Medical Scribes: Bulls#!t Job or Linch Pin of Modern Health Care?

In his aptly-titled volume, Bullshit Jobsanthropologist David Graeber discusses the advent of jobs that are,

so completely pointless, unnecessary, or pernicious that even the employee cannot justify its existence, even though as part of the conditions of employment, the employee feels obliged to pretend this is not the case (p.22)

This description is not altogether different from a sentiment expressed by Upton Sinclair in 1935:

“It is difficult to get a man to understand something when his salary depends on his not knowing it.”

Among the five types of bullshit jobs Graeber outlines are “duct-tapers“: jobs in which individuals “fix problems, glitches, or faults that shouldn’t exist.”


Because of negligence, incompetence, or malice elsewhere in an organization, proverbial duct-tape needs applying to remedy an issue that could otherwise be avoided.

In my post on electronic health records (EHRs), I touched on the inefficiencies that plague the current state of the healthcare technology and the stop-gap measures offered to temporarily compensate for those deficits.

The advent of medical scribes in the twenty-first century is perhaps the most prominent attempt to ameliorate the persistent flaws of EHRs. Largely absent, meanwhile, are initiatives to actually address those deficits within user interface and functionality.

This short piece explores the rise of the medical scribe industry and surveys the current literature to examine the effect of scribes on the cost and quality of patient care as well as their impact on physician work-life balance.

TL;DR

Medical scribes add substantial economic value to healthcare facilities, but their effect on healthcare quality and their bullshit nature is less certain. Indeed, with better EHR tech, the use of scribes could dissipate.

A Scribe is Born

Medical scribes were first documented in American emergency departments in the mid-1970s and 1980s[1,2] as an additional role assigned to nurses and other licensed medical personnel.

Besides those few errant reports, scribes appear to be largely absent from U.S. healthcare for the remainder of the twentieth century.

With the rise of electronic health records in the early 2000s, however, came mounting clerical tasks that often detracted from clinical responsibilities and patient care. Healthcare providers pined for any source of relief from this technological deluge.

Image result for entrepreneur gif

In time, so-called disruptors saw a golden entrepreneurial opportunity to fill in the perceived gaps left by the inadequacies of EHRs. Lightening the documentation workload for physicians was surely an important goal, as was increasing revenue for healthcare systems.

That answer came primarily in the form of medical scribes: non-licensed medical workers who could document patient encounters based on dictation from a provider and observations from the interaction.

With the incentivizing of electronic health records under the HITECH Act of 2009, scribes became part and parcel for using EHRs, replete with promises to improve the physician-patient relationship and increase the bottom line for clinics.

In time, the medical scribe industry grew to be valued at $125 million in 2014 and is projected to become a $1 billion industry by 2020 with 100,000 scribes employed[3] as more clinicians adopt EHRs.

As is a common phenomenon in capitalist societies, the rapid expansion of a sector or industry is often only possible through a lack of regulation or oversight. (Recall the runaway growth of Uber, a ride-hailing smartphone app, in the last five years. Regulators are only now catching up in earnest with policy measures.)

Indeed, there are few stipulations made by the Joint Commission, a regulatory non-profit that provides accreditation to health systems, concerning the purview of medical scribes.

Notably, the Joint Commission restricts scribes from entering orders for medications or diagnostic tests within EHRs, largely due to the high risk for error and subsequently adverse patient outcomes. Scribes may instead “pend” such items for later provider approval.

The medical scribe industry otherwise dominates a cordoned-off Wild West of healthcare, with little regulatory oversight in how scribes are trained or monitored, or in the expectations of their clinical duties.

One might hope that stakeholders in healthcare would sound the alarm about the rapid growth of a largely unregulated industry placing unlicensed personnel into emergency rooms and outpatient clinics across the country.

