Turn over the data entry to someone else, doctor.
Recently, in the online version of The New York Times, I saw an article by Katie Hafner titled "A Busy Doctor's Right hand, Ever Ready to Type." The article described a new movement among medical personnel, one to hire scribes to make entries into an Electronic Health Record (EHR).
The concept made great sense to me, but it's clearly not a new one. Our ophthalmologists have, over the last fourteen years, routinely had an assistant who entered data into some form of a medical record, allowing the physician to concentrate on examining us.
Only five years back the use of an EHR was clearly the exception for other medical personnel with perhaps a tenth of physician office practices and hospitals utilizing them. now that percentage is well over two-thirds.
So what are the problems with universal acceptance of EHRs?
One that I touched on in my previous post on EHRs is interoperability between different health-record systems. My translation of that term is that Dr. A using, for instance, Epic at a UCH site like our local hospital, should be able to access and read my medical record from the Department of Defense or the Veteran's Affairs' systems. At the moment I doubt that's even remotely possible and there will obviously be issues with patient confidentiality. Those should be eventually solvable, although the mechanism for doing so is well beyond my computer skill level.
But, for an individual practitioner, on a day by day patient-care basis , there's an entire other set of issues.
I had mentioned in a recent post our pleasure at watching a Family Practice intern who kept eye contact with her patient (in this case my wife) while she examined her and informed her about test results.
The intern wasn't entering data and there's the rub with an EHR. She presumably had the choice of doing her examination and keeping as much eye contact as possible with her patient while remembering all the accumulated data points versus typing while she asked questions and, if she were a typical doc typist, looking at the keyboard and the screen much of the time.
The opposite end of the spectrum was a nurse who, in order to give Lynnette an ibuprofen tablet, spent twelve minutes (I timed the interaction) between my request for her pain med and it being put in her mouth, mostly on the computer, occasionally glancing up to ask a question (e.g., "On a scale of one to ten, what is your pain level? What is your full name and date of birth?{the fourth time she'd asked that during her shift}).
As the EHR has grown more complex, with more mandated information being necessitated by organizational, certifying and governmental entities, the potential for increased human-machine time has grown hugely, while the doctor-patient segment of a physician's day is squeezed.
The potential for burnout of physicians, especially in emergency medicine, family practice and primary care internal medicine has increased. The link is to a free article that appeared in the Archives of Internal Medicine in 2012 comparing both burnout and satisfaction (with physicians' balancing work and outside life) to others in the United States. Bottom line was of the 7,000+ docs who filed in a survey, over 45% had some symptoms of burnout and were much less satisfied with their ability to find a counterpoise between their work time and the rest of their life than those with comparable professional degrees.
Burnout meant less enthusiasm for work, development of cynicism and less of a sense of accomplishment than those of us who practiced medicine years ago had. There are lots of components as to why this has become more common among "front-line" physicians, but as I've talked to some recently the EHR has been a very significant contributor.
This was a somewhat unexpected development for me, although based on what I had seen with my radiologists attempting to dictate into an earlier version of an EHR in 1988-1991, not one that I should have been surprised by.
Adding one more to the medical team should be easy.
There is a growing industry providing medical scribes to physicians and others and, since 2010, certification available through a non-profit, the American College of Medical Scribe Specialists. I was somewhat surprised that patients not only haven't objected to a scribe being present, but often have warmly welcomed them. They may be introduced as "my data entry specialist." Obviously, in teaching hospitals, patients see a team of physicians already. Only the most intimate parts of a physical examination would need to be conducted in a one-on-one basis. Then the scribe could be on the other side of a curtain and the doctor would verbally describe her or his findings.
If I had the choice of my physician looking at me almost all of the time and, in essence, dictating her findings (my own doctor is female) or having to type much of the time, my choice would be simple.
Then there's the possibility of a remote scribe. I had envisioned a future EHR which had set areas to be filled in and a practitioner being able to wear a headset and dictate into the EHR directly. I hadn't realized that some practices already have scribes who may be thousands of miles away from the patient-physician encounter, sometimes in India.
I went back to the New York Times article I mentioned initially and saw a quote from a family medicine physician who said, "Having the scribe has been life-changing." An article in the journal Health Affairs said two-thirds of a primary care doctors time at work was spent on clerical duties that could be done by others. Another doctor said, "Making physicians into secretaries is not a winning proposition." She had surveyed over 50 primary care practice in the past five years, finding those who used scribes were more satisfied with their work and their choice of careers.
Doctors have been dictating patient records for fifty years, but those transcriptions often made their way to the chart many hours later. Having a scribe could cut that lag time immensely.
With our growing need for primary care physicians and the tendency for medical students to avoid those specialities, aiming toward more financially rewarding and less laborious fields in medicine, the advent of medical scribes may be not only a significant improvement for the lives of those already in front-line medical areas, but an inducement for new prospective physicians to join their ranks.
I'm heartily in favor of the idea.
Tags: electronic health record (EHR), medical scribe, physician burnout