Urgent message: As urgent care operators look for ways to speed patient flow and raise visit revenue, medical scribes may be a solution for increasing provider efficiency and improving documentation accuracy. How this article helps you: provides information useful in deciding whether your center would benefit from hiring scribes.

Introduction
Urgent care is unique among health-care delivery models in its focus on providing quick turnaround. To get patients in and out of the center in less than an hour, urgent care operators focus on developing systems, processes, and training to speed patient flow. In emergency medicine and other specialties, medical scribes— unlicensed individuals who enter information in an electronic medical record (EMR) under physician supervision— have been used to improve the efficiency of providers, enabling them to see more patients versus spending time on documentation. According to a recent article, 22 companies provide scribe services across the United States, and interest in medical scribes is being driven by perceived inefficiencies in EMRs, which detracts from time available to treat patients, which in turn translates to less income.1 Although there are no statistics on the prevalence of scribes in urgent care, there are opportunities for urgent care to explore the concept, as explained in the following question-andanswer session with Cameron Cushman, vice president of marketing and  sales for PhysAssist Scribes of Fort Worth, Texas.

Interview
Ayers: what are the responsibilities of a medical scribe?
Cameron Cushman: We’ve asked a lot of physicians, physician assistants, and nurse-practitioners what they like most about using a scribe, and overwhelmingly the response is that medical scribes alleviate the burden of documentation in the EMR, giving them more time for actual patient care. Medical scribes are specifically trained to document all aspects of patients’ charts during a visit, including the history of present illness, the provider’s assessment and plan, and the eventual diagnosis. More seasoned scribes can engage in advanced workflow activities, such as bringing in electrocardiograms for physician interpretation. After patient discharge, providers always review, approve, and sign charts, just as they would without a scribe. The bonus here is that they have spent little to no time writing in the chart.

Most medical scribes are pre-med students or plan to go on to study to become physician assistants, so they are eager to understand what they are documenting in EMRs and why. This job is an excellent way for them to be part of a medical treatment team while learning about medicine on the ground. Under guidelines established by the Joint Commission, scribes are not allowed to enter orders, touch patients, perform procedures, or interact with patients. They are trained to assist in medical charting but are to act like a fly on a wall in the patients’ rooms. Once out of the room, they are encouraged to interact with their assigned provider to be sure that patient charts are recorded to the provider’s specifications and that no relevant parts of the patient story are missed.

Ayers: How are scribes trained to be maximally effective with documentation and advanced workflow?
Cushman: We have found that the best scribes are those aspiring to become medical providers. They are intelligent, astute, and motivated. They are there for the experience and the education, rather than to just pick up a paycheck. Scribing is tough work, often with long hours; they are on shift for the same amount of time as providers, anywhere between 6 and 12 hours. Thus, we are looking for individuals who are truly committed. We tend to hire pre-med students who are finishing their undergraduate degree, are in the process of applying to medical school or a physician assistant program, or are in a gap year.

Various scribe companies have their own proprietary methods of preparing scribes for EMR work in a medical facility. PhysAssist Scribes has created a unique training program called I Am Scribe University. We have been refining the curriculum since the company’s inception, and we are currently using a serious of rigorous online courses, closely monitored by a mentor, as well as on-the-floor training in the specific EMR on which they will be working. In general, scribes go through a series of courses to learn and understand each section of a medical chart, including the structure of a proper SOAP (subjective, objective, assessment, and plan) note, how to craft a history of present illness, what physical findings are relevant to document, and what signs can be associated with common diagnoses (e.g., right upper quadrant pain could indicate cholecystitis).

Ayers: How do scribes work in EMRs?
Cushman: Scribes enter a patient room with the provider, write down the patient’s medical history, and consequently complete the chart under the instruction of the medical provider. An attestation statement is included in the chart that states that the scribe filled out the chart on behalf of their assigned provider, but the chart is ultimately the provider’s responsibility. Each provider must review and sign the chart prior to discharge. The scribe is trained to fully understand how to navigate the EMR used in the facility where they are working during their first weeks of on-the-floor work (we call this their residency phase). Scribes must be provided their own unique log-in for EMR use and in some cases are required to pass hospital-designated EMR courses.

