Scribes lead to unintended consequences from electronic medical records

Recently, Dr. Scot Silverstein over at Health Care Renewal published this update to the ongoing story of electronic medical records that are so simple, intuitive and easy to use that doctors and hospitals everywhere are being forced to hire “scribes” to run them.

We’d looked at the resurgence of scribes in a previous post, and Dr. Silverstein’s article seems to confirm that the phenomenon is is here to stay for as long as most “conventional” EMRs remain fundamentally defective.  As the good doctor observes so astutely, “you should not have to work around something that is not in the way.”

There is, however, one big difference between this new update on medical scribes and my post of several months ago.  Back then, the media had described the salary of these new denizens of healthcare administration as being “$10-$15 per hour”.  At the time I opined that this was way too low.  After all, you’re lucky in you can hire someone to mow your lawn for those sorts of wages these days.  Sheesh, our neighbors paid my middle-school-aged offspring $10/hour to water their garden over the summer.

In truth, the Los Angeles Times article cited by Dr. Silverstein gives a slightly confusing picture of the true cost of EMR scribes.  Early on in the report, the newspaper characterizes them as,

typically young, tech-savvy and undaunted by computers. They are willing to work for $8 to $10 an hour with no benefits. Most do the job part-time as college students and plan to go on to full-time careers in medicine or nursing. They say the experience gives them a valuable head start.

Wow, the rates have gone down!  Only $8-$10 per hour for these folks?  That’s great!  Minimum wage in Oregon is currently $8.40 per hour.  That means that I can get someone smart enough to learn medical terminology (the average medical student’s vocabulary doubles over four years of medical school), operate an EMR (every one is different, and most all of them are hideously complex), listen carefully (a rare commodity in itself), type quickly (remember, the average follow-up visit only lasts around 7.5 minutes, and you’re supposed to speed things up rather than slow things down), follow instructions and not make any serious mistakes, all for the same salary as someone working at the Taco Bell around the corner.  Is the high rate of unemployment in a severe recession great or what?

Of course, all of this assumes that the average medical clinic is willing to hire someone who is: (1) virtually guaranteed to be a temporary and/or part-time employee; (2) hand them a computer; (3) train them in the use of the current EMR du jour (a process which typically takes months to years); (4) cater to their college classes with complex clinic coverage schedules; and (5) then do the same with dozens of other students who will fill in for the rest of the working hours.

If all of this isn’t a winning proposition for improving healthcare productivity, I don’t know what is.  Surely most clinics and hospitals will jump at the chance to pay $50,000 per clinician for an EMR plus 19% annually in maintenance fees and other costs, just to make use of this new, inexpensive and transient source of labor.  After all,

the system also makes it easier for doctors to bill for all the services they provided. Between seeing more patients and optimizing billing, physicians can boost their revenues by $50 to $60 an hour … Murphy of ScribeAmerica estimates that doctors can see eight additional patients over a 10-hour shift, hiking Medicare revenues alone by $91 an hour.

What a money-maker!  Presumably using a scribe gets docs back up to the level of productivity – and income – they had when using paper.  Too bad those extra billings will increase Medicare spending, but it is the federal government mandating the use of these things.  Fair is fair.

But wait, what’s this?  A little further on we find out what’s required to train a modern medical scribe.  Again quoting the LA Times,

Dr. Michael Murphy, an emergency physician who started Lancaster-based ScribeAmerica in 2003, said his company has grown from 32 clients last year to 51 now. It’s currently setting up seven programs around the country. The company’s growth is limited by the time it takes to recruit and train high-quality scribes. Even with high demand, there’s no way to cut corners.

‘If scribes write something down inaccurately, lives are affected,’ he said.

Dr. David Strumpf, chief executive of Emergency Medicine Scribe Systems in Santa Barbara, said his company prefers to take on clients located near a four-year college so he can hire bright, ambitious and highly literate pre-med and nursing students. But it’s challenging to learn all the medical terminology and coding procedures, and 20% to 40% of trainees drop out.

