Diagnostics Errors: Medical Scribes Improve Physician Satisfaction. Can They Improve Diagnosis, Too?
By Susan Carr
As the demand for clinical documentation grows, physicians find themselves torn between attending to patients and recordkeeping, often working on computer systems that are distracting for physicians and patients alike. One way for physicians to manage this dilemma is to partner with a medical scribe who creates a record of patient visits in real time. When used effectively, scribes can produce detailed clinical notes, improve physicians’ access to information such as laboratory and test results, and remove the distraction of data entry from the patient-physician encounter.
Although the use of medical scribes continues to grow, there is very little data about the effect this new role has on care delivery. The research that has been done so far has focused primarily on physician productivity, return on investment, and satisfaction of both physicians and patients (Bank et al., 2013). Recently, individuals on the Society to Improve Diagnosis in Medicine’s (SIDM) email discussion list discussed possible effects of the use of medical scribes on the diagnostic process (Scribes and diagnostic error, 2014). While there is not yet published research on this question (Bank et al., 2013), the experience of individuals and organizations points the way toward future study and the most appropriate and effective use of this new member of many medical teams.
Medical scribes were first used in emergency departments to help physicians process information and document clinical encounters in an often hectic environment. Currently, however, the use of scribes has expanded throughout hospitals and most care settings (Conn & Meyer, 2013; Hafner, 2014). Physicians face new requirements to track outcomes and report quality measures, and the amount of data generated for and by patients continues to grow. The computerized systems that are supposed to help often don’t and are usually cited as the main reason why physicians need help with clinical recordkeeping.
In The New York Times, Hafner (2014) observed, “For decades, physicians pinned their hopes on computers to help them manage the overwhelming demands of office visits. Instead, electronic health records have become a disease in need of a cure, as physicians do their best to diagnose and treat patients while continuously feeding the data-hungry computer.” At the moment, scribes can provide the cure. As current electronic health records (EHR) systems mature or are replaced with new systems that work better, the use of medical scribes will either evolve, or we will learn that this trend was a temporary “workaround” for a broken system (Huff, 2012).
Training and Certification
Scribes may be hired directly by providers and organizations or work for an independent company that contracts with hospitals, clinics, and physician practices. Regardless of the employment arrangement, scribes must receive training for the clinical environment, including medical terminology and regulations such as the Health Insurance Portability and Accountability Act or HIPAA, as well as the documentation system used by the practice. Scribes may achieve certification through the American College of Clinical Information Managers (Conn, 2013).
In July 2012, The Joint Commission issued standards to clarify the roles and responsibilities of scribes and their employers. The Joint Commission defines a scribe as “an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse, or Physician Assistant)” (The Joint Commission, 2012). In addition to listing required standards for things such as job description, training, competency assessment, and authentication protocols, The Joint Commission reversed a clarification it made in June 2011 (The Joint Commission, 2011), stating clearly that scribes do not have authority to enter orders.
While they clearly have no role in delivering patient care, scribes do share physicians’ access to patients’ personal health information (Campbell et al., 2012). With physician-level access to patients’ records in electronic systems, scribes may be the first to see alerts and warnings generated by clinical decision support software. How this situation is handled has important implications for care delivery and safety, and is but one indicator of complex issues that scribes and the providers and organizations they serve may encounter.
Risks and Rewards for the Diagnostic Process
Many of the risks inherent in EHRs—entering data into the wrong field or the wrong patient record, inaccurate time stamps, misplaced decimal points—exist regardless of who is at the keyboard. Because physicians are required to review, amend, and authenticate records created by scribes, errors introduced by scribes have more potential to be discovered and corrected than errors introduced by physicians whose work is not double-checked. Scribes may also be less likely than physicians to introduce errors by copying and pasting information from one record into another. Although patients report satisfaction with scribes’ participating in visits, some physicians worry that patients may not be as forthcoming with information or frank during office visits when a scribe is in the exam room (Huff, 2012).
Other aspects of a scribe’s involvement may have a positive influence on the diagnostic process. The SIDM email discussion list and other anecdotal reports identify the following effects as potentially advantageous:
- Scribes can track down missing information such as lab and test results.
- Scribes provide a “second set” of eyes and ears, to augment the physician’s experience and memory.
- Relieved of the need to enter data into computers, physicians can give patients their undivided attention during exams.
- With the assistance of a scribe, physicians may be able to create more complete and timely clinical records.
- Supported by scribes in these ways, physicians may rediscover their “joy in work,” which can improve the safety and quality of the care they deliver (Roundtable on Joy and Meaning, 2013).
