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Use of Medical Scribes Spurs Debate About Costs, Difficulties of Electronic Health Records


 

ILLUSTRATION/PAUL JUESTRICH; PHOTOs shutterstock.com
Image Credit: ILLUSTRATION/PAUL JUESTRICH; PHOTOs shutterstock.com

The hospitalists at six Illinois hospitals, physicians who are provided by Best Practices Inpatient Care, were grappling with some issues that might sound familiar to hospitalists around the country. The issues revolved around the electronic health record (EHR).

First, “it’s a pain,” says Jeffry Kreamer, MD, chief executive officer of Best Practices. The Long Grove, Ill.-based practice also wanted EHRs to include notes that were standardized, not limited by a template.

The big issue, however, was job satisfaction.

“Our docs are very smart people. If they would have wanted to do a clerical-type job, they would have done a clerical-type job,” Dr. Kreamer says. “They want to be doctors. They don’t want to be keyboardists.

“It makes no sense to take your most experienced asset, which is our physician, and then deploy them for a clerical task which can be done for a much lower cost.”

That’s where medical scribes come in. Scribes work as assistants to physicians and are responsible for entering information into the medical record with physician oversight. Scribes have a history that goes back a decade in emergency medicine, a setting in which doctors traditionally spend much more time in face-to-face contact with patients than they do in documenting the encounter.

Although scribe use in the emergency medicine and hospital medicine settings is growing, with supporters praising programs for boosting volume and allowing physicians to focus on patient care, not all attempts at using the scribe model of care have worked well. Some suggest scribes are a crutch for cumbersome EHRs and excessive administrative work that most doctors would prefer not to deal with.

Dr. Kreamer, however, says the majority of his scribe programs are tapping into a growing segment of the medical industry. There are now more than 15,000 scribes represented by the American College of Medical Scribe Specialists, and the numbers are increasing along a steep curve. There are still far more scribes working in EDs than alongside hospitalists, but as their track record in the inpatient setting lengthens, the number of inpatient scribes is likely to continue to grow.

Dr. Kreamer sensed that scribes would work as well in the inpatient setting as in the ED—maybe even better. He got in touch with the head of ScribeAmerica, the company that provides most of the scribes that work in U.S. hospitals.

ScribeAmerica had been providing scribes to hospitals for use in the inpatient setting, but in a limited way. With Dr. Kreamer’s input, the company developed a more elaborate plan to provide medical scribes for hospitalist programs.

Dr. Kreamer says scribes save his groups’ hospitalists a little more than 10 minutes per chart, or about three hours of productivity per day on a typical 18-patient census. There’s also less physician fatigue, and documentation is better, he adds.

Michael Murphy, MD, an emergency medicine physician by training and co-founder of ScribeAmerica, was introduced to the scribe concept when he was an undergraduate in California. He was asked to start a scribe program by a friend who was a physician and an attorney.

“The overwhelming benefit that I saw was that, A) Physicians were super-happy when they had a scribe,” says Dr. Murphy, now CEO of ScribeAmerica. “B) The patients were happy. The docs sat down and did different things,” allowing more interaction.

“We saw that huge benefit and said, ‘Why don’t we start this on a national level?’”

In 2004, ScribeAmerica was launched. It expanded to 32 hospitals through 2009. Since then, its client base has exploded to 610 hospitals.

Success Story

An early adopter of hospital medicine scribes was Rochester General. Researchers there performed a 10-month study evaluating length of stay of patients who were admitted using a “patient-centered admission team,” (PCAT), which included a scribe, a physician, a clinical pharmacist, two nurses, and a patient care technician.1 The team has a dedicated workspace near the ED and follows a standardized admission process—part of which involves the scribe entering history and exam findings into the system as the physician explains to the patient what he has found during the exam.

The process also involves the physician simultaneously completing orders while the pharmacist receives pertinent information from the patient, along with other pre-determined steps.

Researchers compared about 2,200 admissions done using this PCAT process and about 6,000 that didn’t use the process; results showed the average length of stay for the PCAT patients was 0.18 days less than the non-PCAT group.1

An analysis of lllinois hospitals in Dr. Kreamer’s Best Practices group found the use of scribes led to a dramatic increase in the case mix index (CMI), a measure of the level of complexity of care that relates to the reimbursements hospitals receive. In the first year using scribes, the CMI increased by 0.26, helping to boost revenue by tens of thousands of dollars, Dr. Murphy says.

The reason for the increase is that when scribes document in real time, the accuracy and detail on the care provided increase, Dr. Murphy says. With fewer omissions and clearer notes, CMIs show a greater level of care complexity. At a tertiary hospital in the Midwest, the CMI was 1.1 but should have been 1.7, Dr. Murphy explains.

Our docs are very smart people. If they would have wanted to do a clerical-type job, they would have done a clerical-type job. They want to be doctors. They don’t want to be keyboardists. —Jeffry Kreamer, MD

“These physicians are so busy and don’t really have an incentive to document,” Dr. Murphy adds. “They’re just surprised and shocked that, how could they be so inefficient, but they are.”

Scribes are typically pre-professionals, he says, who eventually become the next generation of doctors, nurses, physician assistants, and nurse practitioners. They receive three to four weeks of a mix of online, classroom, and hands-on clinical training. They also have a monthly continuing scribe education requirement.

Their schedules tend to match the schedules of the physicians with whom they work. Some are paid hourly, and some are salaried, he says.

Since the first hospitalist program was added to ScribeAmerica’s rolls, the number has grown to 40 programs.

“What a lot of hospitalist programs are doing is they’re saying, ‘Look, you can’t document for three hours by yourself. We just can’t afford that, because that means we have to have two to three extra docs on staff just to allow you to do what you’re doing,’” Dr. Murphy says, noting that scribes allow hospitalists “to document in sequence while you’re seeing the patients.”

