Impact of Scribes on Performance Indicators in the Emergency Department

R. Arya, M.D., D. Salovich

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, and M. Merlin, D.O.

Department of Emergency Medicine, UMDNJ- Robert Wood Johnson Medical School, Piscataway, NJ Medical Student, UMDNJ- Robert Wood Johnson Medical School

Introduction

Scribes are touted as a way to increase physician productivity. Scribes assist physicians with the clerical aspects of patient care with the intent of improving physician productivity. Their roles are diverse including  Recording patient histories and physical exams  Documenting procedures  Following up on lab reports and  Assisting with discharges

Purpose

Identification of factors that enhance physician productivity is important to the specialty of Emergency Medicine.

Scribes can afford the average emergency physician the ability to  Evaluate and treat more patients  Potentially generating increased Relative Value Units (RVU’s)  Maintaining high levels of patient satisfaction However, hiring and maintaining an active scribe program can be a potentially costly endeavor depending on work hours and benefits.

Unfortunately, not much published data Many current articles use only anecdotal evidence to justify the need to initiate a scribe program.

Objective

To determine if scribes increase emergency physician productivity by evaluating primary endpoints of:  Patients per hour (PPH)  Relative Value Units (RVUs) per hour  Turn around time (TAT) to discharge in shifts with scribes versus shifts without scribes. We considered a physician generating greater RVU’s per hour as a potential justification of the expense of a scribe program.

Methods

Study Design

A retrospective case-control study from July 1, 2006 through December 31, 2007 Performance indicators:  RVU per hour  Patients per hour  Turnaround Time (TAT) for discharge

Participants

Thirteen Board Certified Emergency Physicians  3562 clinical hours evaluated.  358 clinical shifts

Shifts evaluated when scribe was not present

 Matched by day of week  Matched by time of shift  High acuity patients over 20 years

Setting

  Adult Emergency Department at a University Based Academic medical center 58,872 adult patients per year.  Level I trauma center and a tertiary care center

Data Collection

 Extracted patient specific time stamps and emergency medicine codes from department electronic medical records  The difference between the arrival and discharge time, turn around time for discharge, was used as the through-put measure of productivity.  The E&M codes for each patient encounter were used in the calculation of RVUs from the 2008 conversion guidelines.

Results

Without controlling for percent Physician Assistant use

  10% increase in scribe usage results in a 0.18 increase in RVU/Hr (p=0.0067, SE 0.07) 10% increase in scribe usage results in a 0.05 increase in Patients/Hr (p=0.0399, SE=0.02)

Controlling for percent Physician Assistant use

  10% increase in scribe usage results in a 0.24 increase RVU/Hr (p=0.0011, SE 0.07) 10% increase in scribe usage results in a 0.08 increase in Patients/Hr (p=0.0024, SE=0.02)

No SS difference with scribes in TAT for discharge patients

Data Outcome Variable Effect Estimate RVU per hour

% Scribes % PAs

$ $

Model 1 Model 2

0.18 (0.07) .0067

0.24 (0.07) .0011

- %Scribes variation* .2108

0.20 (0.10) .0418

.4447

Patients per Hour

% Scribes % PAs

$ $

0.05 (0.02) .0399

0.08 (0.02) 0.0024

- %Scribes variation* .2216

0.09 (0.03) 0.0056

.3082

Table 1:

Effects of independent variables on outcome variables from different models with alternative combinations of independent variables: For RVU and Patients per Hour, Model 1 includes PerScribes, and Model 2 includes PerScribes+Pthr.

Limitations

This was a retrospective study Most of the control scribe shifts were nights and weekends with less volume Did not assess other outcome measures such as  Door to Doctor  Patient Satisfaction Limited assessment of shift acuity It is unknown if these results can be extrapolated to academic Emergency Departments settings where residents are present

Conclusion

Statistically significant changes in RVU/hr and PPH were demonstrated with scribes Potential to increase the number of patients seen per hour by 0.8 When moving from 0% scribes to 100% scribe utilization Determination of scribe coverage by increasing ED volume now possible Additional studies are needed to determine how to maximize scribe usage and the affect on other metrics

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