Should You Subscribe to the Scribe? Embracing the Importance of the Medical Scribe in the Era of Electronic Health Records

Kaitlyn N. Pytlak Flaherty Sensabaugh Bonasso PLLC, Charleston, WV

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Introduction

What will it take for you to subscribe to the medical scribe? Currently, more than half of

all physicians in the United States are experiencing burnout related to work—and the number

one culprit is the electronic health record (“EHR”).1 According to a 2016 journal article

published in the Annals of Internal Medicine, two or more hours are spent documenting in the

EHR for each hour spent with patients.2 Over the years, many physicians and hospitals have tried to combat this issue by hiring more mid-level practitioners such as nurse anesthetists, physician’s assistants, and nurse practitioners. However, mid-level practitioners come with a hefty price tag.

For example, in West Virginia, the annual mean wage for a certified nurse anesthetist is

$176,110.3 Not only is the expense an issue, but also the misallocation of resources. Hiring mid-

level practitioners may help with the division of patient-related responsibilities, but the

documentation and charting is still a timely task.

Recently, in the past twenty years, a new solution has taken off—the medical scribe.

“Medical scribes offer an innovative approach to the challenge of providing patient care while simultaneously documenting the care in the medical record. These individuals sit in on patient

1 Amelia Sattler, MD et al., One Year of Family Physicians’ Observations on Working with Medical Scribes, 31 J. AM. BD. OF FAM. MED. 1 (2018). 2 Sinsky C. et al., Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties, 165 ANN. INTERN. MED. 753, n. 6 (2016). 3 Occupational Employment and Wages, May 2016 Nurse Anesthetists, BUREAU OF LAB. STATISTICS, https://www. bls.gov/oes/current/oes291151.htm#st (last visited March 12, 2018). 1

consultations and input information into the record for physicians.”4 At the end of 2014, there were approximately 7,000 medical scribes in practice.5 By 2016, there were approximately

17,000, and by 2020, it is estimated that 100,000 scribes will be working throughout the

country.6 The transition to electronic medical records has proved to be a grueling evolution, and

while electronic records have improved some of the pitfalls, it has also created new ones.

Currently, many healthcare facilities are stuck in a hybrid system where some records are stored

electronically, while other records continue to be filed away in hard copy. During this transition,

focusing on keeping accurate and well-documented medical records is more important than

ever.7 As such, health care providers—including both facilities and private physicians—should consider how a medical scribe could improve their practice.

From Egypt with Love: The History and Evolution of the Modern Scribe

The history of today’s medical scribe can be traced back to the scribes of Ancient Egypt

as far back as 3400 BCE.8 Due to the rampant rates of illiteracy among the Egyptians,

individuals who could read and write were considered to be in the upper echelons of society.

Scribes were educated at a specific school dedicated to learning to reading and writing

hieroglyphics and hieratic script. “Hieratic was written on papyrus or ostraca and practiced on

stone and wood. It developed into a cursive script around 800 BCE (known as 'abnormal

4 Medical Scribes: An Increasing Reality, CAN. MED. PROTECTIVE ASS’N, (February 2018), https://www.cmpa- acpm.ca/en/advice-publications/browse-articles/2018/medical-scribes-an-increasing-reality. 5 Melissa Bailey, The Pay is Low, the Typing Nonstop, But the Medical Scribe Business is Booming, STAT NEWS, (April 25, 2016), available at https://www.statnews.com/2016/04/25/scribes-emergency-room/ (last visited March 12, 2018). 6 Id. 7 Kaitlyn N. Pytlak, Tale as Old as Time: Avoiding the Pitfalls of Medical Record Documentation in the Age of Technology, USLAW MAGAZINE, Fall/Winter (2017). 8 Joshua J. Mark, Ancient Egypt, ANCIENT HISTORY ENCYCLOPEDIA, available at https://www.ancient.eu/egypt/ (last visited March 12, 2018). 2

hieratic') and then was replaced c. 700 BCE by demotic script.”9 For the most part, only male

children of scribes were given the opportunity to become scribes. Once educated, these

individuals used their new skills to preserve their way of life for future generations. Duties of

scribes included: keeping track of livestock and textiles; recording trade information; and

maintaining narratives and stories.

