Medical Scribes: A Reality Check

In this age of electronic medical records, health-care professionals in an emergency department clicked 6 times, on average, to order one aspirin. Viewing an old test result took 11 clicks; documenting a physical exam for back pain, 47. Tired of having to work long hours to finish digital charting, some health-care providers have turned to medical scribes, data-entry helpers both praised as physicians’ “angels” and slammed as a “threat to patient privacy.”

I saw my first medical scribe at an urgent care center, where I sat with a testy back in a curtained cubicle. When my doctor came in and introduced herself, another woman followed, wheeling a shiny metal laptop stand. The second woman said nothing to me but started keyboarding. She, a medical scribe, was creating a digital record of my visit there, freeing my doctor from record-keeping duties and letting her focus on me.

My curiosity piqued, I learned that scribes differ from medical transcriptionists, who type up dictated reports. Scribes document medical encounters in real time by entering information into the electronic medical record (EMR) or chart. Typically, they document the physical exam, patient medical history, clinician’s diagnosis, recommended treatments, and more. They may also perform other tasks, such as tracking down test results, typing discharge forms, and scheduling follow-up visits.

Most medical scribes work in emergency departments, although some document care in other outpatient settings or in hospitals. Unlike the scribe who shadowed my doctor, virtual scribes use technology to listen in remotely.

A boon for doctors?

Stories abound of scribes enabling doctors to breeze through their days, see more patients, finish record keeping in time to spend evenings with their children, and earn more money to boot. Few studies have tested such claims, but early findings hint that scribes may benefit doctors. In two emergency departments and one outpatient cardiology clinic, scribes freed doctors to see more patients in less time. That increases revenue.

In an outpatient urology clinic, researchers randomly assigned doctors to one session with a scribe and one without. On scribe days, the physicians rated record keeping easier and their office hours more satisfying than on no-scribe days.

Although these studies back claims that scribes enhance doctors’ productivity, they also leave room for doubt. For instance, one emergency department study lacked a no-scribe control group; in the other, scribes were more likely to work during the busiest times. The urology study included few women patients and only male urologists; a female urologist with mostly female patients declined to participate. A conflict of interest mars the cardiology study: One of its authors runs the company that provided the scribes.

A mixed bag for patients

Scribes may help doctors see more patients, but the cardiology study found that doctors who used them spent 9 fewer minutes per patient. Despite shorter visits, cardiologists with a scribe put in 5 more minutes interacting with patients directly, with no computer between them. An expert watched one doctor and found that he interacted better with patients when he used a scribe. In another study, primary-care patients agreed more strongly that the doctor spent enough time with them if he or she had a scribe. In short, scribes seem to give doctors more quality time with patients.

In my one scribe-assisted visit, the doctor looked me in the eye as we talked. That helped me trust her, even though we had just met. Our face-to-face conversation sure beat visits I’ve had with my primary-care doctor. She spends most of our time together pecking away at the computer, her back facing mine.

Such experiences might explain why most patients feel comfortable around a scribe. Nonetheless, 1 in 5 patients at a urology department felt uncomfortable telling their doctor about urological problems with a scribe in the room. About the same percentage of primary-care patients admitted unease around a scribe. If that keeps patients mum about their problems, that extra quality time could be an illusion. Perhaps patients would speak more freely around virtual scribes.

Some scribe vendors, such as Precision Scribes and Scribe Solutions, say that scribes improve patient satisfaction with care. Indeed, medical scribes restored one emergency department’s patient satisfaction ranking to what it had been before it switched to computerized order entry. On the other hand, scribes did not improve patient satisfaction in two outpatient clinics. As one research team wrote, “The biggest benefit of the scribe appeared to accrue to the physician.”

Big unknowns

Despite the breathless accounts of how scribes are fixing health care, I haven’t found any peer-reviewed studies on whether scribes improve overall care quality or EMR accuracy. Some scribe companies accept candidates with only a high school education into their training program. This led Joel Sherman, M.D., to blog,” I do not see how anyone with a high school background and a few months of training could possibly understand all the medical conditions covered in a general practice.” On the other hand, many companies recruit students planning a career in medicine, nursing, or another health-care field; they consider them highly motivated to learn. That said, such students soon move on, and the resulting turnover exposes more people to patients’ sensitive information.

To guard against errors, scribes, who are unlicensed, work under the supervision of licensed clinicians. The Joint Commission, which accredits many health-care facilities, requires doctors to review their scribe’s entries, correct them if needed, and sign them before leaving the patient-care area. That helps keep scribes’ unapproved notes from guiding treatment.

Scribes may indeed save doctors, as Scribe America proclaims, but as EMRs evolve, no one knows whether doctors will still need saving. For patients, scribes carry potential benefits and risks, but so does the status quo. My EMR says that I’m taking a drug that I never took; the nurse involved in my care can’t figure out how to fix it. Whenever I see her, she asks if I’m still taking it. Perhaps she needs a scribe.

Photo copyright Geo Martinez/123rf.com stock photo

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