Harried doctors hail the rise of the medical scribe

By Jackie Crosby jackie.crosby@startribune.com

Dr. Alan Bank is no Luddite. He embraced computerized patient records and their promise of improving the way he practiced medicine.

But in recent years, the Allina Health cardiologist began to feel that he was spending more time facing a computer than tending to patients.

"I wasn't happy, I wasn't enjoying my work, I felt like a data entry clerk," Bank said.

His solution was to hire someone to sit in the exam room during patient visits and take care of the computer coding and note-taking.

Such specialists in health care documentation, known as medical scribes, are an increasing presence in emergency rooms and doctor's offices statewide.

After hiring a scribe, Banks said, his productivity went up, he got home earlier and he was happy again. Patients told him they felt like they had his full attention.

"We're moving into an era where doctors can't do everything," he said. "With all the economic pressures in medicine, we should figure out more efficient and better ways to manage our patients."

Medical scribes have been working in Twin Cities emergency departments since 2006, typing in patient data, keeping track of tests that have been ordered and helping clinicians juggle multiple patients among the hubbub of activity.

But health reform efforts are prompting more office-based physicians and specialty clinics to take a look.

The number of medical scribes has been doubling annually, with about 20,000 expected to be working at the nation's hospitals and clinics by the end of the year, according to the American College of Medical Scribe Specialists (ACMSS).The industry expects their ranks to swell to 100,000 by 2020.

The vast majority of scribes still work in emergency departments and urgent care centers. But increasingly they're being used by ophthalmologists, dermatologists, gastroenterologists and OB/GYNs, said Kristin Hagen, executive director of the ACMSS, which offers a certification program.

In Minnesota, medical scribes are making rounds with hospitalists, and they're showing up at orthopedic rehab clinics and at a handful of primary care clinics, as well.

"They're more than documentarians," said Dr. Jay Westwater, an Allina Health emergency doctor who also is medical director and partner of a Twin Cities company that staffs and trains scribes. Westwater said a scribe is at his elbow practically from the time he starts a shift until he leaves for home.

"They're empowered to do those types of things that I should be doing, but am thinking of something else," he said. "The good ones develop more into doctor minders — someone at your sleeve who can tug on it and say, 'Don't forget this.' They're like peripheral brains, especially in the ER."

Hospitals typically contract with outside companies, often physician-owned, that hire and train scribes. There are at least four, including Westwater's Emergency Care Consultants, that provide scribes for health care organizations around the state.

Hospitals and clinics typically pay about $20 to $25 an hour for scribes, who typically are college students or recent grads who want to work in the medical field. Scribes spend up to 100 hours getting on-site training plus additional time learning billing and coding.

Tibor Kovacs, 74, said he hardly noticed as scribe Jaeda Roth typed up notes during a recent follow-up appointment.

"She didn't make herself known, or ask for clarifications," said Kovacs, of Hastings, who had quadruple bypass surgery in March. "She was at her computer doing her thing, and the doctor was taking the initiative. I felt very comfortable. "

Before each appointment, Roth assembles patient information, such as surgeries, diagnostic tests and medications, and prepares a summary. That way, doctors enter the exam room with the relevant medical data top of mind. After the appointment, she and the doctor have a brief follow-up meeting, Roth enters the billing codes and the physician's "paperwork" is done.

"We help make everything run smoother," said Roth, a recent University of Minnesota graduate who has worked as a scribe for more than a year. "Doctors see so many patients and hear so many things."

Roth earned a degree in biology, and plans to keep working as a scribe for the next year while she applies to medical school.

Aside from helping doctors, Roth believes she is gaining valuable experience about the medical field and insight into such things as bedside manner.

"You definitely see how different physicians interact," she said. "I want to sit down at eye level and have a conversation."

Some doctors worry that scribes will interfere with the sacred doctor-patient connection or make patients feel uncomfortable. Others charge that scribes add another layer to a health care system that already is burdened by inefficiencies.

But Bank is convinced that scribes help doctors get more done and reduce billing errors.

After hiring the first scribe at his St. Paul-based cardiology clinic a few years ago, Bank conducted a simple test using four doctors to try to measure the scribe's impact on the medical practice. The physicians worked 65 hours the traditional way and 65 hours with a scribe. The results were dramatic.

Doctors who worked with scribes spent 15 minutes with patients on a routine follow-up visit compared with the typical 20, and saw nearly a third more patients. Revenue at the clinic increased nearly $206,000 during the test period because of the scribes, Bank calculated.

"It wasn't because patients were billed more," he said. "It was that we were more efficient and could see more patients in the same amount of time."

The cardiology clinic now has half a dozen part-time scribes, and 10 out of the 24 doctors at the heart clinic regularly work with them.

Bank is on something of a mission to expand the use of scribes, hoping that small-practice doctors and administrators will see their worth. He has written articles in medical journals and an opinion piece in the Wall Street Journal.

"I think it's better care," he said. "It's the way the field needs to move."

Note: An earlier version of this story said that scribes earn $20 to $25 an hour. That is how much hospitals and clinics typically pay contractors for their services.

Jackie Crosby • 612-673-7335