‘It’s an incredible experience for the kids,’ said Strumpf, the emergency department chief at Santa Barbara Cottage Hospital who started the company with his medical colleagues four years ago. “They see everything you do, they learn the whole thought process right on the front line. It’s the best exposure to medicine you could possibly get. When I was a pre-med student I would have done this for free.’

Then they drop the other shoe.  The good news is that these scribe services train these young bucks and does for you, so that your office, clinic or emergency room doesn’t have to.  The bad news?  Now their services, “typically cost $20 to $26 an hour, said Alex Geesbreght, president of PhysAssist Scribes in Fort Worth.”

Gosh, that’s a lot more than $8-$10 per hour.  Let’s see.  That amounts to just about $50,000 per scribe per year.  What the heck will all of this cost?

Well, there are about 800,000 clinically active physicians in the U.S., but we can subtract some in specialties where scribes probably aren’t needed, such as radiology, pathology and nuclear medicine.  Let’s say that the government eventually succeeds in getting 600,000 physicians to use EMRs.  Let’s further assume that that all of these will require scribes in order to practice efficiently enough to take on the 32 million new patients brought into the system by the ACA.  And lets further assume that we won’t run out of pre-med students, for if we did I can guarantee that their qualified replacements would be unwilling to work for minimum wage and without benefits.  Paying them more could easily double the $20-$26 per hour that scribe companies are already charging for their services.

Simple math tells us that 600,000 scribes x $50,000 per year (not including any benefits!) will add about $30 billion per year to the cost of American healthcare.  That may not seem like much given that we currently spend about $2.3 trillion on healthcare each year; it’s only 1.3% of today’s spending.  But wasn’t the whole point of our nation’s EMR initiative to drive costs down?  Let’s see if we can put $30 billion per year in perspective.

  • The $800 billion “American Recovery and Reinvestment Act” that was passed in 2009 allocated $20 billion to subsidize the purchase of “certified” EMRs by physicians and hospitals.  The average installation and training cost for one of these things is around $40,000 to $50,000 per physician, so even under the most optimistic scenario $20 billion will only cover the acquisition costs for around 444,000 docs.  The other 156,000 will have to fork out their own $7 billion to purchase the things.  Adding in the cost of scribes, this means that American doctors are incurring $37 billion in capital and operating costs in just the first year of this great experiment, and then (with maintenance, upkeep and scribes), just over $35 billion in ongoing operating expenses each and every year thereafter.
  • According to this Medicare fact sheet, total Medicare payments to physicians in 2010 are expected to be around $66 billion.  That means that scribes and EMR maintenance in future years will eat up about 53% of the gross income physicians receive from Medicare.
  • What else could we Americans have bought with that much money?  At this rate, spending on scribes will cost as much or more than Medicare will spend this year on skilled nursing facilities ($25.5 billion), home health ($20.4 billion), or hospital outpatient services ($30.5 billion).  The same amount of money would buy 41% of all generic drugs consumed in the United States in 2009 ($74 billion).

Hmmm.  We seem to be bending the healthcare “cost curve” the wrong way – all in the name of modern technology and cost efficiency.  (And, of course, subsidizing healthcare information technology industry companies like GE, Cerner, Epic and Allscripts.)

Of course, no one really knows if we’re ultimately going to employ all of those scribes, or even if we can physically find and train that many.  Pre-med students don’t grow on trees, and our low costs assume that scribes derive some sort of secondary gain that makes it worth working for minimum wage.  But none of that is really the point.

The point is that, like so many things in healthcare, the headlong rush to mandate the use of electronic medical records is chock full of unintended (and almost always adverse), consequences.  Dr. Silverstein has written about many of them.  These include the creation of new sources of medical errors, the need for additional nursing staff, hopelessly complex user interfaces and massive leaks of sensitive data that would have been unimaginable 20 years ago.  Together they generate costs that were never even remotely considered by our elected and appointed officials.  These very decisions are now going to help break the bank, and probably without delivering any net increase in the quantity or quality of actual healthcare services.

