Scribes lead to unintended consequences from electronic medical records

Recently, Dr. Scot Silverstein over at Health Care Renewal published this update to the ongoing story of electronic medical records that are so simple, intuitive and easy to use that doctors and hospitals everywhere are being forced to hire “scribes” to run them.

We’d looked at the resurgence of scribes in a previous post, and Dr. Silverstein’s article seems to confirm that the phenomenon is is here to stay for as long as most “conventional” EMRs remain fundamentally defective. As the good doctor observes so astutely, “you should not have to work around something that is not in the way.”

There is, however, one big difference between this new update on medical scribes and my post of several months ago. Back then, the media had described the salary of these new denizens of healthcare administration as being “$10-$15 per hour”. At the time I opined that this was way too low. After all, you’re lucky in you can hire someone to mow your lawn for those sorts of wages these days. Sheesh, our neighbors paid my middle-school-aged offspring $10/hour to water their garden over the summer.

In truth, the Los Angeles Times article cited by Dr. Silverstein gives a slightly confusing picture of the true cost of EMR scribes. Early on in the report, the newspaper characterizes them as,

typically young, tech-savvy and undaunted by computers. They are willing to work for $8 to $10 an hour with no benefits. Most do the job part-time as college students and plan to go on to full-time careers in medicine or nursing. They say the experience gives them a valuable head start.

Wow, the rates have gone down! Only $8-$10 per hour for these folks? That’s great! Minimum wage in Oregon is currently $8.40 per hour. That means that I can get someone smart enough to learn medical terminology (the average medical student’s vocabulary doubles over four years of medical school), operate an EMR (every one is different, and most all of them are hideously complex), listen carefully (a rare commodity in itself), type quickly (remember, the average follow-up visit only lasts around 7.5 minutes, and you’re supposed to speed things up rather than slow things down), follow instructions and not make any serious mistakes, all for the same salary as someone working at the Taco Bell around the corner. Is the high rate of unemployment in a severe recession great or what?

Of course, all of this assumes that the average medical clinic is willing to hire someone who is: (1) virtually guaranteed to be a temporary and/or part-time employee; (2) hand them a computer; (3) train them in the use of the current EMR du jour (a process which typically takes months to years); (4) cater to their college classes with complex clinic coverage schedules; and (5) then do the same with dozens of other students who will fill in for the rest of the working hours.

If all of this isn’t a winning proposition for improving healthcare productivity, I don’t know what is. Surely most clinics and hospitals will jump at the chance to pay $50,000 per clinician for an EMR plus 19% annually in maintenance fees and other costs, just to make use of this new, inexpensive and transient source of labor. After all,

the system also makes it easier for doctors to bill for all the services they provided. Between seeing more patients and optimizing billing, physicians can boost their revenues by $50 to $60 an hour … Murphy of ScribeAmerica estimates that doctors can see eight additional patients over a 10-hour shift, hiking Medicare revenues alone by $91 an hour.

What a money-maker! Presumably using a scribe gets docs back up to the level of productivity – and income – they had when using paper. Too bad those extra billings will increase Medicare spending, but it is the federal government mandating the use of these things. Fair is fair.

But wait, what’s this? A little further on we find out what’s required to train a modern medical scribe. Again quoting the LA Times,

Dr. Michael Murphy, an emergency physician who started Lancaster-based ScribeAmerica in 2003, said his company has grown from 32 clients last year to 51 now. It’s currently setting up seven programs around the country. The company’s growth is limited by the time it takes to recruit and train high-quality scribes. Even with high demand, there’s no way to cut corners.

‘If scribes write something down inaccurately, lives are affected,’ he said.

Dr. David Strumpf, chief executive of Emergency Medicine Scribe Systems in Santa Barbara, said his company prefers to take on clients located near a four-year college so he can hire bright, ambitious and highly literate pre-med and nursing students. But it’s challenging to learn all the medical terminology and coding procedures, and 20% to 40% of trainees drop out.

