LAS VEGAS -- Medical scribes are interfering with the improvement of electronic health records, two speakers said here Wednesday.
"We believe there's a role for us -- as individual practitioners, as physicians, as other care providers, to demand that electronic health record [vendors] improve their product," , of the CHRISTUS Health hospital system in Texas, said at the .
"But if you insert a scribe permanently between the physician and the EHR, you are going to have significant deceleration of technological advancement of EHRs because there's no pressure."
He explained, "The use of scribes is undermining the usual market forces that would drive the advancement of EHRs," arguing that physicians may be "satisfied with a suboptimal product because 'my scribes deal with it'" and so don't complain to the vendor or seek better systems elsewhere.
, also of CHRISTUS, noted that all physicians in the U.S. have been affected by the Meaningful Use regulations. "Many things have been added to physicians' workflow that provide little or decreasing value -- clicking, checking [boxes] -- that have absolutely increased the time physicians and other clinicians have to spend with the EHR, and physicians are increasingly concerned about that."
"Everybody's heard [someone say] this: 'I didn't go to medical school to be a clerk or order entry person.' Clearly, almost all of us who are clinicians by background understand the world is changing, and that digital information and expert advice at the point of decision is critical .... However, the prevailing sentiment among many of our colleagues is that the current state of EHRs is a little bit disappointing, and we think that drives some of the desire for scribes."
Gellert and Webster defined a scribe as "an unlicensed individual [not a nurse or physician assistant] -- they may be high school graduates, college students, or medical students -- that go through training programs and are authorized by a facility to enter information into an EHR at the direct supervision of the physician they're working with."
Scribes have become somewhat of a fixture in the medical world, Webster said, with scribe training programs in schools, associations to certify scribes, and a medical scribe journal. And, he added, "in some specialties [having a scribe] does enable physicians to see more patients in the same time period ... There is a growing body of evidence that workflow productivity and efficiency is improved with scribes."
As of 2014 -- according to research that Webster and Gellert published in an -- there were 10,000 scribes working in the U.S., "and the industry expects its ranks to swell to 100,000 by 2020 -- that is, within 6 years, there will be 1 scribe for every 9 physicians in the U.S.," Webster said. "That's pretty amazing."
There is also the American College of Medical Scribe Specialists -- a nonprofit organization that lobbies for this industry, he said.
And the industry is pretty much unregulated, according to Gellert. "The Joint Commission does not endorse or prohibit the use of scribes," he said. "The Joint Commission is, however, very unequivocal that scribes should not be able to perform computerized patient order entries (CPOEs).
"If you're not a trained person, you're eliminating the whole value proposition of CPOE, which is our systematic method of introducing evidence-based medicine to healthcare," he continued. "A medical scribe has extremely finite or no clinical expertise."
It's one thing if the physician is at the scribe's elbow to see every alert that pops up with an order entry, "but how likely is that to be in every office in the country? We think very unlikely," said Gellert. "We think physicians will allow 'functional creep' to occur, consciously or unconsciously."
And with a lobbying organization and other professional accoutrements, Gellert said he was afraid scribes would become even more entrenched in the healthcare system. "When something gets professionalized, organized, politicized and has influence, it's very hard to deconstruct."
Gellert held up his own hospital system's response to the issue as an alternative way forward. "We have held regular meetings since we launched our CPOE in 2012, with the objective of soliciting [the staff's] needs, ideas, requests, and recommendations, and driven those to our EHR vendor." CHRISTUS has lots of influence with the vendor because it's one of the vendor's biggest customers, Gellert said.
"The company has responded with a completely revolutionary user interface; it really spoke to what our physicians have been asking for. This is the way products evolve, with incremental but notable improvements."
In addition to providers demanding more from the EHR, the government or other third-party organization should monitor the growth in and impact of the medical scribe industry, he suggested. "We believe that physicians and hospitals shouldn't support scribes becoming permanent workarounds to EHR use ... [But] if this is going to be a sub-industry, it needs to be more transparent."
And there should be a confidential hotline where scribes can anonymously report misuse of their profession, such as being asked to report activity not done or using a scribe for physician order entry, Gellert said.
But despite all these calls for change, "We don't think the scribe solution is going to be temporary -- it will be part of the system going forward," said Webster. "As George likes to say, it's one way to light a candle in the darkness -- we just think it's the wrong candle."