Two recent studies are shedding light on an important phenomenon in U.S. healthcare—the growing use by physicians in clinical practice, of medical scribes—and the issues around scribe use. Most medical scribes are medical students who are hired by physicians working in their offices and clinics, with the employment of those scribes designed to alleviate some of the documentation burden that is adding significantly to physicians’ workdays—and to their stress.
The two studies—one whose results were published this summer, and the other whose results were published earlier this month—underscore important concerns around the use of scribes. They were executed by Oregon Health & Science University (OHSU). The first study, done in collaboration with The Doctors Company (based in Napa, Calif.), the nation’s largest physician-owned medical malpractice insurer, revealed a lack of standardized training, and variability in experience among scribes, posing major risks to data accuracy and delivery of care.
Further, the first study, based on a survey of 355 physicians, found that:
> 44 percent of scribes have had no prior experience.
> Only 55 percent of scribes are trained by the doctor.
> Only 22 percent of scribes have had any form of certification.
> Around 24 percent of practices that use scribes hire them as employees.
> Nearly 13 percent of practices use scribe staffing agencies.
Meanwhile the second study, published under the title “Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study” in the publication JMIR Medical Informatics, involved the video-recording of the work of five scribes, all of whom had at least six months’ work experience working inside electronic health records (EHRs), and whose work transcribing an identical simulated physician-patient encounter was studied. That study found that “There was significant interscribe variability in note structure and content. Overall, only 26 percent of all data elements were unique to the scribe writing them,” the study found. What’s more, it found that, “Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%.”
The lead author of both studies is Jeffrey A. Gold, M.D., a critical care pulmonologist practicing at Oregon Health & Sciences University, in Portland, Ore., and a researcher.
Healthcare Informatics Editor-in-Chief Mark Hagland spoke with Dr. Gold twice about the implications of the two studies, as well as about the broader questions around the use of medical scribes in U.S. healthcare—first after the publication of the first study; and again, after the publication of the second study. Below are excerpts from those two interviews.
Dr. Gold, one broad question that comes to mind is whether there are any formal mechanisms for certifying medical scribes.
It’s really interesting; scribes fall into two categories. Medical students and others, who work full-time as scribes. Then there are people who work part-time as scribes, MAs and Pas [medical assistants and physician assistants]. And there are scribe service companies that certify them, and a lot of people don’t like to go through those companies. One company that does certify its scribes is ScribeAmerica, which requires that individuals go through 40 hours of online training, combined with 200 hours of work in practice. And there’s really no national set of guidelines over what scribes should be doing; it’s all over the place.
How does this strike you as a physician?
If I were a physician in clinic, I would say, I can’t keep up anyway, so at least I can be happy at work. That’s how the average physician feels about it, and rightfully so. EHRs are the single biggest cause of burnout, and anything you can do to untether physicians from the EHR will improve their satisfaction. But as a health IT safety person—the problem is that nobody knows how to use the EHR well at all. Every professional group studied has trouble using the EHR. And the trouble is that they’re the ones doing the training. It really is a challenge that most scribes have no significant medical knowledge at all.
And if you believe the literature, which finds that there is a big problem with selective data-gathering or selective data-processing—meaning that you don’t collect all the information, or it is incomplete or incorrect—then, theoretically, that phenomenon is contributing to delayed or incorrect diagnoses. That means that adding a middle-person into the process, to get the information in, or out, adds latent patient safety issues, especially if the people aren’t trained. If a scribe were just a pure Dictaphone—if all they do is regurgitate exactly, like a court stenographer, then that’s probably not a major issue; but as soon as the scribes are interpreting what’s going on, or are asked to find information or help physicians navigate the EHR—well, we know from our previous research that physicians themselves struggle to navigate the EHR. In addition, it’s the ones who struggle with navigating the EHR who turn to scribes, which is like asking a blind person to drive and to teach you how to drive. And that’s what scares me the most.
So what’s the high-level solution to this?
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