LiveWell Nebraska: As doctors go paperless, more turn to medical scribes for help

By Rick Ruggles / World-Herald staff writer

Physician frustration with electronic health records has prompted a boom in a profession called “medical scribing.”

Medical scribes generally sit in the exam room and type into the patient’s electronic chart as the doctor and patient talk. The number of doctors using scribes in the Midwest and across the nation is fairly small but growing fast. Scribes can help doctors see more patients, and patients don’t have to wait so long for appointments. Scribes also can reduce the amount of time tacked onto the end of a doctor’s day while he punches information into the computer system.

Doctors from North Platte to the Nebraska Medical Center’s emergency department to a large primary care center opening in Omaha in July are trying out scribes.

“What is happening is they (doctors) have become really highly paid secretaries or data-entry specialists,” said Dr. Michael Murphy, CEO of the largest scribe company in the nation. “Doctors save lives, scribes save doctors.”

Murphy, of Florida-based ScribeAmerica, estimates that there are 14,000 scribes across the nation, up from 10,000 early last year. The American College of Medical Scribe Specialists, a voluntary certification program for scribes, predicts that there will be 100,000 scribes by 2020.

Scribes maximize doctors’ time with the patient, “and they minimize their time with the electronic medical record,” said Dr. Wesley Zeger, an emergency department physician at the Nebraska Medical Center who has helped create a scribes program that started this week in the ER.

The federal government a few years ago began to ask doctors to convert their paper records to electronic charts. The government gave incentives early on to make the change, and it has now begun to penalize doctors for failing to make the conversion.

Many agree that an electronic record won’t get misplaced like a paper file can, an electronic file removes the risk of bad handwriting leading to an error and it gives specialists easy access to key information from the primary care doctor and vice versa.

But some doctors find typing their notes and diagnoses adds time and frustration to their day. Some say the pleasure of helping an ill patient is eroding under government requirements and the need for better typing and computer skills.

Last week at an Alegent Creighton Clinic family medicine office near Lakeside Hospital, scribe/licensed practical nurse Miki McGill weighed patient Greg Cade and checked his blood pressure. McGill is known as a “super scribe,” because with her LPN credential, she can do more than type into the electronic record.

She has worked with Dr. Russ Bowen for years but became his scribe through an Alegent test project in 2010. She has remained in that role since.

As Bowen talked with Cade, 63, about his high blood pressure, McGill typed away on a computer connected to the wall by a metal arm.

“I thought today I was going to impress you with low blood pressure. Nope,” Cade said to Bowen.

Bowen carried a computer tablet that he referred to at times, but McGill did all of the heavy typing onto her own computer. McGill said little as Bowen and Cade talked until the physician used the word “telangiectasia” in reference to Cade’s skin condition. Bowen started to spell it for her and checked himself. McGill eventually found the spelling.

Bowen, 45, said he loves having a scribe. McGill’s presence “lets me communicate more directly with the patients,” he said. She puts in the doctor’s instructions and the note on the patient’s condition or illness, symptoms and diagnosis.

“So at the end of the visit, that’s all done,” Bowen said. He said there are days when McGill might save him three hours of work.

Alegent Creighton Clinic, which is part of CHI Health, uses 24 scribes in doctors’ offices and outpatient clinics across the metro area. Dr. Dana Zanone, medical director of informatics for Alegent Creighton Clinic, said physicians “didn’t go to med school to learn how to type.”

Alegent-employed doctors who use scribes pay a small part of the scribes’ costs — about a quarter of it — and not just any doctor may have one. Doctors who have a huge patient load and do a great deal of work may have access to a scribe if they want one, Zanone said.

“Typically a doctor will see three to four more patients using a scribe and get home earlier,” Zanone said. “And it allows you to really concentrate on the patient.”

Scribes perform data entry in real time, as the doctor sees the patient, unlike transcriptionists, who transcribe a dictated message through recording technology. Most experts see scribing as a profession rising in demand while medical transcription declines.

Scribes, like most clinic or hospital employees, are informed of federal privacy requirements and are required to adhere to them.

They aren’t universally adored. A December 2014 opinion article in the Journal of the American Medical Association suggested that scribes aren’t a long-term answer to electronic health records that are hard for doctors to navigate. Doctors need to demand that vendors provide better, more user-friendly technology, the article said.

“The medical scribe industry may impede the technological evolution of EHR (electronic health record) products by undermining market demand for needed improvement, and it is unlikely that scribes will be used only as a temporary solution,” the article said.

The Joint Commission, an independent medical accrediting body, recommends that scribes not be allowed to punch in “order entry,” such as prescriptions, lab orders and radiology orders. Scribe programs generally adhere to that recommendation.

Methodist Health System doesn’t use scribes but relies on Dragon, a form of voice-recognition technology that inputs dictated words into the electronic system. Alegent and the Nebraska Med Center also use Dragon but are trying out scribes as well.

Todd Searls, head of the Nebraska firm Wide River LLC, which helps doctors and hospitals with information technology, agreed that over-reliance on scribes can be a problem. Doctors need to review what scribes put into the system, and if they’re disengaged from the electronic record, mistakes may occur, Searls said.

A malpractice defense based on “I didn’t do that, my scribe did that” is no defense at all, Searls said — the doctor remains responsible for the record.

Searls said his firm reviewed the implementation of an electronic record system in a small Midwestern hospital and found that doctors had complained about the system in front of patients. That makes doctors appear grumpy, shows that they don’t have solutions to problems and indicates that they’re not competent with the system, he said. It opens them up to liability, too.

A study reported in Health Affairs last year found many physicians upset over poor electronic record usability, the time consumed by data entry, interference with face-to-face care and an overwhelming volume of electronic messages and alerts.

Those factors have given rise to scribes.

Dr. Ronald Anderson, an independent hospitalist who practices at Immanuel Medical Center, employs two scribes, who he said help him work more efficiently. The electronic record can be “just horrendous,” he said, but his two scribes — Angela Reeg and Lisa Tiedje — help him see twice the patient load he otherwise would see.

Anderson believes in registered nurse-scribes because they understand medical principles, diseases and terminology, and they can coordinate care with physical therapists and dietitians. “And they’re both wonderful,” Anderson, 62, said of his scribes.

April Diaz, 28, will be one of four part-time scribes in the Nebraska Medical Center emergency department. Diaz, of Sutton, Nebraska, is getting a master’s degree in biology at the University of Nebraska at Omaha and eventually will apply to medical school.

“I’m eager to get a routine down and see how each physician likes to have things charted,” she said. “I’m really excited for this program.”

Dr. Erica Carlsson was a scribe for four years in Texas. Now a resident doctor in the med center’s emergency department, she helped put together the department’s scribe program. “It’s good for patients. They can move through the ER a lot faster.”

The Great Plains Physician Network in North Platte expects to hire two scribes in the near future.

And Think Whole Person Healthcare, a 24-physician primary care center in Omaha that will open this summer, intends to have a scribe for each doctor.

Sandy Lane, chief financial officer for Think, said patients want quality time with their doctor, not time spent watching him type. “We are firm believers that the doctor doesn’t have to be a technician on the computer.”

Anderson said his two scribes “leapfrog” patients, one scribing for one patient, the other scribing for the next. It gives each more time to organize and write in the record.

“So it saves us a ton of time,” Anderson said. He can devote his energy to patients, Anderson said, and his RN-scribes can help with patient safety by giving the charts a thorough review.

Scribes are expensive, he said, “but it’s more expensive to have your production cut in half.”



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