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Documenting Better in the New Healthcare

February 26, 2015
by Gabriel Perna
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David Goldman, D.O. a medical director for an emergency medicine department within Florida Hospital, a not-for-profit health system with 22 campuses throughout the Sunshine State, went a lot farther than most providers do when they invest in a health IT system.

He took a leap of faith.

In 2008, before the American Recovery and Reinvestment Act (ARRA) made meaningful adoption of electronic health records (EHRs) mandatory through the Health Information Technology for Economic and Clinical Health (HITECH) Act, which raised requirements for the level of documentation to unforeseen levels of intensity, the idea of having a documentation scribe was practically unprecedented. Dr. Goldman not only bought into the idea of having someone document for a practitioner, he lent ScribeAmerica, a Fort Lauderdale, Fla.-based company that does this, money during its earliest days.

“With Cerner coming to Florida Hospital, we figured EHR was coming within a year. We had heard about Scribe, but it wasn’t as mainstream as it is now. In 2008, it wasn’t even a hunch. We wanted them to come, but they needed money just to come out and do the gig. We lent them money to come out,” Goldman says.

Today, the company and industry is booming. According to data published in an article in the Journal of American Medical Association (JAMA), there were 20,000 scribes working by the end of last year. By 2020, the profession will swell to 100,000.

The ironic thing is that Goldman’s facility is still in the process of implementing an EHR. Yet, he says the scribes work for electronic or paper records, especially in an environment where physicians are pressed for time and face-to-face interactions with patients is almost an afterthought.

“They’re putting the information down. They’re keeping you focused. It improves efficiency, productivity, and the patient experience,” he says. More than just documenting, the scribes can assist with lab metric levels or help with continuity of care efforts by referring them to the right person.

Even though the scribe is supposed to be the mostly silent sidekick—sitting in the far corner of the room— their presence can be cause for pause. Some patients, Goldman notes, will ask them to leave for privacy reasons. The problem isn’t widespread though and in his hospital, people have gotten used to them.

Having those extra set of eyes can help deter medication errors. Since HITECH was enacted, the role EHRs have played in preventing or adding to medical errors has been a hotly debated topic. In an article in US News promoting a study, Clement McDonald, M.D. lead author of the study and director of the NLM Lister Hill National Center for Biomedical Communications, outlined how many people in the medical field view EHRs: “It simply takes longer [to enter patient information into a computer].” This long time, along with the fact that practitioners are crunched for time, means the potential for typos and errors.

Despite this, the use of scribes remains controversial in some corners of the industry. Some have expressed concern scribes will slow the advancement of EHR systems while adding an unnecessary person to the equation. The Centers for Medicare and Medicaid Services (CMS) prohibits scribes from entering medication orders electronically, worried that the process removes clinical eyes from clinical decision support.

Scribes go through rigorous training and evaluation before they’re partnered with a doctor, says Goldman, who confirms they do not fill out medication orders. He notes that the computer is never going to inform the doctor when he’s made an obvious mistake, documenting on the wrong part or something for the wrong patient, whereas a Scribe will. “That’s not something I want to brag about but it definitely happens,” he says.

Goldman isn’t afraid to say what many in healthcare are thinking: current electronic health record (EHR) systems just aren’t that intuitive for doctors. “It’s a computer system with a lot of clicks,” he says. “It cripples and your ability to be as efficient. I’m a productive guy. In a nine hour day, I could probably see 20-30 patients. With an EMR and no scribe, I’d be on the low end. That’s not sustainable.”

Maybe that will change in the future but for now, he is ascribing to the scribe mentality.