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Drilling Down into Important Issues Around the Use of Medical Scribes

October 15, 2017
by Mark Hagland
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Two recent studies are shedding light on some of the challenges inherent in the growing use of medical scribes by physicians in medical practice

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.


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>  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.

[first interview]



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?

I think there are a few solutions to this. One is that there needs to be more specialty-specific, context-specific, training for the scribes. Second, there needs to be training for physicians on how to use and train scribes. Most physicians aren’t teachers. And if you’re going to be responsible for training a scribe…

But doctors don’t have the time to take courses to train scribes, correct?

We’re about to get a five-year grant from AHRQ [the federal Agency for Healthcare Research and Quality] to create an all-encompassing training program, one that is video-based, for scribes. It would video-based training, and a grading sheet at the end. I’ve applied for the grant; that’s in the public record.

How do you see this evolving over the next few years?

I don’t know. Some people believe that the EHRs will get useful enough that we will no longer need scribes in five to ten years; that the EHR vendors will take into account usability and workflow so that scribes become superfluous. I don’t think that’s true; I think as scribes become more and more prevalent, that the EHR vendors will give up on their efforts, because we will have found that workaround through this. The biggest problem with electronic health records is that we have taken our workflow in medicine, based on a paper-based workflow, and assumed that introducing a computer into the process wouldn’t change things. But the reality is that adding computerization into this, and then assuming that you can do the same number of things in the same amount of time, is ludicrous. The real answer would be to make patient visits longer, but that’s impossible because of payment and reimbursement issues.

So one thing we want to look at is, how much are scribe notes proofread and looked at by the physicians? The idea is that scribes are useful because they’re doing the inputting and the physician doesn’t need to be involved in the computer. The thing is, if the physician never looks at the notes, that’s a patient safety problem. On the other hand, if the physician has to spend two hours reviewing the scribe’s notes, then that actually will make the problem worse.

The issue with scribes is that there are multiple competing issues around why scribes exist in the first place. Some say physician notes already are not accurate. The question is whether there’s anyone arguing for patient safety, with regard to completeness of notes and completeness of billing within the notes.

[second interview]

Looking at the results of this second study, Dr. Gold, clearly, you found tremendous variability in note structure and content, correct?

Yes, that’s right. We don’t know how significant that is. It’s no different from physicians; five physicians recording the same patient encounter would describe things differently. Point number one is that scribes themselves are not like court stenographers; that’s the first thing. Some things might be described differently, and some things might not even make it into the note. And as an attending, you can’t just have someone write the note, and keep going. The physician will still end up being responsible. I think the most powerful thing here is that while there is value in scribes—and they are valuable, because physicians are getting burned out on documentation—scribes tend also to write things more consistently. And now, through a proof-of-concept study, we’ve been able to demonstrate that you can assess how good a scribe is at communicating what happened in an encounter, and can then improve it.

And not 100 percent of what happens in a visit is communicated in a note. And why is that? One element is when scribes just can’t keep up, and some random filtering occurs. Why would that be? One, the conversation may go to quickly; two, the EHR may be slowing down the scribe, just as it slows the physician down; and third, maybe the scribe just can’t type fast enough—maybe the scribe is just a terrible typist. You’d assume they could type well, just as you’d assume a taxi driver knows how to driver, right? But if scribes either are not good for any of those reasons, or because of the unique templates of a clinic—for whatever reason they can’t keep up—lack of medical knowledge or terminology, or whatever—that means that information is being filtered out.

When you’re a physician, you understand things based on your medical knowledge. And for the scribe, that filtering is not going to be determined based on medical knowledge, but based on random reasons. So this allows us to assess, and therefore, improve, how scribes perform. And this also allows you to see—with the grant we’re going to do, eventually, you’re going to be able to say, as a provider, I’ve had my scribes do these exercises, and I was able to see where their weaknesses were. To assume every scribe is perfect, is ludicrous, and to assume that they are all the same, is also ludicrous.

What would you say to laypeople who might be discomfited by the idea of non-perfect scribes being used?

