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Embracing the Importance of the Medical Scribe in the Era of Electronic Health Records

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Embracing the Importance of the Medical Scribe in the Era of Electronic Health Records 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 _________________________________________ 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 16 problems that have afflicted medical records for centuries.” 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.
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