Here’s a thought.  Is there any chance that the management of the healthcare system could please be turned over to people who: (a) actually know something about topic; and (b) are not already firmly committeed to government-run healthcare or the medical-industrial complex?  If so, it sure would be less expensive.

If not, every voting patient, provider, parent and taxpayer in the country ought to be asking: “Why not?”

Doug Perednia is an internal medicine physician and dermatologist who blogs at Road to Hellth.

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  • http://bookblogtourguide.com Diane

    I used to be a medical transcriptionist — in fact, I was one for 18 years. It began as something with a decent wage. However, the profession has completely deteriorated due to factors such as outsourcing overseas and voice recognition software to where indeed the current rate does seem to be about $8 to $10 an hour. That’s self-employed too so one is paying their own taxes. Not surprisingly, I found a new career.

  • http://www.ahdionline.org Lea M. Sims

    As one who works for the professional association representing the healthcare documentation profession, I have to say that the medical transcriptionist/editor community continues to be mystified over this scramble for “scribes.” We have watched the evolution of this for close to 15 years. What seems to have gone unmentioned here is that ER physicians had “scribes” for years – they had highly skilled, trained, and in many instances credentialed professionals partnering with them in the documentation process through traditional dictation/transcription. This is not about physicians moving from a paper-based record to an EMR and needing the assistance of a scribe because it’s too complex. This is about healthcare facilities deciding a few years back that having a “scribe” service (ie, transcription) was too great an expense. This decision was made without true due diligence and an cost-vs-benefit evaluation of the revenue generation associated with well-documented narrative and the “savings” associated with keeping physicians focused on patient care and not on data entry). Those ER physicians were forced into “T” systems where they dumped their “scribes” in favor of a template documentation system that most agree (now) become cumbersome, unwieldy, and time-consuming. The detail-rich narrative that used to take the ER physician (or PA) about 2 to 3 minutes to dictate became a data entry, point-and-click nightmare for those physicians – which has only been made worse by increasing requirements for documentation based on reimbrsement critiera and now the complex questionably “customizable” EMR systems that have pulled physicians away from patient care.

    So what is their solution? Oh wait…scribes! It is rather disconcerting to the transcription community that healthcare is heralding “scribes” as some kind of innovative, never-heard-of-before strategy for helping physicians document care encounters. Do they not realize that all those years they were dictating into that telephone outside the patient room there was a “scribe” on the other end of the line capturing that information and producing a legally sound, detailed care encounter record – usually back on the floor and on the chart within 2-4 hours of dictation (30 minutes if it was a priority)?

    If heathcare was thinking clearly, it would recognize that physicians (most of whom really don’t want to give up the ease and speed of dictated narrative) would be best supported by adopting a truly practical, hybrid approach to capturing care encounters in a way that preserves critical detail and meets the criteria for EHR consumption. Let those physicians dictate. Use traditional transcription or speech-recognition capture and back-end editing to draft a rich narrative. Use NLP and other technologies to codify that narrative so that it can be consumed by EHR systems. What is the result? A data-rich EHR record and an INFORMATION-rich narrative preserved in concert with that record to be shared with healthcare providers and consultants and meaningful, if called upon, in a court of law.

    And I think another critical point of clarity needs to be made here. These are NOT medical students who are working as scribes. Per the article, they are “college students” who “plan to go on to careers in medicine and nursing.” These are individuals at an undegrad level (majoring in who knows what) who have had limited applicable coursework in clinical terminologies and virtually NO practical experience with the complexity of the diagnostic process or the unique storytelling of patient care.

    What makes a college student with no practical experience (and a few weeks of training by a scribe company) qualified to document patient care? What makes them capable of partnering with the physician to identify error and inconsistency in the data capture process and provide a risk management benefit to the physician? How could these college “kids” possibly be more equipped to do this than the thousands of medical transcriptionists across the country who have been immersed in the capture of health information every day for years and understand not only the complexity of the health story but how it connects up to meaningful use, continuity of care, and reimbursement?

