When medical scribes first came to prominence, many in the healthcare community thought they would be a temporary solution. Scribes work alongside physicians and enter necessary information into the electronic medical record (EMR) while physicians work, relieving them of the burden of documentation. The thinking was that as physicians became accustomed to using EMRs they would need scribes less and be able complete the electronic clinical note by themselves. But as a recent Kaiser Health News article reported, six years after the passage of the HITECH Act ushering in widespread EMR implementation, the scribe community is stronger than ever. The American College of Medical Scribe Specialists says there are 20,000 scribes in the U.S. today, and projects the number will reach 100,000 by 2020.
Physician productivity and satisfaction driving a continued interest in scribes
The scribe movement continues to be strong because scribes markedly increase physician satisfaction and productivity. Many studies have documented the impact that the EMR – and its accompanying data entry burdens – have had on physician satisfaction. A landmark 2013 report on factors affecting physicians satisfaction noted, “for many physicians, the current state of EHR technology significantly worsened professional satisfaction in multiple ways.” Scribes enable physicians to bypass a laborious and tedious part of their job. Scribes can also increase the number of patients physicians see per day, especially for slow typers (the 15 or 20 minutes they take after the visit to complete documentation, can be instead used to see another patient). A 2013 study reported that scribes increased the number of patients physicians saw per hour by 60%.
Increased physician productivity and satisfaction are not insignificant upsides, especially in a time when nearly half of physicians are considering leaving medicine. But there are serious downsides to scribes as well. Most importantly, there is no mandatory licensing for scribes, so there’s no guarantee as to the quality of their documentation. In many cases, scribes have little-to-no clinical background. Compared to the threat of physician exits, the consequences of “average” documentation may seem trivial. But it’s worth taking a minute to understand what we are giving up when we accept “average” documentation.
The benefits of strong documentation: proving quality and enabling data analytics
First, complete and accurate documentation is an essential piece of executing on quality mandates over time, mandates which the implementation of the Affordable Care Act (ACA) and accompanying legislation have made more urgent and difficult. Only with a thorough patient health history can physicians provide targeted and individual care delivery. During the clinical encounter, a scribe may not hear something small a physician says; for example, that the patient has leg pain. This small piece may not be important for the treatment or coding of that day, but it may become relevant in the future. For example, continued leg pain could indicate rheumatoid arthritis. The physician would likely have known this, due to years of clinical training, but a scribe doesn’t have such attuned senses to what is important and not important about the encounter (other than getting a diagnosis code and prescription).
Second, strong documentation is the fuel for data and analytics solutions that will power the future of healthcare. Cognitive computing platforms, like Apixio’s Iris, will use the unstructured data in health care records to establish more evidenced care standards and enable strong care decision support. However, as they say in data science, ‘garbage in, garbage out.’ The value of these analytics are entirely dependent on the quality of the documentation data entering the system.
The long-term adoption of scribes was a good a short-term solution to the difficulties that came with EMR implementation. Still, as members of the healthcare community, we should think long and hard about whether we want this to become a permanent solution. Having physicians write their own notes is tiresome and difficult, but it’s also an essential part of accurately capturing the patient narrative and building the long-term infrastructure for quality care.