In the early years of the Common Era, the importance of the scribe’s role in society was

solidified by the Maya civilization. From 250 CE to 800 CE, the Mayans controlled more than

fifty king-ruled territories throughout Mexico, Belize, Guatemala, and Honduras.10 The Mayan

kings used scribes as personal assistants tasked with the responsibility of documenting their

storied legacies. “By immortalizing a king's victory in battle and ready communication with the

gods, a scribe played an important and highly visible role in maintaining the king's power. In

Maya society, writing was a political tool of persuasion and authority. Scribes were deliberately

targeted in warfare to silence the king's mouthpiece, which would compromise his power and

reveal his vulnerability.”11

From these ancient traditions came the idea of the modern scribe. Throughout the 18th

and 19th centuries, scribes were primarily employed to copy manuscripts, novels, and even the

Bible. However, despite the long and varied history of scribes, evidence of medical scribes is

traced only to the 1970s. Then, “[i]n 1991, the Institute of Medicine recommended that all

physicians implement computers to record patient information and thereby improve patient care.

Shortly afterward, in the mid-1990s, hospitals in Nevada and Texas started the first medical

scribe programs across the country and in 1995 the first incorporated scribe organization,

9 Joshua J. Mark, Ancient Egyptian Writing, ANCIENT HISTORY ENCYCLOPEDIA, available at https://www.ancient. eu/Egyptian_Writing/ (last visited March 12, 2018). 10 Hillary Mayell, Maya Murals May Depict Murder of Royal Scribes, NATIONAL GEOGRAPHIC NEWS, https://news. nationalgeographic.com/news/2001/11/1126_Mayanscribes.html (last visited March 12, 2018). 11 Id. 3

Physassist, was created.”12 In 2006, President George W. Bush doubled federal funding for

health care information technology and the EHR, and the scribe business boomed.13

Today, the medical scribe is becoming commonplace in hospitals and physician offices

all across the world. ScribeAmerica, one the nation’s premier scribe company, defines the

modern medical scribe as “a personal assistant to the physician; performing documentation in the

EHR, gathering information for the patient's visit, and partnering with the physician to deliver

the pinnacle of efficient patient care.”14 A large portion of medical scribes are pre-med students;

current medical students; and individuals applying to become a physician’s assistant. For most,

becoming a medical scribe is not a career, but rather a stepping stone toward forging their own

path in the world of medicine. In fact, many schools and programs across the country suggest

having a background in medical record keeping.15

Solving the Puzzle: Problems with the EHR and Potential Solutions

The majority of lawsuits that arise in the context of healthcare are civil cases that revolve

around alleged medical negligence. “Well-documented medical records can be a

physician/defendant’s best defense, but illegible, inaccurate, or incomplete records can weaken

or even destroy the chances of defensibility. Poor documentation, including contradictory

statements, missing data, and incoherent plans of treatment are just a few examples of the

problems that have afflicted medical records for centuries.”16 With the increasing use of medical

12 What is a Medical Scribe?, MEDICAL SCRIBE INFORMATION, http://www.medicalscribe information. com/ (last visited March 12, 2018). 13 President Bush Continues EHR Push, Sets National Goals, HEALTHCARE IT NEWS, (April 26, 2004), available at http://www.healthcareitnews.com/news president-bush-continues-ehr-push-sets-national-goals (last visited March 12, 2018). 14 Who We Are, SCRIBEAMERICA, (May 25, 2002), http://www.scribeamerica.com/who_we_are.html. 15 Id. 16 Pytlak, supra note 7. 4

scribes, many believe that we can solve that problem. The following are three potential benefits

of using medical scribes in the everyday practice of medicine.17

1. Face Off: An Increase in Patient Satisfaction

One of the most prevalent areas of patient complaints surrounds the breakdown of the doctor-patient relationship. In the minds of many physicians (and patients), the introduction of the EHR caused a rupture in the sanctity of the doctor-patient relationship.18 According to Santa

Barbara, California-based physician David Strumpf, “[i]t’s a challenge to be both data entry person and clinician, and it’s very distracting to the process [of patient care].”19 The burdens and

extent of electronic record-keeping can be both time consuming and burdensome. Because of

this, a patient’s encounter with his or her physician has become fragmented. The physician is

now focused on “checking the boxes” and “selecting from the drop-down menus,” rather than

critically listening to the patient concerns or attentively examining the patient’s physical

ailments.