Alas, as is also true in capitalist societies, money frequently talks louder than most other concerns…

Image result for show me the money gif

Money, Money, Money, Money

Perhaps the most appealing component of introducing scribes into a clinical workflow is the potential to increase reimbursement from insurers for patient visits.

Empirically, there is much evidence to suggest that scribes provide immense economic value by,

(a) increasing clinical efficiency (i.e. the number of patients seen within a given hour)

and

(b) documenting patient visits with a higher level of reimbursement, or billing (sometimes known as “up-coding”)

The majority of evidence comes from studies in emergency departments, though the degree of economic value added by scribes varies widely.

First, a word on terminology:

Some studies measure economic value with Case Mix Index (CMI), which averages the severity of conditions treated at a given healthcare facility along with the total number of patients treated. A higher CMI indicates that more expensive services are provided, leading to higher revenue.

As measured by CMI, scribes allowed two hospitals in a 2015 study to gain $12,000 in revenue per patient, although the overall length-of-stay in the hospital among patients did not change.[4]

Another study in 2014 at an ED documented a modest increase of $44.31 in charges per patients in tandem with a 3 percent decrease in down-coding of medical charts (billing a patient visit at a level lower than deemed medically appropriate).[5]

Similarly moderate increases in revenue were also observed in a cardiology clinic: the introduction of scribes added $142 in reimbursement per patient.[6]

Other work measures the value of scribes using relative value units (RVUs), which capture the resources used to provide services to a patient. The more extensive a given service, such as an invasive surgical procedure compared to a routine annual physical, the higher number of RVUs.

Calculating the equivalent economic value of RVUs, however, is difficult and may vary widely depending on healthcare setting. As such, some studies omit this additional conversion.

In an academic ED setting, scribes helped to produce an additional 0.20 RVUs per patient when documenting encounters with adults. When scribes worked with pediatric patients, however, those RVUs diminished by 0.08.[7]

In another 2017 study, the use of scribes in a community-based ED corresponded to an increase in clinical efficiency (nearly 40% more patients seen per hour) and clinical satisfaction among physicians. These outcomes accompanied an increase in RVUs from 241 to 336.[8]

An academic urology center saw comparable results, with higher self-reported physician satisfaction and 2.15 more patients seen per hour, leading to an additional 2.16 wRVUs (work relative value units). This increase translates to an additional $542 in physician charges and $861 in hospital charges per hour. [9]

Another 2018 study in a primary care setting found that scribes contributed to a 10.5% increase in wRVUs along with an 8.8% increase in patients seen per hour.[10]

Despite these results, a robust cost-benefit analysis is also required to determine whether the use of scribes impinges upon a given healthcare facility’s financial solvency.

So far, only a few studies have taken this approach.

A 2018 study found that primary care physicians would need to add 127 patients to their clinic and an additional 279 appointment slots annually in order to prevent revenue-loss following the addition of a scribe.[11]

For a typical academic urology setting, a 2015 study estimated that there would need to be an additional 162 patient visits per month with the average net revenue per patient increasing to $107.78 per visit. This additional revenue would offset the cost of hiring three scribes and the corresponding medical personnel to accommodate a higher number of patient visits.[12]

“I have my life back”

Said no physician surveyed anywhere in the literature covered in this review.

Perhaps the second most compelling reason for hiring and maintaining medical scribes is decreasing the overall time spent on non-clinical tasks, which can impact work-life balance.

In a number of studies, physicians self-reported that scribes increased productivity in their clinical workflow, the quality of physician-patient interactions, and improved satisfaction among clinicians.

Providers in a 2018 study at a pediatric ED reported they were more efficient with the use of scribes and also less likely to experience burn-out[13]. Increased professional satisfaction was found in a number of healthcare settings, including EDs[14], a family medicine practice[15], and an urology practice[9].

Similarly, other studies have shown that with the use of scribes, ER physicians spend less time charting at home[16], including a five-hour reduction in documentation time per week in one family medicine clinic[17].

