Fast-growing medical scribe industry poses risks to patients, and to product design

Soon there will be one scribe for every seven doctors. What will that mean for EHRs?
By Mike Miliard
09:35 PM

LAS VEGAS – As electronic health records have proliferated in recent years, so has the use of medical scribes. That's an unwelcome development for two big reasons, said two chief medical information officers at HIMSS16 on Wednesday: patient safety and EHR usability.

Scribes are unlicensed individuals hired and trained to enter clinical information into EHRs at the direction of physician. The scribe industry has grown quickly since HITECH Act spurred massive EHR adoption.

More than 20 companies provide scribe services in 44 states, according to data provided by S. Luke Webster, MD, system CMIO at CHRISTUS Health, and his colleague, George Gellert, MD, associate system CMIO. A tally in 2014 estimated that 10,000 scribes were working in the U.S. That number is doubling annually, with more than 20,000 expected this year.

Within six years, they said, there will be one scribe for every seven physicians in the U.S.

Why the explosive growth in this unregulated industry? “It's a reaction,” said Webster, "to what most of us as clinicians see as inadequate usability" of EHRs.

[Also: Do medical scribes defeat the purpose of EMRs?]

From that perspective, he said, he understood the desire of physicians to get help with the voluminous documentation that many say has turned them from "clinicians into clerks."

"Dissatisfaction with EHRs has been immense," added Gellert. "Understandably, physicians are looking for release."

No question, meaningful use has caused docs to have to spend much more time with their EHRs. Those who use scribes to help share the burden of data entry report workflow improvements, productivity gains, increases in patient satisfaction scores and better profit margins.

But the safety risks are easy to see, said Webster.

While each company sets its own hiring and training criteria, the most basic requirement for scribes is a high school diploma or GED. Many are college students. Often their "orientation and training very brief," he said.

Compared to doctors and nurses, most scribes have "extremely finite or no clinical experience," said Gellert.

"It's very troubling to us that we are interjecting a third-party individual, with minimal education and minimal training, into a sacred and risky clinical process that is rife with potential error of omission or commission, without much in the way of background training or regulation," said Webster.

[Also: See photos from Day 2 of HIMSS16]

But Gellert has another reason for strong opposition to scribes. If the rise of this industry is directly predicated on suboptimal EHRs, he worries that the more established and widespread it becomes, the less incentive vendors will have to innovate and improve their products.

Here at HIMSS16, it's apparent that many EHRs are already much better-designed and more intuitive than they were even a few years ago, he said. Market pressure and complaints from clinicians are working: "Customer dissatisfaction is driving improvements in EHR products."

On the other hand, "if you insert a scribe permanently between the physician and the EHR, and the physician totally disengages from using the EHR, you are going to have a significant deceleration of technological advancement because there's no market pressure," he said.

CHRISTUS Health offers an object lesson in what can happen when clinicians communicate their UX concerns to their technology providers. Gellert and Webster enlisted their physicians for regular meetings dedicated to improving EHR usability – soliciting their ideas, requests and recommendations and then relaying those to their EHR vendor.

We "captured every single physician complaint," he said. It wasn't long before the vendor released a next-generation version of the EHR with hugely improved usability. In fact, 80 to 85 percent of the clinical suggestions were included in new product.

Twitter: @MikeMiliardHITN

This story is part of our ongoing coverage of the HIMSS16 conference. Follow our live blog for real-time updates, and visit Destination HIMSS16 for a full rundown of our reporting from the show. For a selection of some of the best social media posts of the show, visit our Trending at #HIMSS16 hub.

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