Since the adoption of medical scribes, however, studies have found that this dynamic is

changing.20 In fact, the Journal of the American Board of Family Medicine has reported an

increased satisfaction in doctor-patient interactions.21 Now, when a physician enters an

examination room, he or she can begin the appointment by making a face to face introduction,

while the scribe begins taking-down any pertinent information. “Having a scribe in the room

17 The Author would like to note that based on her research, there are both benefits and drawbacks to the use of medical scribes. This article was not written to be an exclusive reference for this issue. Rather, this article is a brief look at a timely and burgeoning medical issue. Fully discussing the pros and cons of the medical scribe industry is beyond the scope of this paper. 18 See generally Josh Kosowsky, M.D., FACEP, The Effect and Impact Scribes Can Have on Patient Experience, STUDERGROUP, (October 30, 2015), https://www.studergroup.com/resources/articles-and-industry-updates/insights /october-2015/the-effect-and-impact-scribes-can-have-on-patient. 19 Aubrey Westgate, Medical Scribes: Pros and Cons, Vol. 24 PHYSICIANS PRACTICE (April 2, 2015). 20 Kelly Gooch, 17 Things to Know About Medical Scribes, BECKER’S HOSPITAL REVIEW (January 26, 2016), available at https://www.beckershospitalreview.com/hospital-physician-relationships/17-things-to-know-about- medical-scribes.html (last visited March 13, 2018). 21 Kate Dubé, BA, Re: The Use of Medical Scribes in Health Care Settings: A Systematic Review and Future Directions, 28 J. AM. BD. OF FAM. MED. 684 (2015). 5

allows the physician to focus on key drivers of patient experience such as eye contact, body

language, position (sitting vs. standing), therapeutic touch, and active listening. During the

physical exam, physicians are able to describe and articulate the findings to the patient and the

scribe at the same time, making the patient feel informed and involved in their care.”22 In the

end, using a medical scribe does not eliminate a physician’s duty to chart, but using a medical

scribe does allow the physician to spend more time with patients and less time on clerical

charting.23

2. Be Productive: Better Documentation and Productivity

Electronic medical records have been a staple in the healthcare industry for the past decade, and with the adoption of the Health Technology for Economic and Clinical Health Act24

(“HITECH”), many healthcares facilities are actively transitioning to a completely electronic system of storing medical records. In some ways, EHRs have created an easily-accessible, streamlined method of providing quality care among various health care providers.25 Yet, in

other ways, EHRs have created a “paradigm of information chaos.”26

“[P]hysician dissatisfaction with EHRs remains high, a phenomenon probably linked to

the perception that EHRs do not improve efficiency, do not decrease workload, have increased

total operating costs, and have yet to overcome operating challenges.”27 Although EHRs have

22 Kosowsky, supra note 18. 23 Sattler, supra note 1. (The following quotes are from Physicians polled in the study. “I think I have a deeper level of intimacy with patients when I’m not on the computer and I’m just connecting with them. I’m using my body language, I’m leaning in, and it’s just the two of us.” “So glad [the scribe] was in clinic with me today!! Had a particularly complex patient encounter where she helped me gather support and additional resources to best care for the patient.”). 24 See generally HITECH Act Enforcement Interim Final Rule, U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html (last visited March 13, 2018). 25 Pytlak, supra note 7. 26 Robert Pranaat, et al., 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, J. MED. INTERNET RES. (2017; 5(3): e30). 27 Id. 6

increased the “ease-of-access” and the streamlined transfer or medical records, it has also

increased the time physicians spend on record-keeping and documentation.

With the assistance of medical scribes, this clerical burden has decreased, and caused an

uptick in physician productivity. According to Becker’s Hospital Review, a study published in

2015 “by the National Center for Biotechnology Information found physician productivity in a

cardiology clinic was 10 percent higher when scribes were used. The study compared the

productivity during routine clinic visits of 10 cardiologists using scribes versus 15 cardiologists

without scribes. According to the study, physicians with scribes saw 9.6 percent more patients

per hour than physicians without scribes. Physician productivity in a cardiology clinic, overall,

was 10 percent higher for physicians with scribes.”28 In the same study, evidence gathered