What I would say is that, until the EHR gets better or our structure for how we see patients gets better, this may make things safer in the meantime. And so I would ask, how does your doctor do things now? They’re either typing into the computer all the time and trying to multitask. Or they would say, I don’t know when they do their documentation. And I would say, they’re doing it after you’ve left. And how much do they actually remember later on? The fact is that the physician is talking and documenting and thinking, and trying to process information at the same time, or documenting after the fact. And one could argue that a natural filtering takes place that actually is useful; that would be great if that filter happened right after the patient left the room. But the reality is that a lot of the documentation is actually not happening until the end of the day, after the physician has seen 20 patients.

So this is a case where it may not necessarily be making things more dangerous at all; it may just be shifting the error from one professional group to another. And because we have a professional group that has a singular role, to interface with the EHR, that it becomes easier to train for one purpose than to train a physician, who has to be trained on documentation, on meaningful use, on outcomes, on everything else. So if a person only needs to be trained on one thing, that’s an advantage. However, the problem is, that sounds all fine and dandy when we say, look, here’s someone who has only one job, to interface the EHR. However, we know that EHR training has never been great to begin with. And with this group, we need it more than ever, because that’s the only thing they do.

So I would argue that it can be made to be just as safe, if done the right way. The real issues will be things like, one, it’s a transient workforce, that’s a real problem. A large number of scribes are kids going to medical school, so they’re only doing it for a year. And it’s difficult to invest in people knowing you’ll only have them for a year, or for two at most. The second thing is that physicians are always going to have to be worried, as we do more and more coding of diagnoses. If the scribe is just writing the note, that’s one thing. The issue will be if scribes are also expanding and modifying the problem list, and are ordering tests and associating those tests with diagnoses, then the physician is also responsible for things that could potentially be billing fraud or other issues.

What will the landscape around this be like five years from now?

I honestly don’t know. Here’s the thing: if you’re an EHR vendor, you’re supposed to improve billing effectiveness, efficiency, clinical outcomes, everything. And I’m not sure what the vendors’ interest will be to dramatically change processes, if a workaround is already in place. So if you’re one of the biggest vendors, and you say, well, they’ve figured it out with scribes anyway; and the reality is that you go to the issues that are the most pressing need. And you have this ready supply of medical students. So I’m not sure scribes will go away. But when we look at EHR use, it’s not just efficient use, it’s also effective use.

And it’s not just about whether you can get through your day as quickly as possible, but whether you’re making good clinical decisions, and that’s based on what tests you order, and other considerations. And I do not believe for one second that when HER vendors created their products, that they intentionally created things that they thought would result in patient harm. I think they truly are trying to do the best job they can. The problem is not a lack of good intentions, but a lack of good processes.

This is about patient care scenarios that happen to involve the EHR. So it’s got to be patient-centric. And the problem now is that everybody and their brother is going to be creating their own patient-facing app. So if you don’t like the testing that the vendors are doing, what about the app developer at some random think tank or vendor out in La Jolla? So the elephant in the room is that what we need are standardized means for assessing whether we can deliver safe, efficient, and effective care for patients, using electronic devices. And this paper and our grant started with a focus on patient interaction, and can you improve that process? It’s not EHR-centric, it’s patient care-centric. So we need everyone to take care of complex patients across all specialties and professional groups, and make sure you don’t affect efficiency, but also that you don’t affect patient care.

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Allscripts Sells its Netsmart Stake to GI Partners, TA Associates

December 10, 2018
by Rajiv Leventhal, Managing Editor
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Just a few months after Allscripts said it would be selling its majority stake in Netsmart, the health IT company announced today that private equity firm GI Partners, along with TA Associates, will be acquiring the stake held in Netsmart.

In 2016 Allscripts acquired Kansas City-based Netsmart for $950 million in a joint venture with middle-market private equity firm GI Partners, with Allscripts controlling 51 percent of the company. With that deal, Allscripts contributed its homecare business to Netsmart, in exchange for the largest ownership stake in the company which has now become the largest technology company exclusively dedicated to behavioral health, human services and post-acute care, officials have noted.

Now, this transaction represents an additional investment for GI Partners over its initial stake acquired in April 2016, and results in majority ownership of Netsmart by GI Partners.

According to reports, it is expected that this sale transaction will yield Allscripts net after-tax proceeds of approximately $525 million or approximately $3 per fully diluted share.

