The Medical Scribe – An Unintended Industry

The medical scribe industry is booming.  The American College of Medical Scribe Specialists (ACMSS) says there are approximately 20,000 medical scribes currently and predicts this number will climb to 100,000 by 2020. As more and more medical practices are implementing and using EHR’s, physicians are finding themselves becoming expensive clerical staff. It can take nine times as long to input data into an EHR note compared to dictating.  An analysis of EHR use in an emergency room setting revealed that the physicians spent 44% of their time on data entry and only 28% on direct patient care. “Total mouse clicks approach 4000 during a busy 10-hour shift.”

Healthcare is the only industry that has managed to lose productivity while going digital.

athenahealth CEO, Jonathon Bush

There is no doubt that physician productivity falls when implementing an EHR. Navigating through the layers of menus, drop-down lists, and check boxes when documenting an encounter takes time. Planning for a 30% drop in productivity when implementing an EHR is reasonable but in reality it may even be higher. Some of this productivity loss can be regained over time, but returning to pre-EHR volumes is not the norm.

Enter the Medical Scribe

The Joint Commission defines a scribe as “an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner”. A scribe accompanies a physician into the exam room and acts as an intermediary between the physician and the EHR. Scribes enter history and physical findings as well as retrieve information such as test results and notes from previous encounters.

There is an abundance of data demonstrating how the use of scribes increases physician productivity. Not just through decreased physician time spent with the EHR, but also improvements in patients seen per hour, fewer down-coded charges, and increased RVU’s.  Even though medical scribe hourly rates range from $10-20/hour, the ROI for their use is typically turns out positive.

The scribe industry is not regulated. At this time certification is voluntary and can be obtained through the ACMSS. Many scribes have some clinical background (CMA, LPN or RN), but others may have minimal or no clinical background (pre-med students). It is up to the physician to judge the competency of the scribe. Companies such as ScribeAmerica and ProScribe provide scribe services for hire.  ScribeAmerica states that their scribes are certified by ACMSS and ProScribe employs “talented and reliable Pre-Health students”.

Competency can make a difference. A scribe may enter the documentation for a physician, but the physician is still responsible for the content of the chart. There is no “the scribe did it” defense for chart errors or discrepancies in documentation. Scribes with less clinical acumen may not pick up on all of the things the physician intends to have documented. In some cases the scribe may be at odds with what the physician says to document.

Without reflection, we go blindly on our way, creating more unintended consequences, and failing to achieve anything useful.

Margaret J. Wheatley

An Unintended Opportunity

Clearly the scribe industry fills a well defined need in modern healthcare. But the better question is how and why did healthcare get to the point where we even need such an industry?

The delivery of healthcare in the US is broken. There is no question about that. EHR’s hold the potential for positive change. The ability gather and analyze patient and population data and easier access to clinical data exist now. The promise of reducing medical errors and increasing patient safety remain to be seen. However, the content quality and readability of clinical documentation has taken a step backward.

In my practice and community, there are a wide array of physician opinions about using the EHR. On the whole they are not positive, but the degree of negativity varies. Many of us see the EHR as here to stay while some of my colleagues, often closer to retirement, are fighting it tooth and nail. Why are opinions so negative and adoption so slow? Usability or lack thereof. Clinic throughput as fallen and the physician-patient interaction has become the physician-laptop interaction.

While the healthcare system needs fixing, the physician-patient interaction was never broken. Inside the four walls of the exam room, it’s about the physician and patient. Patients who are comfortable with their physician will open up and reveal things that they may not tell anyone else. We are privy to information from the deepest and most personal parts of people’s lives. The human body does not care about social or societal comfort zones. Thus, physicians need be able to talk to patients in a setting that promotes trust and comfort. How does bringing a third person into the room affect this bond? I suspect the discussions are less open and honest.

There are many studies published demonstrating potential economic and patient throughput benefits of scribe use. There are even studies that show an improvement in physician-patient interaction. The scribe companies readily promote these results. But what is the reference point? When comparing the physician-EHR combo to the physician-EHR-scribe team, the scribe team wins. What if we compare the quality of the physician-patient interaction to pre-EHR numbers? Tough to tell. As far as I can see, there are no data to show benefit or detriment.

I participated in stage 1 and at six months I discarded my certified EMR in favor of going back to my old EMR, which helped me take care of patients. It didn’t distract me from talking to them — it provided me what I needed to provide high-quality care.

Gary Botstein, MD.

Basically we have taken a critical part of the healthcare cycle that was working and broke it by injecting the EHR. In doing so a new industry was created. The analogy that comes to mind is prescribing a second medication for the sole purpose treating a side effect caused by the first medication prescribed. I have nothing against the scribe industry.  There are days when I really wish I had a scribe to help get through the never-ending daily clicks. What I really need is an EHR that works with me. Works for me.

Time and innovation will eventually solve the usability issue. The recent comments by CMS Acting Administrator Andy Slavic about revamping Meaningful Use are encouraging. Opening access to and improving the interoperability of existing EHR’s will help accelerate positive change in the industry. Focussing on the quality of care delivered and not data collection for the sake of data collection is moving in the right direction.

When it comes to technology in healthcare, let’s make sure the treatment is not worse than the disease.

Cheers – Doc W

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