On the SIDM listserv, emergency physician Michael Kohn, MD, reports on his experience working with scribes and the positive effects he has seen regarding diagnosis:
Using scribes has made my job easier and more enjoyable in many ways, but for this email list, the question is how using scribes might reduce diagnostic error. As mentioned above, they can remind me to check a lab or an x-ray. Taking an accurate history is important to making the diagnosis; the scribe writes down what the patient says in real time, both providing a second pair of ears and decreasing my reliance on my memory. Certain physical findings are also important to making the diagnosis; in the process of seeing as many as 30 patients on a shift, I might forget which patient had which finding, but the scribe made notes as I examined the patients. By decreasing the time I spend typing, the scribes free me up to focus on the patient, think harder, and use online decision-support tools (Scribes and diagnostic error, 2014).
Aside from the potential for increased use of decision support, the effects of the use of scribes on diagnostic accuracy are indirect and currently untested. Until research investigates these questions about scribes and the diagnostic process, physicians and organizations will have to proceed based on their best instinct and experience, which so far indicates that scribes increase physician satisfaction and allow them to devote more “quality time” to patients and the diagnostic process without harming the patient’s experience or introducing unmanageable risk.
Art Papier takes these thoughts a bit further and imagines a time when the scribe’s role might evolve into something quite different, with expertise and responsibility for developing the patient’s history and physical, supported with software that offers advanced decision support:
Larry Weed advocates that trained people working with the right software can be more than scribes (Weed & Weed, 2011; Weed & Weed, 2014). They would be able to take a complete, guided history, do a directed physical exam, and enter problem-oriented data guided by the software. The clinician would have a thorough, reliable, complete data set, and a differential diagnosis. Imagine someone is trained to be really good at the physical exam, and the software is problem-oriented—they could produce a higher quality history and exam than most generalists produce today. There is simply no way that a generalist can perform a thorough, accurate history and physical for all the presenting problems of medicine. The shortcuts doctors take can lead to premature closure, decisions made with incomplete data, and misdiagnosis (Art Papier, MD, email communication, January 26, 2014).
Unless and until that happens, and as long as EHR systems’ usability problems persist, the use of medical scribes as currently defined will continue to grow. With careful study, it may be that the role of scribes can be leveraged to support physicians in diagnostic improvement.
Susan Carr is editor of Patient Safety & Quality Healthcare and ImproveDx. She may be contacted at susan.psqh@gmail.com.
REFERENCES
Bank, A. J., Obetz, C., Konrardy, A., et al. (2013). Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: A prospective study. Journal of Clinicoeconomics and Outcomes Research, 5, 399–405. doi:10.2147/CEOR.S49010
Campbell, L. L., Case, D., Crocker, J. E., et al. (2012). Using medical scribes in a physician practice. Journal of AHIMA, 83(11), 64-69. [Expanded online version]. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049807.hcsp?
Conn, J. (2013, September 5). Medical scribes lack consensus on training, certification. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20130905/NEWS/309059952/medical-scribes-lack-consensus-on-training-certification
Conn J. & Meyer, H. (2013, August 24). More docs get EHR help. Medical scribes move beyond the emergency room. Modern Healthcare, 43(34), 40–41, 43.
Hafner, K. (2014, January 14) A busy doctor’s right hand, ever ready to type. The New York Times. Retrieved from http://www.nytimes.com/2014/01/14/health/a-busy-doctors-right-hand-ever-ready-to-type.html?
Huff, C. (2012, February). Scribes: A write way and a wrong way. ACP Internist. Retrieved from http://www.acpinternist.org/archives/2012/02/scribes.htm
Roundtable on Joy and Meaning in Work and Workforce Safety, Lucian Leape Institute. (2013). Through the eyes of the workforce: Creating joy, meaning, and safer health care. Boston, MA: National Patient Safety Foundation. Retrieved from http://www.npsf.org/wp-content/uploads/2013/03/Through-Eyes-of-the-Workforce_online.pdf
Scribes and diagnostic error. Improvedx listserv discussion. January 25–31, 2014. Retrieved from http://list.improvediagnosis.org
The Joint Commission. (2011, June). Clarification: safe use of scribes in clinical settings. Joint Commission Perspectives, 31(6), 4-5.
The Joint Commission. (2012, July 12). Use of unlicensed persons acting as scribes. Standards FAQ Details. Oakbrook Terrace, IL: Author. Retrieved from http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=426
Weed, L. L. & Weed, L. (2011). Medicine in Denial. Charleston SC: Createspace.
Weed, L. L. & Weed, L. (2014). Diagnosing diagnostic failure. Diagnosis, 1(1), 13–17. doi:10.1515/dx-2013-0020