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
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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)