“showed physicians with scribes generated an additional revenue of $24,257 by producing

clinical notes that were coded at a higher level. Total additional revenue generated was $1.4

million at a cost of roughly $99,000 for the employed scribes.”29 Overall, the studies generally

show an increase in productivity when medical scribes are employed to assist in the demanding

tasks of record-keeping and charting.30

28 Gooch, supra note 20. 29 Id. 30 Sattler, supra note 1. (The following quotes are from Physicians polled in the study. “I enter the day with a little a bit more positivity knowing that I’m not going to have this onslaught of all these charts to catch up on at home.” “I ran out of town right after clinic this morning and it is so nice to know that my notes are nearly done! I won’t be able to complete them before I leave, but am happy and feel SO MUCH BETTER knowing that there will be usable content in the notes. . . .” “. . . [the scribe] adapted to my A&P style, which I had been too shy to bring up to her because I am so incredibly grateful for her I don’t want to appear ‘nitpicky’ but she—completely without prompting—must be reviewing my notes and made relevant changed in anticipation of what my notes end up looking like. AMAZING.”). 7

3. Put on a Smile: Increasing Physician Happiness

Physicians across the country are overworked and “burnt out.”31 In a 2014 Mayo Clinic

Proceedings survey, 54% of physicians reported experiencing at least one sign of burnout.32 This

is compared to a 2011 survey, in which only 45.5% of physicians reported the same signs.33

Some experts contribute the increase in burnout to the EHR. Similarly, in an effort to prevent burnout, the American College of Physicians (“ACP”) has created the “Physicians Before

Paperwork” initiative.34 “ACP has long identified reducing administrative complexities or

burdens as a priority. Ongoing actions to achieve this goal have included developing and

maintaining related policy, participating in various efforts to work to alleviate specific regulatory

and insurance requirements, and eliminating other unessential tasks that detract from patient care

and contribute to physician "burn-out."35

One way physicians are combating burn-out, is by employing the services of medical

scribes. According to many, the EHR is a complicated system that no one really knows how to

use in an advantageous manner.36 However, Dr. Michael Murphy—co-founder and CEO of

ScribeAmerica37—“says scribes are helping alleviate productivity challenges associated with

EHRs, but they are also helping providers through the transition to ICD-10—the 10th version of

the World Health Organization’s medical classification system.”38 When the medical scribe is

educated properly, their insight into the EHR can transform a physician’s practice. For example,

31 Tammy Worth, Hiring Scribes, Delegating Tasks Can Help Ward off Burnout, RENAL&UROLOGY NEWS (February 14, 2018), available at https://www.renalandurologynews.com/practice-management/physician-practice- medical-scribes-can-reduce-doctor-burnout/article/744487/. 32 Id. 33 Id. 34 Patients Before Paperwork, AMERICAN COLLEGE OF PHYSICIANS, https://www.acponline.org/advocacy/where-we- stand/patients-before-paperwork (last visited March 13, 2018). 35 Id. 36 Mark Hagland, Drilling Down into Important Issues Around the Use of Medical Scribes, HEALTHCARE INFORMATICS (October 15, 2017), available at https://www.healthcare-informatics.com/article/ehr/drilling-down- important-issues-around-use-medical-scribes (last visited March 13, 2018). 37 See generally SCRIBEAMERICA, http://www.scribeamerica.com/. 38 Gooch, supra note 20. 8

ScribeAmerica, requires its scribes to go through 40 hours of online training, combined with 200 hours of work in practice.39 Moreover, some physicians choose to educate scribes on their preferences and charting techniques unique to their practice.

When physicians and scribes work together toward a common goal, physician happiness can be obtained. For most physicians, utilizing a medical scribe allows them to think about the patient, not just the charting.40 Additionally, with good communication and a teamwork-centered attitude, the medical scribe can become a “partner in crime,”41 “a friend,”42 and “a colleague.”43

Conclusion

Ultimately, despite the burnout and burden related to the electronic health record, it appears that a potential solution is burgeoning. With the passage of time, and the passage of legislation such as HITECH, medical record documentation will only continue to get more challenging, and physicians will continually be faced with clerical work that overshadows the doctor-patient relationship. However, with the increased use of medical scribes, we can slowly revitalize healthcare by increasing patient satisfaction; improving record documentation, and easing the paperwork burden on physicians. As such, health care providers across the country should take a critical look at the positive impact medical scribes could have on their practice.

After all, what will it take for you to subscribe to the medical scribe?

39 Hagland, supra note 36. 40 Bailey, supra note 5. 41 Sattler, supra note 1. 42 Id. 43 Id. 9