Founded 50 years ago, Netsmart is a provider of software and technology solutions designed especially for the health and human services and post-acute sectors, enabling mission-critical clinical and business processes including electronic health records (EHRs), population health, billing, analytics and health information exchange, its officials say.

According to the company’s executives, “Since GI Partners' investment in 2016, Netsmart has experienced considerable growth through product innovation and multiple strategic acquisitions. During this time, Netsmart launched myUnity, [a] multi-tenant SaaS platform serving the entire post-acute care continuum, and successfully completed strategic acquisitions in human services and post-acute care technology. Over the same period, Netsmart has added 150,000 users and over 5,000 organizations to its platform.”

On the 2018 Healthcare Informatics 100, a list of the top 100 health IT vendors in the U.S. by revenue, Allscripts ranked 10th with a self-reported health IT revenue of $1.8 billion. Netsmart, meanwhile, ranked 44th with a self-reported revenue of $319 million.

According to reports, Allscripts plans to use the net after-tax proceeds to repay long-term debt, invest in other growing areas of its business, and to opportunistically repurchase its outstanding common stock.

The transaction is expected to be completed this month.

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Study Links Stress from Using EHRs to Physician Burnout

December 7, 2018
by Heather Landi, Associate Editor
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More than a third of primary care physicians reported all three measures of EHR-related stress
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Physician burnout continues to be a significant issue in the healthcare and healthcare IT industries, and at the same time, electronic health records (EHRs) are consistently cited as a top burnout factor for physicians.

A commonly referenced study published in the Annals of Internal Medicine in 2016 found that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day.

Findings from a new study published this week in the Journal of the American Medical Informatics Association indicates that stress from using EHRs is associated with burnout, particularly for primary care doctors, such as pediatricians, family medicine physicians and general internists.

Common causes of EHR-related stress include too little time for documentation, time spent at home managing records and EHR user interfaces that are not intuitive to the physicians who use them, according to the study, based on responses from 4,200 practicing physicians.

“You don't want your doctor to be burned out or frustrated by the technology that stands between you and them,” Rebekah Gardner, M.D., an associate professor of medicine at Brown University's Warren Alpert Medical School, and lead author of the study, said in a statement. “In this paper, we show that EHR stress is associated with burnout, even after controlling for a lot of different demographic and practice characteristics. Quantitatively, physicians who have identified these stressors are more likely to be burned out than physicians who haven't."

The Rhode Island Department of Health surveys practicing physicians in Rhode Island every two years about how they use health information technology, as part of a legislative mandate to publicly report health care quality data. In 2017, the research team included questions about health information technology-related stress and specifically EHR-related stress.

Of the almost 4,200 practicing physicians in the state, 43 percent responded, and the respondents were representative of the overall population. Almost all of the doctors used EHRs (91 percent) and of these, 70 percent reported at least one measure of EHR-related stress.

Measures included agreeing that EHRs add to the frustration of their day, spending moderate to excessive amounts of time on EHRs while they were at home and reporting insufficient time for documentation while at work.

Many prior studies have looked into the factors that contribute to burnout in health care, Gardner said. Besides health information technology, these factors include chaotic work environments, productivity pressures, lack of autonomy and a misalignment between the doctors' values and the values they perceive the leaders of their organizations hold.

Prior research has shown that patients of burned-out physicians experience more errors and unnecessary tests, said Gardner, who also is a senior medical scientist at Healthcentric Advisors.

In this latest study, researchers found that doctors with insufficient time for documentation while at work had 2.8 times the odds of burnout symptoms compared to doctors without that pressure. The other two measures had roughly twice the odds of burnout symptoms.

The researchers also found that EHR-related stress is dependent on the physician's specialty.

More than a third of primary care physicians reported all three measures of EHR-related stress -- including general internists (39.5 percent), family medicine physicians (37 percent) and pediatricians (33.6 percent). Many dermatologists (36.4 percent) also reported all three measures of EHR-related stress.

On the other hand, less than 10 percent of anesthesiologists, radiologists and hospital medicine specialists reported all three measures of EHR-related stress.

While family medicine physicians (35.7 percent) and dermatologists (34.6 percent) reported the highest levels of burnout, in keeping with their high levels of EHR-related stress, hospital medicine specialists came in third at 30.8 percent. Gardner suspects that other factors, such as a chaotic work environment, contribute to their rates of burnout.

