Next time you visit your doctor, there's a growing likelihood a third person will be in the exam room - the medical scribe. This new category of health care "specialist" has emerged to deal with the widespread and growing physician disatisfaction with the current versions of the electronic medical record (EMR). The recently created American College of Medical Scribe Specialists (ACMSS) estimates that there are already more than 17,000 scribes working in more than 1700 health care organizations with predictions of more than 100,000 by 2020. The growing army of medical scribes is largely a "workaround" for poorly designed EMR technology. I've already described the negative impact of current, dated EMR technology on both caregivers and patients. At least 50% of physicians currently report symptoms of burnout, frequently attributed to daily confrontation with the click-happy EMR. The few small studies of the impact of scribes on medical practice all have flaws but suggest improved caregiver satisfaction and at least no negative effect on patient satisfaction. Modest increased revenue related to improved documentation and coding as well as increased patient numbers has been noted by some. However, the most recent report of physician, scribe and patient perspectives on their experience raised serious and important questions about the quality of documentation, patient privacy, and even "scribe burnout." Do we really want to deal with bad health care technology by bringing tens of thousands of additional personnel into exam rooms across the country? I'd suggest medical scribes represent, at best, a temporary band aid for bad health care technology. Here's my top three reasons why.
Increased documentation for revenue purposes doesn't work in a value based world
Claims for increased RVU production and revenue enhancement with scribes rest in part on enhanced documentation to upcode to a higher level of service. This might work in a shrinking fee-for-service world. It's not a smart path in a value-based environment where the financial risk is increasingly borne by the provider, not the payor. As CMS implements the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA), the transformation of health care delivery will be driven by reimbursement for cost-effective quality care.
The scribe shouldn't come between the patient and the doctor
The scribe's presence may inhibit sensitive patient-doctor discussions. A doctor patient relationship with open, comfortable discussion of the most personal and private issues is central to delivery high quality care with the best outcomes. Some patients in Yan's recent study expressed hesitation about the scribe's presence when a more "invasive checkup" was performed. A male patient felt uncomfortable discussing sexual problems in the presence of a female scribe. While CMS requires the scribe be a "certified medical assistant" at a minimum to enter orders in the EMR, some scribes have minimal training or clinical experience simply to function as clerical documentation assistants. Bringing a nonprofessional into the exam room may compromise patient trust. Incredibly, as scribes by the thousands enter exam rooms, quality studies of their impact on the patient-doctor relationship are virtually nonexistant.
The scribe shouldn't come between the EMR and the doctor!
The EMR should not simply be a documentation tool. Unfortunately, most of today's antiquated first generation EMRs fail to tap the enormous potential of the EMR to be the physician's partner - not the enemy. A scribe can unload the physician of the burden of entering reams of data into the record - often clinically irrelevant but mandated for billing. However, as Yan, et al report, scribes "don't know what to type in here, what not to type in here; what's important, what's not important." A scribe can't craft a meaningful and clinically relevant note encapsulating the clinician's diagnostic and therapeutic reasoning. The note is central to communication to all caregivers for the patient, particularly important in the era of bundled care. A scribe with a high school diploma or G.E.D. and a 2 week training program shouldn't be the one receiving and interpreting best practice alerts in the EMR. Putting the scribe between the EMR and the doctor is a huge missed opportunity. Realizing the true potential of smart health care technology requires reimagining the EMR as a source of point of care clinical decision support built along workflows capable of capturing the nuances of the individual patient's problem. Rather than clicking boxes in a generic template, the clinician should navigate an EncounterFlow which matches real and meaninful cognitive work. The clinician-user interface must be designed to facilitate documentation while preserving eye contact ("glance time") with the patient. Real time documentation has the potential to give back to the caregiver the hours spent after clinic "catching up" on computer "paperwork." Capturing truly clinical relevant information drives a meaningful assessment and note.
Schiff et al have recently expressed concern that relying on the scribe as a workaround for bad technology may actually inhibit the efforts to fix the real problem. Similarly, Gellert, et al suggest that rather than rely on scribe support which might impede much needed improvement in EHR technology, physicians must demand products that understand how clinicians think with an intuitive user interface. Heath care must be one of the few areas where technology has actually increased user workloads, requiring the addition of thousands of new employees just to stay afloat. The scribe workaround isn't the answer.
Innovative, smart health care IT built with real clinician input is the best path forward.