Digital Health Duct Tape: Medical Scribes for the EHR

Creativity is the friend of the desperate, and medical scribes are the answer overwhelmed providers are turning to—the latest digital health duct tape for broken systems in need of some care.

When it comes to “do no harm,” it seems the electronic health record (EHR) doesn’t always apply. A recent study revealed that its use is actually causing providers to lose time, and we know there have been a plethora of complaints about interoperability issues and cumbersome use.

In typical U.S.-healthcare-system-fashion, the proverbial tail is wagging the dog—since physicians are feeling the pressure to meet EHR implementation deadlines, or face stiff Medicare penalties if they don’t. With a heart for providers, even I’ve questioned whether all these requirements are misplaced.

These issues and more have exhausted providers shaking their heads—overwhelmed by growing demands most are unable to bear. Since necessity if the mother of invention, we shouldn’t be surprised that a new field has emerged in the wake of the weary—medical scribes to stay on their heels, observing every move and typing away.  

It’s the latest version of digital health duct tape, and reminds me of the creativity of the desperate—and the endless end-arounds I’ve witnessed throughout my career.

The Doctors’ Two Cents

The birth of medical scribes can be traced to the birth of EHR dissatisfaction. If the latter didn’t exist, the former wouldn’t either. According to a recent Deloitte survey, there are a whole range of emotions and opinions in the physician space regarding EHR use—but most responses just weren’t that pretty. 

Do you agree with this? EHRs Don't Save Money or Time, Docs Say http://t.co/R9aHY7jjHB

— Barbara C Phillips (@barbaraphillips) September 20, 2014

Although some tech-minded physicians have adopted digital health with excitement and ease, others cite a range of difficulties, frustrated by cumbersome input processes and a sad-but-ongoing lack of interoperability with other providers. 

Doctors Find Barriers to Sharing Digital Medical Records - New York Times - http://t.co/DYEjBzI8Cp

— Chris Van Gorder (@ChrisDVanGorder) October 1, 2014

This only adds to a doctor’s burden, which is significant and growing. A recent survey by The Physicians Foundation entitled, “2014 Survey of America’s Physicians: Practice Patterns and Perspectives” revealed that 81% of physicians say they’re either over-extended or at full capacity, with only 19% saying they have time to see more patients. It’s one of the reasons many physicians are turning to answers such as scribes—and others are packing their bags and heading for the door.  

Overwhelmed by patient load, many #doctors plan to cut back hours, services #healthcare #practicemanagmentnews http://t.co/ZnOPgrhCv3

— FiercePracticeMgt (@PracticeMgt) September 16, 2014

Enter the Scribe

The use of medical scribes has been gaining momentum for some time—as reflected in the Joint Commission’s guidelines for use of scribes issued in 2012, which defines a scribe as “an unlicensed individual hired to enter information into the electronic health record (EHR) or chart at the direction of a physician or licensed independent practitioner.”

According to a practice brief by the American Health Information Management Association (AHIMA), a scribe’s core responsibility is to “capture accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter in a timely manner.” The brief further describes a variety of issues that must be addressed, including:

• Legal considerations
• Documentation and training guidelines
• Costs
• Benefits
• Workflow challenges
• Management and monitoring of scribes
• Monitoring scribe education and qualification
• Recommended scribe practices

Some Physicians Love Scribes

Many physicians feel that medical scribes help improve efficiency and improve their own quality of life.

Lauren Silverman of NPR recently reported on one specific instance of medical scribe use by an orthopedic surgeon, who says that it has helped him to focus more on patient care, and achieve more balance with his work.

“I was really focused on just trying to get the information in, and not really focusing on the patient anymore…I would happily sacrifice a significant chunk of my income for the improved quality of life I have.”

Dr. Devesh Ramnath

Some Physicians Don’t

But some physicians don’t think scribes are a good idea, citing privacy issues for patients as well as number of other concerns. Burke Mamlin, MD, is one of them.

An Associate Professor of Clinical Medicine at Indiana University’s School of Medicine and co-founder of the Regenstrief Institute, Mamlin sees the role of the scribe through a lens filled with potential drawbacks:

• “The frequency of documentation and medical errors could increase as scribes do the active entry and physicians passively review their input later.
• We miss critical opportunities for clinical decision support, where the computer can help guide the physician to more effective, safe and less expensive care.
• Physicians can become dependent on a scribe. If the scribe is unavailable, the physician cannot effectively use the medical record.”

Dr. Art Caplan, of the Division of Medical Ethics at the New York University Langone Medical Center in New York City, has his own concerns as well. 

Source: YouTube, Uploaded by Medscape

And then there are stories from the scribe front lines that’ll make a clinician cringe—like those in this anonymous post, “The Disturbing Confessions of a Medical Scribe.”

The word “confession” in a healthcare title always catches my eye.

Apparently functionalities within the EHR which link to more lucrative billing codes, and macros that auto-populate care rendered are too tempting for some docs to pass up—and low-on-the-totem-pole scribes are sometimes directed to click and not ask, whether the service was provided or not.  

Since there are documented concerns about billing fraud associated with the EHR, our anonymous scribe seems to be right on the mark.

Delegate at Your Own Risk

It’s not as if there aren’t enough legal landmines lacing the EHR, without adding the risk of delegating documentation to someone else.

Medscape’s recent clinician-beware article entitled “8 Malpractice Dangers in Your EHR” is a perfect example. Included in the list? A number of things that could potentially get worse through the use of a scribe:

• Liability for what’s in the record—how closely is it actually reviewed?
• Copying and Pasting Text—ugh.
• Ignoring Clinical Decision Support— if the doctor isn’t in the record, how can she see the alert?
• Using an EHR in Nonstandard Ways—that seems to fit.
• Legal Consequences of Input Errors—no matter who types, the doctor is still liable.

The bottom line? The physician is legally responsible for the contents entered into the EHR while he or she is providing care—whether that be by the tap of their fingers, or those of someone else.

Since a recent article in the Ava Maria Law Review said that EHRs aren’t reliable enough to stand the muster of court, clinicians should be aware of the outcomes of their input—whether it’s something they enter, or by a scribe in their stead. 

#EHRs too inauthentic to be relied on in court via @UCCharting http://t.co/aGwc4jzbX1 #healthlaw #digitalhealth

— Adrian Adewunmi Ph.D (@AdrianAdewunmi) September 27, 2014

Hope on the Horizon?

In a recent Health IT News article, Mike Miliard provides a comprehensive summary of the future of the EHR—where current struggles will be a thing-of-the-past, and supercharged functionality reins. Citing John Halamka, MD, the CIO at Boston’s Beth Israel Deaconess Medical Center, Miliard notes that the successes we have now are merely a foreshadowing of great things to come.

#HITBriefing @JHalamka "EHRs are bi-planes, not yet jet aircraft" ... on the road (or in the sky) , patient access still lags :(

— Ted Eytan, MD (@tedeytan) August 7, 2014

We can only hope to trade in our biplanes for jet engines soon, since the digital health duct tape of medical scribes is merely that—a bandage for broken systems that hinder-not-help, and providers who are looking for answers other than the nearest exit door.