These findings, however, aren’t uniform. Some studies found no change in physician satisfaction in an ED setting[18] or a rheumatology and endocrinology clinic[19] after the introduction of scribes.

But Is It a Bullshit Job?

Given the preponderance of empirical evidence that points to the usefulness of medical scribes within clinical practices, we can conclude that this position does not adhere to David Graeber’s stated definition of a “bullshit job.”

Indeed, the work of medical scribes is neither pointless nor pernicious, though one might still hold reservations regarding whether their work is wholly necessary.

To review, medical scribes emerged in conjunction with electronic health records, which are repeatedly noted to have severe deficits that increase burden for medical providers and promote lower-quality healthcare.

Scribes, therefore, could exist as a fix for a problem—EHRs—that ought not to exist, independently of how robustly scribes function in their role.

The issue with this proposition, however, is that there is little empirical evidence to confirm that medical scribes are indeed performing an unnecessary job, given that the current state of EHRs and their lack of usability.

In the coming years, as electronic health records continue to be iterated and improved based on physician feedback, medical scribes might lose prominence as an important component of documentation and disappear from clinics just as quickly as they arrived.

References

[1] Witt, R. C., & Haedtler, D. R. (1975). Nurse-scribe system saves time in the ED. Journal of emergency nursing: JEN: official publication of the Emergency Department Nurses Association, 1(1), 23.

[2] Hixon, J. R. (1981). Scribe system works like a charm in sarasota ED. Emergency department news: EDN, 3(2), 4-4.

[3] Berger, Eric. 2015. “Medical Scribe Industry Booms.” Annals of Emergency Medicine 65 (4): A11–A13. doi:10.1016/j.annemergmed.2015.02.016.

[4] Kreamer, Jeff, Barry Rosen, Debra Susie-Lattner, and Richard Baker. 2015. “The Economic Impact of Medical Scribes in Hospitals..” Physician Leadership Journal 2 (3): 38–41.

[5] Gupta, N J, M Kopp, and B M Becker. 2014. “247 Scribes in an Academic Emergency Department Lead to Increased Charges and Decreased Down Coding.” Annals of Emergency Medicine 64 (4): S88. doi:10.1016/j.annemergmed.2014.07.274.

[6] Bank, Alan J, Christopher Obetz, Ann Konrardy, Akbar Khan, Kamalesh M Pillai, Benjamin J McKinley, Ryan M Gage, Mark A Turnbull, and William O Kenney. 2013. “Impact of Scribes on Patient Interaction, Productivity, and Revenue in a Cardiology Clinic: a Prospective Study..” ClinicoEconomics and Outcomes Research : CEOR 5: 399–406. doi:10.2147/CEOR.S49010.

[7] Heaton, Heather A, David M Nestler, Derick D Jones, Rachelen S Varghese, Christine M Lohse, Eric S Williamson, and Annie T Sadosty. 2017. “Impact of Scribes on Billed Relative Value Units in an Academic Emergency Department..” The Journal of Emergency Medicine 52 (3): 370–76. doi:10.1016/j.jemermed.2016.11.017.

[8] Shuaib, Waqas, John Hilmi, Joshua Caballero, Ijaz Rashid, Hashim Stanazai, Alan Ajanovic, Alex Moshtaghi, et al. 2017. “Impact of a Scribe Program on Patient Throughput, Physician Productivity, and Patient Satisfaction in a Community-Based Emergency Department..” Health Informatics Journal 64 (11): 1460458217692930. doi:10.1177/1460458217692930

[9] McCormick, Benjamin J, Allison Deal, Kristy M Borawski, Mathew C Raynor, Davis Viprakasit, Eric M Wallen, Michael E Woods, and Raj S Pruthi. 2018. “Implementation of Medical Scribes in an Academic Urology Practice: an Analysis of Productivity, Revenue, and Satisfaction..” World Journal of Urology 165 (12). Springer Berlin Heidelberg: 753–57. doi:10.1007/s00345-018-2293-8.

