Medical Scribes: Salvation for Primary Care or Workaround for Poor EMR Usability?

Journal of General Internal Medicine, Jul 2016

Gordon D. Schiff MD, Laura Zucker MPH, MD

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Medical Scribes: Salvation for Primary Care or Workaround for Poor EMR Usability?

J Gen Intern Med EDITORIAL AND COMMENT Medical Scribes: Salvation for Primary Care or Workaround for Poor EMR Usability? Gordon D. Schiff 0 1 2 Laura Zucker 3 4 0 Department of Medicine, Harvard Medical School , Boston, MA , USA 1 Harvard Medical School Center for Primary Care , Boston, MA , USA 2 Brigham and Women's Hospital Center for Patient Safety Research and Practice , Boston, MA , USA 3 Mount Auburn Hospital department of Internal Medicine , Cambridge, MA , USA 4 Family Practice Group-Sagov Center for Family Medicine , Arlington, MA , USA - Yan et al. highlight challenges related to staffing and training of medical scribes. Should scribes be retrofitted MAs (medical assistants) versus pre-med (or nursing/physician assistant) students eager for a chance to spend time learning medical terminology and see “real” patients? The former raises serious challenges, documented in the study, about unrealistic expectations required in potentially doing two jobs at once; the latter, while a boon for enthusiastic health care provider aspirants, means that frequent turnover, disruptions in team continuity, and investments in training fresh crops of scribes will be the norm. Finding optimal balance of work responsibilities, cost effective staffing and training will remain a challenge. While initial fears of major detrimental impacts on exam room patient interactions and relationships appear to be allayed, there are many subtle ways the constant presence of a third person can affect medical encounters. Although all of these are not all necessarily bad (quotes we have heard at a recent workshop: “it keeps me honest, so I don’t document things I didn’t do”; “helps moves me along to keep up the pace of workflow”; “can look up things in the chart for me, quickly and easily” are all echoed in Yan’s interviews), many issues remain unaddressed (especially when the patient is undressed!). These, including gender, language, differences among the three parties, emotionally charged moments where patients break down and/or share intimate or stressful history, and the impact on the provider–patient–scribe relationship, are deserving of further study. TAKING CLINICIANS AWAY FROM THE EMR Liberating the physician from the EMR during the encounter is not only good; it is also a problem. Well-designed EMRs should be serving as a rich and helpful resource for directly supporting the clinical encounter and clinician’s cognitive work5—reminding the clinician about the patient, past problems, history and assessments, social history and issues, as well as overdue prevention and monitoring; otherwise the clinician has to rely on memory or the scribe searching and reading this information aloud during the encounter. Doctors and patients ought to be jointly navigating through electronic information, working collaboratively and viewing the computer screen together. While this should not necessarily preclude physicians creatively re-engineering office exam room design and processes to include scribes as part of the team, having a scribe in the middle of this can at times interfere with EMR interactive work flow, real-time clinician access to helpful information, and clinician interactions with clinical decision support messages.3 ENHANCING BILLING AND “UP-CODING” Helping to justify and capture higher reimbursement is another widely cited and documented benefit of scribes, but one that should not be accepted without more critical reflection. Here is another example of something that appears to be a plus when viewed narrowly as a way of increasing doctors’ productivity and revenue, but that needs to be considered in the context of societal goals for better and more efficient primary care. To what extent do knowledgeable scribes, who become experts at meeting billing documentation requirements, serve a socially useful function vs. mainly functioning to aid individual clinicians and practices in better gaming the system?6 On the other hand, one study from a cardiology clinic did suggest that additional revenue came mainly from increased productivity and “right coding” rather than inappropriate upcoding.7 Regardless, it is ironic that one of the consequences of EMRs, initially touted as a way to decrease medical costs, is to drive practices to bring on scribes whose documentation practices could be contributing to the overall cost of medical care. In their interviews, Yan et al. found a mix of comments regarding ways scribes can enhance or detract from note quality. What is a good note? This subject is only beginning to be defined, explored and measured in the literature. With electronic notes, now that legibility is no longer an issue, most of us can subjectively invoke qualities such as completeness, accuracy (including being free from copy-paste errors), organization, succinctness, and formatting as aspects that are important to us as we read others’ (and our own) notes. It is worth pondering and measuring how scribes might impact on each o (...truncated)


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Gordon D. Schiff MD, Laura Zucker MPH, MD. Medical Scribes: Salvation for Primary Care or Workaround for Poor EMR Usability?, Journal of General Internal Medicine, 2016, pp. 979-981, Volume 31, Issue 9, DOI: 10.1007/s11606-016-3788-x