As a medical scribe working with a large, well-known scribe company, unnamed to protect my job, it makes me proud reading all the articles published about how much having a scribe benefits a physician, especially in the emergency department. I enjoy my job immensely and I am grateful for the opportunity to learn and engage in patient care. However, as a pre-medical student working next to several other doctor-hopefuls in a high stress environment, being a scribe frustrates me on an ethical level.
Let’s examine the structure and reasoning that has made medical scribe programs so successful. When EMR systems were first introduced, there was resistance, but it gave way to the push for efficiency. The biggest benefit of EMRs is easy: risk management. By allowing for documentation of every little part of a patient’s care, EMRs significantly decrease the risk of mistakes slipping through the cracks. It allows for better defense of the physician’s medical decisions, even months down the line.
For example, a physician I worked with was asked to go to court for a patient who had been assaulted by her boyfriend. The patient had been seen several months ago in the ED. Few physicians would be able to remember all the details of an encounter so long ago. His testimony was therefore entirely based on the medical chart, written by me and approved by him. The EMR allowed for comprehensive, detailed documentation of test results, discussions with the patient, and interactions with the police.
Unfortunately, such comprehensive medical records take time and effort to write. Physicians complain that they were becoming little more than data entry specialists, dedicating large portions of the time they should be spending with patients to clicking buttons. In comes the scribe. Usually students or recent graduates interested in becoming a medical provider, we become the physician’s right hand. Scribes are purported to decrease physician burnout considerably and increase ED efficiency. Better documentation also leads to better billing, so hospitals make more money. The physicians I work with, in a hospital who has been using scribes for over 3 years now, have all been grateful for the program.
Sounds great, right? The winning combination of EMRs and scribes. The road to increased efficiency, increased Press-Ganey scores, increased billing accuracy, increased fraud, increased profits for the administration. Happiness abounds.
How many of you missed the “increased fraud”?
Medical billing is based off charting and documentation, and that can have different levels. Level 5 charts are billed the most, when the provider offers the higher level of care. Ideally, EMRs make documentation more accurate, allowing for more level 5 charts for medical coding and billing. But when all it takes is a few buttons to increase your billing, how many physicians submit to small temptations and conveniences?
In Epic’s CareConnect, a widely used EMR, there is a small button that, when pushed, indicates the physician has counselled the patient to stop smoking. It adds a small amount ($20-30) to the billing, and the physician makes a little more.
I’ve been told by physicians, “If the patient is an active smoker, just click that button about the counselling.” Most of the time, the patient is counselled. Sometimes though, they aren’t. But if that button isn’t pressed, eventually, it comes back onto me.
“I told you to press it, so just press it.” At which point, I protest, “But you didn’t counsel them.”
The physician responds, “You probably just weren’t paying attention.” Or “It’s okay, just click it anyways.” As a “good” scribe, I don’t say anything and I click the button.
Similarly, physicians can make “macros” which autopopulate certain parts of the chart, such as the physical exam. It’s nice and saves time, and it is usually accurate. It ensures that there are enough areas input for the physical exam for the chart to be level 5. But sometimes, the physicians don’t do everything their macro says they’ve done. In those cases, I go in and take out the inaccurate information. Sometimes, I’m told to just leave it, that I must have missed when they did it.
How do I know it’s not me? Because as the physician’s right hand, I have been with them the entire shift, even during any breaks they take. I have paid incredibly close attention to everything they say or do so my charts are as complete as possible. That’s my job. I know they did not counsel the patient. I know they did not ask for social history. I know they did not listen to the patient’s heart rhythm or breath sounds. I know every time I “just leave it,” I am lying in a medical document.
I don’t blame the physicians. The pressure on physicians from the administration is incredible. If a physician only charts what they has done, that means their charts sometimes don’t reach level 4 or 5. When that happens too often, administration comes down, and they’re told to write better charts. They lose money when their charts get downcoded.
So what do they do? They click a few extra buttons for that higher level chart, because they’re seeing so many patients in a shift and it’s that much easier to just click a few buttons than double the time in a patient’s room when there are other acute patients waiting. Considering how much debt physicians are straddled with as a result of the insane cost of medical education, it’s clear why that extra $20 per patient counselled is so easy.
These are small, tiny transgressions. In the grand scheme of things, it probably does not matter that that the patient did not actually get counselled about smoking cessation. But small things add up and in the end, the burden of all this comes back onto the patient. More importantly, if thousands of small lies are okay and never brought to light, how many bigger lies are out there, hidden by convoluted billing, poor memories, and a healthcare system that lacks any semblance of transparency?
I will never regret being a scribe — as I prepare to apply to medical school, I know my experience as a scribe will be a core piece of my application. I am lucky to have this opportunity. I am also a person with bills to pay, and I don’t want to lose my job. As a “good” scribe, I understand that the chart I am writing is ultimately a reflection of the physician, and therefore at the end of the day, I will write whatever the physician wants me to write. It isn’t my job to say no. Whether or not it’s my responsibility to is undecided.
The author is an anonymous medical scribe.