[10] Zallman, L., Finnegan, K., Roll, D., Todaro, M., Oneiz, R., & Sayah, A. (2018). Impact of Medical Scribes in Primary Care on Productivity, Face-to-Face Time, and Patient Comfort. The Journal of the American Board of Family Medicine, 31(4), 612-619.

[11] Basu, Sanjay, Russell S Phillips, Asaf Bitton, Zirui Song, and Bruce E Landon. 2018. “Finance and Time Use Implications of Team Documentation for Primary Care: a Microsimulation..” Annals of Family Medicine 16 (4). American Academy of Family Physicians: 308–13. doi:10.1370/afm.2247.

[12] Carnes, Kevin M, Cornelia S de Riese, and Werner T W de Riese. 2015. “A Cost-Benefit Analysis of Medical Scribes and Electronic Medical Record System in an Academic Urology Clinic.” Urology Practice 2 (3): 101–5. doi:10.1016/j.urpr.2014.10.006.

[13] Addesso, Luke C, Mark Nimmer, Alexis Visotcky, Raphael Fraser, and David C Brousseau. 2018. “Impact of Medical Scribes on Provider Efficiency in the Pediatric Emergency Department.” Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, August, acem.13544. doi:10.1111/acem.13544.

[14] Allen, Brandon, Ben Banapoor, Emily C Weeks, and Thomas Payton. 2014. “An Assessment of Emergency Department Throughput and Provider Satisfaction After the Implementation of a Scribe Program.” Advances in Emergency Medicine 2014 (3). Hindawi: 1–7. doi:10.1155/2014/517319.

[15] Gidwani, R., Nguyen, C., Kofoed, A., Carragee, C., Rydel, T., Nelligan, I., … & Lin, S. (2017). Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial. The Annals of Family Medicine, 15(5), 427-433.

[16] Martel, Marc L, Brian H Imdieke, Kayla M Holm, Sara Poplau, William G Heegaard, Jon L Pryor, and Mark Linzer. 2018. “Developing a Medical Scribe Program at an Academic Hospital: the Hennepin County Medical Center Experience..” Joint Commission Journal on Quality and Patient Safety 44 (5): 238–49. doi:10.1016/j.jcjq.2018.01.001.

[17] Earls, Stephen T, Judith A Savageau, Susan Begley, Barry G Saver, Kate Sullivan, and Alan Chuman. 2017. “Can Scribes Boost FPs’ Efficiency and Job Satisfaction?.” The Journal of Family Practice 66 (4): 206–14.

[18] Hess, Jeremy J, Joshua Wallenstein, Jeremy D Ackerman, Murtaza Akhter, Douglas Ander, Matthew T Keadey, and James P Capes. 2015. “Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice..” The Western Journal of Emergency Medicine 16 (5): 602–10. doi:10.5811/westjem.2015.6.25432.

[19] Danila, Maria I, Joshua A Melnick, Jeffrey R Curtis, Nir Menachemi, and Kenneth G Saag. 2018. “Use of Scribes for Documentation Assistance in Rheumatology and Endocrinology Clinics: Impact on Clinic Workflow and Patient and Physician Satisfaction..” Journal of Clinical Rheumatology : Practical Reports on Rheumatic & Musculoskeletal Diseases 24 (3): 116–21. doi:10.1097/RHU.0000000000000620.

1 thought on “Medical Scribes: Bulls#!t Job or Linch Pin of Modern Health Care?”

  1. As with previous posts, this was very informative, interesting, well researched and insightful. Also, provides further understanding as to the ever increasing costs of modern (industrial?) medicine with corresponding ever increasing illness and disease.
    Do the ends justify the means of sustaining lives that are perpetuated by a dependence on the proliferation of a never ending supply of profit making drugs, new technology with the hire of necessary skilled operators and by those who preScribe and subScribe to this method of systemic medicine?

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