Hiring Scribes Before the ER Storm

Your ER may be seeing an increase in the daily census over the past several months. The reasons for this are several, but among them is the new class of under-insured patients created by the ACA. Those enrolled under the Medicaid expansion are often finding themselves unable to get a timely appointment with their primary care physician. The ER is available, capable, and now, for them, free of charge. It makes sense these patients would look to the ER for care. As dedicated ER physicians, we welcome the opportunity to be of service, though it does create additional strain on the system.

We are about to move into Fall and Winter, the times when ER visits typically skyrocket. Flu season, croup and bronchiolitis, and, now, the new respiratory illness due to EV-D58 threaten to make this winter especially chaotic and busy. What plans, if any, have you made in anticipation of this on-rush?

The choices are fairly simple. Adding additional physician hours to cover the busiest times of the day, or adding Nurse Practitioners or Physicians’ Assistants to help with the patient load or work the fast track are reasonable solutions. Unfortunately they are also expensive.

One irony of the sea change we are seeing in health care delivery is declining reimbursement in the face of increasing patient loads. Depending on the demographics, adding additional practitioners may not be financially viable in a particular ER. Still, the expectations for lengths of stay, seeing all patients in a timely manner, and patient safety remain. The Joint Commission and CMS are unlikely to excuse a deterioration in these key metrics for financial reasons.

What, then, can be done to improve patient flow, preserve key metrics, and not break the bank? If you are reading this you already know my answer. Yes, scribes. For a fraction of what you would have to pay for either an NP or a PA, you could improve the efficiency of your existing physician staff sufficiently to handle the surge.

The average ER physician working with the average EMR is spending, on average, a third of the workday sitting in front of the computer. This is a colossal waste of time and a misallocation of valuable resources. A scribe would allow that same physician to see a third more patients per shift. Plus, the documentation would be accurate and complete, allowing for full reimbursement and an end to downcoding.

But scribes do not just float from the sky like fairies, landing in your ER at a moment’s notice, fully prepared to work their magic. Nor is your staff likely to be aware of how best to utilize a scribe to maximize efficiency. Setting up a scribe program takes some time, anywhere from 3 weeks to 2 months depending on the size and location of the practice. It makes little sense, therefore, to start thinking about using them in, say, December. That would be like springing a leak in your sailboat and waiting to break out the buckets until water is lapping across the deck.

You know it’s going to be busy, maybe busier than ever before. You know your staff will be stressed to keep up, and you know, or should know, that one or more of your colleagues will be indisposed at one time or another during the next six months. If the idea of scribes has ever crossed your mind, now is the time to give it some serious thought. If it has not crossed your mind, now it should.

ER physicians pride themselves on being prepared to handle the most difficult emergency medical problems quickly and skillfully. A surge in patient volume, one that is predictable, is a problem that deserves the same level of attention. Waiting until the system begins to fail before exploring options to fix it is a poor strategy in any business or profession. It is inexcusable in ours.

If scribes seem like a reasonable option, we will be happy to discuss it with you. Given the proper information we can do an analysis of your practice and provide you with a better sense of just how beneficial our services could be.

Dr. Jim Pagano is the director of Garfield Medical Center’s Emergency Department.