    This is, yet again, about healthcare delivery wanting to get something for nothing. Emergency room documentation has come full circle. They had scribes and didn’t want to pay for them, so they transferred the documentation burden to the physician. The physicians got tired of being data entry clerks and want to be free to provide care, so they’re turning to the new less-qualified scribe to assist them. Does this sound absurd to anyone else?

    If you agree that the physician needs documentation support, why not give that job BACK to the professionals who are trained and qualified to do it?

    Lea M. Sims, CMT, AHDI-F
    Director of Professional Programs
    Association for Healthcare Documentation Integrity (AHDI)

    • jsmith

      Indeed it is absurd, one of the constellation of absurdities that is American health care.

  • Rose

    ‘If scribes write something down inaccurately, lives are affected,’ he said.

    Dr. David Strumpf, chief executive of Emergency Medicine Scribe Systems in Santa Barbara, said his company prefers to take on clients located near a four-year college so he can hire bright, ambitious and highly literate pre-med and nursing students. But it’s challenging to learn all the medical terminology and coding procedures, and 20% to 40% of trainees drop out.
    *****************************************************
    As a 20-year Certified Medical Transcriptionist, I find the “scribe” occupation ridiculous and insulting because I am a professionally trained expert in my field. I have done for 20 years what these “kids” are doing. I am an expert in medical terminology (not so much coding procedures, but MTs have a basic knowledge of these and are better suited to parse documentation for correct coding). I am certified in my field because I am well aware that if something is inaccurate, it could affect patient care, safety, or treatment. Medical transcriptionists are highly trained professionals, quality experts, and have the eyes and ears and knowledge to KNOW when a dosage is dictated incorrectly, when there is a right vs. left discrepancy, or other errors. Let’s see a “scribe” with that much knowledge in a couple of months. Schools that teach “scribes” in a few months to do what it takes years for MTs to learn are nothing more than “matchbox” schools.

    FYI: Pre-med and nursing students are NOT necessarily “highly literate”; take it from someone who has been listening to them for 20+ years and attempting to make sense of what they say. It is truly scary to think that just anyone can become a healthcare documentation specialist in a few months.

  • http://www.roadtohellth.com Doug Perednia, M.D.

    Lea and Rose,

    I could not agree more with your assessments. The old system was never broken, and did not need to be “fixed”. What is new is the invasion (and many would say “takeover”) of the healthcare community by large corporations intent on forcing clinicians and their staffs to use complex, template and check-box driven systems to gather information for the benefit of third parties. Under the provisions of the 2009 stimulus bill and the Accountable Care Act, the federal government has aided these companies by turning their marketing and sales goals into federal law. One result is that time and money are being diverted from patient care and trained professionals such as yourselves to burdensome medical record technologies and IT departments. As Dr. Silverstein has observed on many occasions, many of these new technologies are clumsy, time-consuming and even dangerously defective. This is a case of technology for technology’s sake, not because it produces medical or economic efficiencies.

    A relatively low-tech hybrid system is the way to go, and have described this approach in my book “Overhauling America’s Healthcare Machine”. (It’ll be released by FT Press this coming February 14th.) Only certain selected pieces of the information in a medical record really need to be in searchable digital format. Everything else can be in the form of free text and images just like we’ve done for years with paper. Take those parts of the document and share them securely using a simple universal technology like Adobe Acrobat. Mission accomplished (secure, universally accessible medical records in an electronic format) at a tiny fraction of the blood and treasure we’re wasting on fancy EMRs. Bring skilled transcriptionists back into the equation.

    • jsmith

      “the invasion (and many would say “takeover”) of the healthcare community by large corporations intent on forcing clinicians and their staffs to use complex, template and check-box driven systems to gather information for the benefit of third parties.”
      Amen to that.

  • http://mtexchange.com Julianne Weight

    I find it interesting that ScribeAmerica chooses to spend its time training college students, essentially guaranteeing high turnover and continued costs of training. They aren’t exactly selling the career as a long-term one, yet it sounds to me like quite a bit of training is required, and it’s ongoing. (From their website section on what to expect for scribes: “Unlimited learning curve.”) It doesn’t sound like they’re even considering converting the existing work force that already possess a lot of the skills they need – although I question whether most transcriptionists are going to want to work for those pay rates AND have to get dressed and drive to work.