Imperfect Solution

The use of scribes has not been a slam-dunk for every hospitalist program that has considered them, though. At TeamHealth, the national management firm that provides both emergency physicians and hospitalists, medical scribes have been used for years in EDs, and to great effect, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the acute care service division.

TeamHealth uses scribes from PhysAssist, which it now owns, along with a few other scribe providers.

“If we can allow our providers to spend more time with their patients and less time on paperwork and documentation, we can not only allow them to see more patients but spend more quality time at the bedside and less at the computer screen,” Dr. Gundersen says.

But when TeamHealth ran numbers to explore scribes in its hospitalist programs, they found that it likely doesn’t make sense in most markets.

“We have investigated several programs and pilots but have not been able to demonstrate a significant uptick in productivity to justify the costs of the scribes,” Dr. Gundersen explains. “That does not mean that scribes is not a workable model; it just requires a better review and adjustment of workflow. Our ED colleagues have had more time to deal with these adjustments and are able to demonstrate the necessary productivity changes.”

Scribes also would mean a fundamental shift in the function of a typical TeamHealth hospitalist, he says. Most studies show that hospitalists can spend less than a quarter of their time on direct patient care, and Dr. Gundersen says TeamHealth is actively working on new pilots and programs for implementing scribes.

The overwhelming benefit that I saw was that, A) Physicians were super-happy when they had a scribe. B) The patients were happy. The docs sat down and did different things, allowing more interaction. —Michael Murphy, MD

“There is an appetite from our physicians looking for the efficiency that we just haven’t seen before,” he says. “I think that is where we are going to see the program’s success. It must be embraced and driven from the providers.

“We are also facing physician shortages in several markets. Scribes have the potential to extend the current provider workforce and improve quality of life for our doctors.”

A well-run scribe program, he says, has the potential “to bring the provider back to the bedside and with the patient where they belong.”

Shifting Savings?

Kendall Rogers, MD, CPE, FACP, SFHM, chair of SHM’s Health IT Committee and associate professor and chief of the hospital medicine division at the University of New Mexico Health Sciences Center in Albuquerque, says he checked with colleagues at SHM and did not get much feedback on the use of scribes. His own center, he says, has “not even considered scribes.”

“I have not given it a lot of thought, though my initial impressions are if the EHR was better designed, there would be no need for scribes,” he says. “My hope would be to put our efforts there first. I think scribes are merely a coping mechanism for poorly designed documentation processes within existing EHRs.”

There are also some broader concerns about the potential effect of scribes on EHRs. In a recent op-ed in the Journal of the American Medical Association, a Texas physician sounded concerns that the use of scribes could stunt the evolution of better EHRs, since scribes can be used as a kind of workaround, lessening the demands for EHR improvements.2

There is an appetite from our physicians looking for the efficiency that we just haven’t seen before. I think that is where we are going to see the program’s success. It must be embraced and driven from the providers.—Jasen Gundersen, MD, MBA, CPE, SFHM

“Use of medical scribes to relieve physicians from using EHRs may limit this process by increasing physician acceptance of and satisfaction with an inferior product,” wrote George Gellert, MD, MPH, MPA, regional medical informatics officer at CHRISTUS Santa Rosa Health System in San Antonio.

Dr. Gellert wrote that while The Joint Commission prohibits scribes from performing computerized physician order entry (CPOE), an “unintended functional creep” could arise.

“Even physicians who understand that prohibition may, under pressure of a busy practice, ask a scribe to enter verbal orders,” he wrote, adding that this is something that can’t be monitored by the Joint Commission.

Dr. Murphy says those concerns are unfounded. In a response letter not yet published, he wrote, “Can you honestly believe that the small minority of providers who find EHR acceptable due to scribes are what is preventing EHR companies from making improvements? No, it is as a result of system and technology limitations.”

On scribes being used beyond their scope, Dr. Murphy says there will always be “‘bad actors’ willing to act outside of accepted industry norms; however, that does not mean that TJC [The Joint Commission] does not have control over the industry.”

SHM has not taken a position on the value or potential value of scribes in the inpatient setting.


Tom Collins is a freelance writer in South Florida.

With a Nod of the Head, a More Seamless Office Visit

In addition to boosting bottom lines, scribes make for more engaged—and happier—doctors, says Jeffry Kreamer, MD, who heads a company that runs six Illinois hospitals. Here’s how it works:

When the doctor meets with a patient during an office visit, a scribe is present.

With a slight nod of the head or other signal to the scribe that what he is about to say should be entered into the chart, the physician begins speaking to the patient: “My understanding is you’re feeling better today, but you’re still coughing,” the hospitalist might say. The scribe can then record that in the chart. An added benefit is that, at the same time, the patient gets confirmation that the doctor has heard what he has reported.

Then, as the exam goes on, the hospitalist might make comments such as, “Lungs clear,” and so on. The scribe can record these in real time as the exam is performed.

“It’s very hard to do critical thought and keyboard at the same time,” Dr. Kreamer says. “While the scribe is working on the chart, you can be talking to the patient.”

Dr. Kreamer says he’s been pleased with the way scribes have helped boost volume and at the same time allowed doctors to focus more on actual care, so much so that now he “couldn’t imagine practicing without it.

“It’s the greatest thing.”

References

  1. Bansal A, Bejerano RL, Cashimere CK, Polashenski WA, Jr. Reducing length of stay by using standardized admission process: retrospective analysis of 11,249 patients [abstract]. Society of Hospital Medicine Annual Meeting 2015. Accessed September 10, 2015.
  2. Gellert GA, Ramirez R, Webster SL. The rise of the medical scribe industry: implications for the advancement of electronic health records JAMA. 2015;313(13):1315-1316.
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