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Clinical Documentation Specialists or Medical Scribes: Who Is Most Cost-Effective?

Physicians are frustrated with electronic health records (EHRs). Data entry is time-consuming (and well below physicians’ skill levels), user interfaces don’t match clinical workflow and templates don’t match medical record needs, and face-to-face care is compromised, they say. In addition, at the same time that EHRs run the risk of creating information overload, there are too often insufficient health information-exchange capabilities. This is nothing new — yet high levels of frustration remain, and are growing.

We can’t tear up EHRs and start over, so the Centers for Medicare and Medicaid Services (CMS) have taken a top-down approach, creating federal policy requirements that force providers to maximize EHR use while pushing EHR makers to step up interoperability and make user interface improvements.

Two bottom-up approaches have been the use of clinical documentation specialists (CDSs) and medical scribes.

Clinical documentation specialists: no return on investment

There’s more bad news: implementation of EHRs imparts next to no return on investment in one key fiscal measurement, according to a recent study.

The study, published in the Journal of Health & Medical Informatics, sought to evaluate the impact of EHRs and the addition of CDSs as a clinical support group on hospitalist documentation using case mix index (CMI) as a measurement tool. A two-group pre/postimplementation retrospective research design was used to evaluate the impact of the EHRs–CDSs combination in terms of CMI in a single, 125-bed, full-service community hospital in the greater Los Angeles area. All hospitalist medical records — 3,536 of them — were reviewed in the pre- and post-phases. Phase one included a review of 1,712 hospitalist medical records before implementation of EHRs, and phase two comprised a review of 1,824 hospitalist medical records after implementation of EHRs with CDSs. Change in CMI data were analyzed over the two phases in order to compare the mean CMI between the two phases. The researchers determined that the mean CMI value for phase one was 1.65 and 1.68 for phase two.

“The implementation of electronic health records and clinical documentation specialists as a clinical support group did not make any significant difference in hospitalist documentation using CMI as a measurement tool,” the authors conclude. “Rather, the diligence of providers that documented accurate and comprehensive MS-DRG diagnoses, with the appropriate addition of MCC and CC diagnoses, guided CMI.”

A cost-effective solution: medical scribes

So, if the key is the quality of documentation — and physicians acknowledge that EHRs keep them from creating high-quality documentation while caring for patients — what is to be done? The practical solution is medical scribes, who are able to carry out numerous documentation-related duties that unburden physicians — in particular, creating high-quality patient records in real time. Numerous studies have also shown that scribes contribute to cost savings and efficiencies.

And now, a study published in the May/June issue of Physician Leadership Journal (subscription required) reiterates these benefits, finding that the use of medical scribes in hospitals saves significant money per patient.

To determine the impact of medical scribes on a hospital’s CMI, a 14-year-old hospitalist group conducted a study in which hospitalist-specific medical scribes were assigned to doctors who worked in the adult internal medicine departments of Advocate Good Shepherd Hospital and Advocate Condell Hospital from 2012 to 2014.

At the end of the study, the CMI for Good Shepherd Hospital had increased by 0.26 and for Condell Medical Center by 0.28. When CMI for the teams with medical scribes were compared to the whole hospital, there was a significant improvement for the hospitalist team, indicating that the increase in CMI was a direct result of the addition of medical scribes to the team. Based on length-of-stay ratios for both hospitals, it was determined that the actual severity of patient conditions did not change over the study period. Considering that an increase of 0.1 in CMI has been shown to result in an increase in revenue of approximately $4,500 per patient, the two hospitals had gained about $12,000 per patient in the inpatient internal medicine setting over the two-year study.

“Medical scribes as well as hospitalists are historically viewed as a line item expense in the inpatient setting,” the authors write. “A doctor is a hospital’s most valuable asset and instead of seeing patients, doctors are being distracted with clerical work. The increased documentation burden that hospitalists might encounter with an EHR is easily overcome by the introduction of medical scribes. Use of medical scribes will help improve a hospital’s standard in documentation and also help a hospital benefit monetarily.”

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