    I wonder how many skilled transcriptionists will even be left by the time anyone decides it’s time to bring them back in the equation.

  • http://mttoolsonline.com Kathy Nicholls

    Thank you for writing this. I also find it sad that first we are fixing something that isn’t broken, and second that it is seen as something people can just train for in a few weeks or months and be ready to do the job. Not how I want my own healthcare records done.

    Julie is correct in wondering why we aren’t working to retrain the current workforce for this role. Medical transcriptionists are already familiar with the things needed to do this. To train a college student, thinking that a 6-month training will suffice, is just full of potential problems and risks in patient safety. It has unfortunately become all about the bottom line under the guise of “controlling healthcare costs.”

  • DKBerry

    Well EHR’s are incentivized by the ARRA Stimulus Act … so maybe it was creating jobs that was the objective.

  • http://www.ahdionline.org Lea Sims

    To DKBerry above, it is true that ARRA was partially designed to create jobs, but fundamentally we’re talking about improving unemployment, which means being smarter about how we redploy the tacit knowledge and skills of those already capable of doing those jobs rather than spending the kind of time and resources associated with training an unskilled worker from the ground up. There are unemployed and underemployed Americans all over the country who already possess the skills to do certain jobs but no one is considering them because all we’re thinking about is “jobs creation” from the perspective of new roles that require curriculum development, resource development, and new training. Not all new roles need that kind of approach. Some just need to consider shifting workers from other diminishing/evolving roles over to the new roles. That’s how you PRESERVE jobs not just create them. ;)

    • DKBerry

      @Ms Sims… thank you for your thoughtful response to my one liner.

      The point of my cynicism was that with poorly designed EHR/EMR applications we’ve created the need for an individual to actually do the inputs. Since ARRA was all about creating jobs to do “shovel ready” projects … I suggest that every doc office that employs a scribe to do the EHR heavy lifting needs to have one of those ubiquitous ARRA signs by the front door for all to see.

      You are correct … the idea of ARRA was not to train new people to do work that didn’t need to be done … but to use people who were out of work and already trained to do the work that didn’t need to be done.

      I despise the idea that we use tax dollars on make work that didn’t pass muster on being done on our public priority list (not many private jobs have been “created” by ARRA other than payoffs to make windmills to politocos in districts who voted for Obama).

      If you need a public handout to work that isn’t PRESERVING a job … that’s stealing from your neighbor.

      • http://fertilityfile.com IVF-MD

        Thank you DKBerry. Well stated. Making the use of EMR a completely VOLUNTARY measure will result in the following. It will give incentives to EMR software companies to innovate, listen to the needs of the doctors and to create a product that gives so much value to me in my care of patients that I would be wise to buy and adopt it willingly. It will also give us doctors whose practices run smoothly, efficiently and economically the way they currently are the option of NOT switching to EMR and NOT taking on the accompanying wasted time, money and safety that comes with it. Please just give us the freedom to do what’s best for our own patients rather than do what the politicians and their sponsoring corporations want. Is that too much to ask?

  • jsmith

    We use transcriptionists to jockey our EHR. I dictate an OK note, they give me an OK note. I dictate a lousy note, they give me an OK note. Plus they fill in the encounter codes and stuff. If I had to jockey the EHR myself, I’d spend an extra hour or more per day at the office.

  • Mark

    The ER I used to scribe at also had a dictation service available for the doctors to use. About 8 out of the 10 doctors choose to use the scribes.

  • http://hcrenewal.blogspot.com Scot Silverstein

    I caught my name in this post via Google alerts.

    See my teaching site “Common Examples of Health IT Difficulties” at http://www.ischool.drexel.edu/faculty/ssilverstein/cases for much more on health IT’s challenges.