‘It’s an incredible experience for the kids,’ said Strumpf, the emergency department chief at Santa Barbara Cottage Hospital who started the company with his medical colleagues four years ago. “They see everything you do, they learn the whole thought process right on the front line. It’s the best exposure to medicine you could possibly get. When I was a pre-med student I would have done this for free.’

Then they drop the other shoe. The good news is that these scribe services train these young bucks and does for you, so that your office, clinic or emergency room doesn’t have to. The bad news? Now their services, “typically cost $20 to $26 an hour, said Alex Geesbreght, president of PhysAssist Scribes in Fort Worth.”

Gosh, that’s a lot more than $8-$10 per hour. Let’s see. That amounts to just about $50,000 per scribe per year. What the heck will all of this cost?

Well, there are about 800,000 clinically active physicians in the U.S., but we can subtract some in specialties where scribes probably aren’t needed, such as radiology, pathology and nuclear medicine. Let’s say that the government eventually succeeds in getting 600,000 physicians to use EMRs. Let’s further assume that that all of these will require scribes in order to practice efficiently enough to take on the 32 million new patients brought into the system by the ACA. And lets further assume that we won’t run out of pre-med students, for if we did I can guarantee that their qualified replacements would be unwilling to work for minimum wage and without benefits. Paying them more could easily double the $20-$26 per hour that scribe companies are already charging for their services.

Simple math tells us that 600,000 scribes x $50,000 per year (not including any benefits!) will add about $30 billion per year to the cost of American healthcare. That may not seem like much given that we currently spend about $2.3 trillion on healthcare each year; it’s only 1.3% of today’s spending. But wasn’t the whole point of our nation’s EMR initiative to drive costs down? Let’s see if we can put $30 billion per year in perspective.

The $800 billion “American Recovery and Reinvestment Act” that was passed in 2009 allocated $20 billion to subsidize the purchase of “certified” EMRs by physicians and hospitals. The average installation and training cost for one of these things is around $40,000 to $50,000 per physician, so even under the most optimistic scenario $20 billion will only cover the acquisition costs for around 444,000 docs. The other 156,000 will have to fork out their own $7 billion to purchase the things. Adding in the cost of scribes, this means that American doctors are incurring $37 billion in capital and operating costs in just the first year of this great experiment, and then (with maintenance, upkeep and scribes), just over $35 billion in ongoing operating expenses each and every year thereafter.
According to this Medicare fact sheet, total Medicare payments to physicians in 2010 are expected to be around $66 billion. That means that scribes and EMR maintenance in future years will eat up about 53% of the gross income physicians receive from Medicare.
What else could we Americans have bought with that much money? At this rate, spending on scribes will cost as much or more than Medicare will spend this year on skilled nursing facilities ($25.5 billion), home health ($20.4 billion), or hospital outpatient services ($30.5 billion). The same amount of money would buy 41% of all generic drugs consumed in the United States in 2009 ($74 billion).
Hmmm. We seem to be bending the healthcare “cost curve” the wrong way – all in the name of modern technology and cost efficiency. (And, of course, subsidizing healthcare information technology industry companies like GE, Cerner, Epic and Allscripts.)

Of course, no one really knows if we’re ultimately going to employ all of those scribes, or even if we can physically find and train that many. Pre-med students don’t grow on trees, and our low costs assume that scribes derive some sort of secondary gain that makes it worth working for minimum wage. But none of that is really the point.

The point is that, like so many things in healthcare, the headlong rush to mandate the use of electronic medical records is chock full of unintended (and almost always adverse), consequences. Dr. Silverstein has written about many of them. These include the creation of new sources of medical errors, the need for additional nursing staff, hopelessly complex user interfaces and massive leaks of sensitive data that would have been unimaginable 20 years ago. Together they generate costs that were never even remotely considered by our elected and appointed officials. These very decisions are now going to help break the bank, and probably without delivering any net increase in the quantity or quality of actual healthcare services.

Here’s a thought. Is there any chance that the management of the healthcare system could please be turned over to people who: (a) actually know something about topic; and (b) are not already firmly committeed to government-run healthcare or the medical-industrial complex? If so, it sure would be less expensive.

If not, every voting patient, provider, parent and taxpayer in the country ought to be asking: “Why not?”

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