"To me, it's a signal to health care organizations that if they're going to 'fix' burnout, one solution is not going to work for all physicians in their organization," Gardner said. "They need to look at the physicians by specialty and make sure that if they are looking for a technology-related solution, then that's really the problem in their group."

However, for those doctors who do have a lot of EHR-related stress, health care administrators could work to streamline the documentation expectations or adopt policies where work-related email and EHR access is discouraged during vacation, Gardner said.

Making the user interface for EHRs more intuitive could address some stress, Gardner noted; however, when the research team analyzed the results by the three most common EHR systems in the state, none of them were associated with increased burnout.

Earlier research found that using medical scribes was associated with lower rates of burnout, but this study did not confirm that association. In the paper, the study authors suggest that perhaps medical scribes address the burden of documentation, but not other time-consuming EHR tasks such as inbox management.


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HHS Studying Modernization of Indian Health Services’ IT Platform

November 29, 2018
by David Raths, Contributing Editor
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Options include updating the Resource and Patient Management System technology stack or acquiring commercial solutions

With so much focus on the modernization of health IT systems at the Veteran’s Administration and Department of Defense, there has been less attention paid to decisions that have to be made about IT systems in the Indian Health Service. But now the HHS Office of the Chief Technology Officer has funded a one-year project to study IHS’ options.

The study will explore options for modernizing IHS’ solutions, either by updating the Resource and Patient Management System (RPMS) technology stack, acquiring commercial off-the-shelf (COTS) solutions, or a combination of the two. One of the people involved in the analysis is Theresa Cullen, M.D., M.S., associate director of global health informatics at the Regenstrief Institute. Perhaps no one has more experience or a better perspective on RPMS than Dr. Cullen, who served as the CIO for Indian Health Service and as the Chief Medical Information Officer for the Veterans Health Administration

During a webinar put on by the Open Source Electronic Health Record Alliance (OSEHERA), Dr. Cullen described the scope of the project. “The goal is to look at the current state of RPMS EHR and other components with an eye to modernization. Can it be modernized to meet the near term and future needs of communities served by IHS? We are engaged with tribally operated and urban sites. Whatever decisions or recommendations are made will include their voice.”

The size and complexity of the IHS highlights the importance of the technology decision. It provides direct and purchased care to American Indian and Alaska Native people (2.2 million lives) from 573 federally recognized tribes in 37 states. Its budget was $5.5 billion for fiscal 2018 appropriations, plus third-party collections of $1.02 billion at IHS sites in fiscal 2017. The IHS also faces considerable cost constraints, Dr. Cullen noted, adding that by comparison that the VA’s population is four times greater but its budget is 15 times greater.

RPMS, created in 1984, is in use at all of IHS’ federally operated facilities, as well as most tribally operated and urban Indian health programs. It has more than 100 components, including clinical, practice management and administrative applications.


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About 20 to 30 percent of RPMS code originates in the VA’s VistA. Many VA applications (Laboratory, Pharmacy) have been extensively modified to meet IHS requirements. But Dr. Cullen mentioned that IHS has developed numerous applications independently of VA to address IHS-specific mission and business needs (child health, public/population health, revenue cycle).

Because the VA announced in 2017 it would sundown VistA and transition to Cerner, the assessment team is working under the assumption that the IHS has only about 10 years to figure out what it will do about the parts of RPMS that still derive from VistA. And RPMS, like VistA, resides in an architecture that is growing outdated.

The committee is setting up a community of practice to allow stakeholders to share technology needs, best practices and ways forward. One question is how to define modernization and how IHS can get there. The idea is to assess the potential for the existing capabilities developed for the needs of Indian country over the past few decades to be brought into a modern technology architecture. The technology assessment limited to RPMS, Dr. Cullen noted. “We are not looking at COTS [commercial off the shelf] products or open source. We are assessing the potential for existing capabilities to be brought into “a modern technology architecture.”

Part of the webinar involved asking attendees for their ideas for what a modernized technology stack for RPMS would look like, what development and transitional challenges could be expected, and any comparable efforts that could inform the work of the technical assessment team.




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