Ayers: How are scribes typically used in emergency-medicine and primary-care settings?
Cushman: The most efficient use for scribes is to match them with providers who do the most documentation, which is not to say with the most senior or slowest-charting providers. Scribes can often show great value in a fast-track area, which is why they can be a great solution for urgent care facilities that can see many patients in a short amount of time. Scribes can help maximize this time, allowing the provider to move quickly from patient to patient without worry of falling behind on their charts.

Ayers: How prevalent are medical scribes in urgent care today?
Cushman: General industry estimates are around 10,000 medical scribes across the United States. PhysAssist Scribes employs a total of more than 3,000 scribes, so we can support this estimate. The majority of our scribes work at in-hospital emergency departments, but we are seeing their adoption at urgent care facilities in increasing numbers. We currently staff approximately 10 urgent care locations nationwide, with inquiries from similar facilities about scribe services growing exponentially.

Ayers: What is the benefit of using medical scribes in urgent care facilities?
Cushman: Simply stated, scribes give valuable time back to medical providers. This means more time for patient care, reduction in door-to-doctor time, and of course, an opportunity to get home at a reasonable hour without late-night charting left to finish. In our research, we have found some physicians spending a half to a third of their shift documenting in the EMR. By removing this burden, they are able to be a doctor again instead of a high-priced and highly trained clerical worker.

Some urgent care facilities are seeing success with cross-training existing employees (like an medical assistant) to perform scribe duties and similar tasks. This model enables these facilities to keep their employee numbers at the status quo while increasing efficiency for all tasks within the facility.

Ayers: Is there a measurable return on investment for using scribes in a medical facility?
Cushman: The value of scribes can be evaluated across many metrics, but the main driver should be what could boost a facility’s bottom line. In general, scribes can help providers see more patients faster. They can help reduce wait times across all aspects of patient flow because documentation is eliminated as a rate-limiting step. Urgent care facilities often see high volumes of patients, so the addition of scribes can ease the documentation burden on providers, helping patients feel better faster.

Recently, PhysAssist Scribes conducted a 1-month pilot program at an urgent care facility in the Midwest. They added one scribe to their treatment team that represented 144 total hours of shifts that month. This resulted in an increase of 1.36 more patients seen per hour. This allowed them to treat 196 more patients during the month, which would equal more than 2300 additional patients seen in a year. These returns far outweighed the investment they made in our scribes.

Ayers: When should an urgent care facility consider adding scribes as a part of their treatment team?
Cushman: The addition of scribes probably does not make sense in the first year or two of the opening of a new facility, because patient volume and provider ratios will not yet be fully understood. Urgent care centers eventually reach an inflection point where they face a critical staffing decision as volumes increase. If single-provider coverage is no longer manageable and wait times are starting to creep up, questions may arise as to what the most cost-effective solution is for managing patient flow. Sometimes the answer is another physician or an advanced practice provider. We encourage the facility to evaluate the addition of a medical scribe to see if this can help reduce wait times and increase flow before tacking on the much higher cost of a more expensive provider. As the facility grows, leapfrogging providers with scribes can continue to help manage patient and provider satisfaction and increase revenue overall.

Conclusion
Medical scribes have been proven in emergency-medicine and specialist settings to speed up patient throughput, improve collections, and boost provider efficiency, affecting performance measures that are also relevant to urgent care, such as the following:

  • Patient door-to-doctor time in center (initial wait)
  • Patients who leave without being seen
  • Patient total door-to-door time in center (length of stay)
  • Undocumented services (which subsequently are unbilled)
  • Patients seen per hour per provider (provider efficiency)

Given urgent care’s focus on rapid turnaround, it is logical that scribes could add similar value in urgent care settings. Urgent care is different from other specialties, however, in that (1) a lower reimbursement per visit may make scribes cost prohibitive and (2) whereas EMRs in hospitals and multispecialty settings are inherently inefficient, urgent care systems focused on facilitating flow and improving provider efficiency should have an intuitive interface that enables physicians themselves to document charts quickly. Urgent care operators should evaluate the costs and benefits of scribes, relative to other options, to determine whether scribes make sense for their specific practice model.

The Rise of Medical Scribes: A Fit for Urgent Care?
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