  • Caitlin

    I worked full time as a Scribe in an ER for two years prior to starting medical school. I graduated college with a BS in Chemistry and Biology. I was not hired or trained by a large corporation, but by the group of physicians who worked in the ER. Our base pay was $8 an hour, but as someone mentioned above, I would have done it for free. I did not simply transcribe what was dictated by me, but rather authored the history myself, and it was then read and approved by the physician. The physicians would use voice recognition software to complete the assessment and plan portion of the note. Our physicians could see more patients with more complete notes and spend less time at the end of the shift completing those notes. It works well in the setting of an ER. I don’t know that it would work as well in a clinic setting.

    Scribes and Physician’s have a symbiotic relationship. For the scribes it is invaluable experience. It made me a more competitive applicant because I had clear clinical experience and there was no question that I knew what I was getting into when I entered medical school. It has made me a better medical student and will make me a better physician in the future. None of the scribes I worked with took the job for the money, but rather for the experience. I worked hard because I was genuinely interested in the field and eager to learn as well as provide a quality product, not because of how much I was getting paid. The Physician’s receive a quality note written in real time by someone who is physically in the room as they see the patient. They trusted us and the efficiency and productivity of the department went up after scribes began working in the department. Granted, not all scribes are created equal, and those who produced an inferior note were fired.

  • Carrie Boatman

    This has been a truly fascinating read. But I’d like to focus on patient safety and care, and REDUCING the costs of medical care and insurance for all of us. Physicians want to treat the patients. In order to do that, they need access to timely, accurate, concise accounts that tell the whole story of the patient. I think the best approach is for ALL OF US to tell the EMR vendors that we want back-end speech rec with some point and click features. Medical language specialists can produce more records faster than anyone else. Even if you pay scribes (who go on to medical school) $8 to $10 an hour, the workforce is always turning over and training costs money. And it disrupts the flow of work. If the AMA, AHDI, and other groups interested in excellent documentation, reducing the cost of producing that documentation, getting physicians back to taking care of their patients (in any setting) get together and make our voices heard, there’s no reason we can’t make this happen. We just need to quit preaching to the choir and get ourselves organized to make our voices heard. I’m willing, are you?

  • steven

    I don’t understand why, as a group, physicians don’t demand better software? I’m a former software developer and I can tell you that it can be done. But it costs the software companies extra time and the use of designers that know the field. Programmers know programming and that’s all they know. (much like physicians)
    Quality of these EMR’s is customer driven and it needs a concerted effort by the physicians to make it happen.

  • http://fertilityfile.com IVF-MD

    Well written, Dr. Perednia! I wonder if these unintended consequences you very astutely pointed out, the ones of added cost, impaired patient care and introduction of new dangers, were truly unforeseen and unexpected. Or if they were anticipated, but just viewed as “collateral damage” by the people who pushed the legislation through. In order to make their donors in benefiting corporations happy, the politicians were willing for us doctors and patients to suffer these “unintended” consequences. Not good.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    I find it fascinating that nobody seems to be looking at this from the patient-privacy point of view. First, we’ve got the information flow to yet another person who becomes privy to a patient’s personal history. That’s all we need in medicine, one more unlicensed individual who knows private medical information. But there’s more. For a simple exam, take a temperature, listen to the heart, — most patients won’t care. But how about a more intimate exam? A pelvic. A testicular exam. Any kind of intimate exam or procedure. Now we have another person in the room. Will they double as chaperones? Or will there be three people in the room? How do patients feel about that? We’re being led to believe that these “scribes” will be future nurses and doctors. Let’s get real. These will be minimum wage jobs, unlicensed, no real profession with a code of ethics. You’ll be able to get your “scribe” certificate with a quckie online course. Why? Because this is essentially a money saving change. Granted, there is an argument that the doctor can focus more on the patient — but the real benefit is moving more patients in and out of the system. I’ve heard some say that patients “love” this or are happy with it. Oh? Where is the evidence? And let’s get rid of this “scribe” title and call them what they are — note takers, secretaries. To make these “scribes” true professionals would take too much training, and require to much pay. What’s happening is the continuing dehumanization of medical culture, the continuing eroding of patient privacy,