scribes, such as those with previous experience in neurology or other subspecialties, may carry higher costs.

Benefits and Outcomes of Scribe Use

The advantages of working with a scribe are harder to predict and dependent on the individual provider’s preferences and interactions with scribes. In an interview with Dr. Nina Riggins, Director of Headache and Traumatic Brain Injury Center at the University of California, San Diego, she notes a positive experience working with scribes at her academic neurology practice. According to Dr. Riggins, scribes tended to be “very motivated bright people who were pursuing medical school, physician assistant, and nursing school… I am proud of their achievements and grateful for their contribution to our patients’ care.” She estimates that she saved 10 minutes per patient visit, with 10 to 15 patients per day, amounting to approximately 2 hours per day. The scribes required training over months, but often could cross-train one another. Dr. Riggins noted that she would also review their notes and make edits afterwards. Overall, she believes patient satisfaction was the biggest benefit because she could focus more attention on her patients, rather than the EHR.

In an interview with Dr. Kandan Kulandaivel, an epileptologist and community neurologist at a private practice in Abington, Pennsylvania, he found scribes to be immensely helpful in the inpatient setting when doing consults at their busy hospital. “We could get as many as 16 new consults a day, but with a scribe it took half the time. Medical history documentation was also so much more detailed than when I rushed to dictate those notes myself after the consult, which led to better patient care and upgraded billing for our consults.”

Practice outcomes of scribe use have been formally studied for specialties outside of neurology. A systematic review from 2015 found 5 studies that evaluated outcomes from the use of medical scribes (3 in emergency medicine, 1 in cardiology, and 1 in urology).³ In 3 of 4 studies that measured productivity outcomes (eg, patients seen per hour), there were improvements. The 2 studies that evaluated relative value units (RVUs) found increases with scribe use. The study involving a cardiology practice measured revenue and demonstrated both direct and indirect increases in per patient revenue with scribe use.

A more recent study of a dermatology practice showed a revenue increase after scribe use that outweighed the cost of scribes. Most physicians were willing to add more patients with scribe support, and 1 additional patient per work shift paid for the cost of the scribes. The average documentation time for these dermatologists was 6 minutes per encounter compared with 3 minutes when using scribes.⁴ Extrapolating this to neurology, which typically involves documenting much longer histories, there would likely be an even greater time savings.

Cost analysis of 2 emergency departments reported that using scribes improved patients seen per hour and reduced the number of down-coded charts. The immediate benefit was seen in the departments’ ability to reduce hours of physician coverage. Their physicians’ average payment was $180 per hour and scribes cost an average of $20 per hour, but the estimated value of the scribe was $36 per hour, meaning that adding a scribe could actually add $16 per hour in revenue.⁵

But Would a Scribe Help Me?

How can you determine the cost benefit of a scribe for your practice? First, start with good metrics: collect data on how many patients a provider sees per day, the RVUs generated, and average reimbursement per day (or per RVU). If your practice has ancillary services such as infusions, EEGs, EMGs, sleep studies, or other procedures, determine how many are ordered in a given time period. The most direct improvement to your practice will be in the volume of patients seen, so estimate this improvement for your calculations. A conservative number for neurology would reasonably be to add 1 to 2 patients per day—for instance 1 new patient or 2 follow ups (40-60 minutes is feasible if documentation time decreases by as little as 5 minutes per visit). Next, calculate the increases in direct revenue and downstream revenue from ancillary services and improved coding, and subtract the costs of the scribe. See the Figure for formulas to start calculating potential gains.

Even if your calculated margins seem close or minimal, consider the intangible costs of end of the day, nighttime, and weekend documentation burdens. The field of neurology is especially prone to turnover because there is a shortage of neurologists.⁶ Adding scribe coverage to your practice could be attractive for candidates, help retain clinicians and prevent early retirement, and reduce overall costs of employee turnover. Dr. Irena Danys is a semiretired neurologist and sleep specialist who held a locum tenens position on the condition that she would have a scribe. Although she worked 11-hour days, Dr. Danys said, “It was all seeing patients, and it was so refreshing to just practice medicine that I was excited to go to work every day.”

Could I Help a Scribe?

The physician-scribe relationship works both ways, and today’s scribe may be tomorrow’s colleague. Many scribes are in the position not just for the pay, but also to absorb medical knowledge firsthand though you. Being an educator for residents and medical students requires dedication in the form of didactic teaching hours and formal evaluations, whereas scribes do not bring these expectations. If you are working in a private practice, but enjoy some aspects of teaching, as many clinicians do, then training a scribe can be a source of professional satisfaction in itself.

Sounding Too Good to Be True?

What are downsides of using scribes? Other than the cost, there is the added administrative work of hiring and training scribes. As described, many scribes are pursuing higher learning, so there can be a fast turnover for scribes. Some agencies offer scribes who are pretrained, but costs are higher for these scribes, who may still need to adjust to a neurology practice. Some patients do not feel comfortable with an extra person in the room, and small exam rooms will feel cramped, especially in the era of the COVID-19 pandemic. Furthermore, relying on a scribe means that your EHR skills can become less habitual and potentially inadequate for days that happen not to have scribe coverage. The liability of adding a nonclinical professional should be considered, because documentation accuracy is ultimately the responsibility of the clinician. For these reasons, not every neurologist will want to use a scribe, but others, as Dr. Danys notes, “will be desperate to shorten their onerous work.”

What Does the Future Hold?

Digital scribes are a newer alternative to a medical scribe. A digital scribe is an advanced dictation software that records the entire visit and then transcribes it into a note. This technologic solution is still in its infancy. Although it could be cheaper, there are drawbacks of using artificial intelligence instead of living scribes. For example, a clinician may need to change their practice style to conform to the software capabilities, potentially creating interactions lacking in nuance if the clinician must use phrases recognized by the software rather than speaking naturally. Clinical records and workflows may need to be altered as well.^7,8 Artificial scribes are not to be confused with virtual scribing, which is a scribe service performed over a HIPAA-compliant remote connection. There are some systems that even partner artificial intelligence software with remote human scribes.⁷ The Table summarizes different types of scribe services to consider.

If your practice is not ready to hire a new employee, consider this innovative solution that Dr. Danys saw during her time at the neurology practice in Anchorage, Alaska. All their medical assistants were cross-trained to be scribes.⁷ Each physician was assigned a medical assistant who would take on the usual roles of vital signs and medication reconciliation but also then stay in the room and transcribe the visit into the EHR. Although not every medical assistant makes a competent scribe, you might find that some assistants in your practice have the skills or are willing to train into the role for an increase in pay.

Summary

Weighing the limitations of the scribe and the nonmonetary benefits to clinicians and patients, many medical practices already see hiring a scribe as a win. After reviewing the numbers and estimating your potential increase in revenue, incorporating medical scribing into your practice might seem to you like less of a luxury and more like a cost-saving strategy.