Doctors hiring scribes because of electronic medical records

I was visiting with my physician colleague Debbie the other day, which is always a pleasure. She is, by far, one of the best dermatologists I know. She had purchased an electronic medical record (EMR or EHR) a year or two ago and I asked her how it was going.

“Pretty well,” she said, “but I’ve had to start using a scribe. It’s just too inefficient any other way. I was losing too much time and money.”

Of course she’s also losing money by hiring a scribe, but Debbie is very persistent and always wants to do the right thing. This is one reason why her patients and I admire her so much. This is her second EMR, by the way. The first one – purchased for tens of thousands of dollars – was a total disaster and had to be scrapped entirely.

Unfortunately, Debbie’s experience is the norm when it comes to provider offices trying to deploy EMR technology. And it’s costing healthcare providers dearly as they struggle to make ends meet. It’s well known that, in the vast majority of cases, EMRs make doctors far less efficient when seeing patients.

This is because it’s rather difficult to tend to the computer when you’re supposed to be tending to the patient. It’s relatively easy to write with pen and paper while listening and explaining. It’s far harder to keep two hands on a keyboard, a third hand on the mouse, one eye on the screen and another eye on the patient and his family. And the fact that most EMRs and user interfaces are designed by computer geeks with no knowledge of clinical care or workflow certainly doesn’t help matters. As soon as EMRs are deployed, physician productivity typically goes down by about 50%. It rarely gets back to where it was prior to installation.

Resorting to “scribes” is an increasingly common way to try to get around this mess. Since physician time is scarce and expensive, the thinking goes, why not hire someone cheaper to handle all the new busywork generated by computers? As a result, whole companies have arisen whose only function is to hire out people to type stuff into electronic medical records.

A recent article on the topic has estimated that there are now over 2,500 of these purely administrative employees. According to the article each of these scribes earns between $10-$15 per hour, or about $30,000 to $40,000 per year when benefits and other expenses are included. (However based upon what I know about the cost of medical office staff, these numbers are far too low. Just try finding quick, smart and highly computer-literate people for that salary who are not students and will be willing and able to work on a long-term basis. You’ll be looking for a very long time.)

Of course, many EMR vendors are delighted with this trend, because it gets them off the hook for creating clumsy and time-sucking software. In this recent article, EMR company founder Dr. Randall Oates explains how good it can get:

Oates said a handful of physicians at two sites in his former group practice based in Fayetteville have completed the first round of testing of a practice overhaul regime using an EHR as a core tool with physicians leveraging their EHRs by using scribes. Oates said the group is in its second round of testing whether the process can be reproduced. Results are expected by summer, he said, but so far, the early returns are impressive.

‘My ex-partners have twice the income of an average family practitioner,’ Oates said. ‘The bottom line, and I’ll make it real simple, the family practitioner only has to see one extra patient every three hours to cover the cost of the remote scribe and the technology.’

Physicians using the system have one computer in the exam room with the patient and another computer in a room set aside for the scribe, who listens in via a microphone in the exam room and documents the encounter.

Well that’s one way to look at it. Here’s another perspective that’s a bit more Hellth-prone. If you don’t want to increase the number of patients you see in the course of the day, this “productivity solution” has just reduced your net revenue by an average of 2.67 patients per doctor each and every practice day. If you’re a doctor who sees an average of 30 patients per day (about one every 15 minutes), that’s going to suck up almost 10% of your gross practice revenue.

If all of the doctors in the U.S. end up doing this, it’ll add at least $50 billion annually to provider overhead expenses. This is more than the annual gross domestic product of Bulgaria. It’s also enough to buy great health insurance for over 4 million families. Of course, this doesn’t even include the cost of the additional room required for the scribe and his computer. That will be extra.

This doesn’t bother Dr. Oates because, he says, using scribes allows his test doctors to see far more patients. As he explained: “They’re scheduling eight an hour with very high patient satisfaction, structured data entry and the note is complete at the end of the encounter.”

That’s just 7.5 minutes per patient visit, including all time for history, physical exam, prescribing, explanation and patient education. Good grief.

Let’s say that you’re the patient. Would you be satisfied with that?

All I can say is that you’d better not be chatty. Or have any complex medical problems.

Doug Perednia is an internal medicine physician and dermatologist who blogs at Road to Hellth.