To Scribe or Not to Scribe: Cardiologists Seek Solutions for Electronic Health Record Woes

Electronic health records (EHRs) are creating challenges for physicians and patients alike. Both say they are seeing less of the other over the barrier of computer screens. To meet documentation expectations, many physicians are working longer hours and suffering alert and click fatigue that may contribute to burnout. For some cardiologists, hiring a medical scribe may help.

Put simply, medical scribes serve as intermediaries between physicians and the EHR (J AHIMA 2012;83:11). Scribes may join physicians and patients in exam or procedure rooms, or they may log in remotely. In either case, their job is to document in the EHR what occurs during the interaction: details the patient shares, the physician’s observations, decisions about next steps and so on. Medical scribes may perform on-the-spot research, such as reviewing medical records, calculating risk scores or pulling up drug information and previous test results. According to a 2014 technology survey, almost 30 percent of physicians across a range of specialties were using scribes (www.physicianspractice.com, 2014). Among cardiologists, however, the utility of these extra hands is a topic of debate.

Believers vs. skeptics

Proponents of scribes say the benefits include improved efficiency and greater revenue for practices. They note increased satisfaction for both patients and physicians.

Opponents eschew adding the cost of another staffer to the bottom line, saying efficiency and patient satisfaction can be achieved with better time management and by assigning some EHR tasks to current team members.

“People who use scribes [say] the value that scribes bring is incrementally much greater for those people who face several of the challenges in documentation:  timeliness, ability to move through their day and navigate their EHR, particularly in an ambulatory setting,” says Ty J. Gluckman, MD, medical director for clinical transformation at the Providence Heart and Vascular Institute in Portland, Ore. His health system, Providence Health and Services, began piloting the use of scribes in its cardiology department in 2015. 

Gluckman’s health system considered hiring scribes in part because of variations in physicians’ experience and comfort using computers.

Although some members of the system had experience with EHRs, his clinic’s shift from paper to an EHR was not smooth. More than three years later, many of those same clinicians are still struggling, working longer hours and expressing disappointment with their patient interactions.

Other cardiologists, such as Jeffrey Westcott, MD, medical director of the cardiac cath lab at Swedish Heart and Vascular Institute in Seattle, say the benefits of scribes can be realized without the costs of hiring, paying and training another team member. He and his team have focused on streamlining workflow and leveraging the skills of nurses and physician assistants (PAs) to help with documentation.

When it comes to scribes, believers and skeptics may be on a different page, but they have similar goals: increased satisfaction for patients and providers, greater productivity and improved efficiency, all while aiming to minimize financial drain on the healthcare system. 

Productivity, time & revenue

Alan J. Bank, MD, director of medical research at United Heart and Vascular Clinic and Allina Health in St. Paul, Minn., conducted a year-long study comparing productivity with and without scribes at his cardiology clinic and emerged in favor of hiring them. He found cardiologists saw almost 10 percent more patients when using a scribe. His hospital system added 16 scribes to assist 10 physicians at a cost of less than $100,000. They added nearly $1.4 million in additional annual revenue (Clinicoecon Outcomes Res 2015;7:489-495). The cardiologists who used scribes saved an average of 2.5 hours per day by eliminating clerical work, according to Bank, who says hiring scribes spared physicians from  “wasting time doing [work] they don’t need to be doing,” such as updating charts and clicking through EHR alerts and windows that contribute to fatigue.

“Everybody wins,” Bank says. “This was a 14-to-1 return on investment,” says Bank. With scribes, he notes, the U.S. healthcare system may also win “because the patient gets better care and it’s a much more efficient system.”

Screen time vs. face time

Data on whether scribes have a positive impact on patient satisfaction are varied (J Am Board Fam Med 2015;28:371-381), with the biggest gains among patients treated in the emergency department. Bank and his colleagues noted sustained satisfaction between baseline and “scribe days” and improved satisfaction with interaction in cardiology clinics among both patients and physicians. He noted that scribes improved physician satisfaction more than patients’ (Clinicoecon Outcomes Res 2013;5:399-406).

The main difference, according to Gluckman, is that scribes remove the barrier of the computer from between the patient and physician. When physicians are distracted by a computer, patients feel their needs are neglected and physicians question the quality of the care they’re providing. Bank points to gains in efficiency. While he is talking with a patient, the scribe can be researching a medication, accessing historical imaging or scheduling appointments.

Teams work

Scribes work best, Gluckman says, when the whole team, including the physicians, nurses and staff, have been trained in standardized documentation, clinic workflows and policies. “It’s not realistic to think that scribes will be familiar with all of these workflows or [cardiology] terms from the start, and so ongoing education is an imperative,” he says.

Adding scribes to cardiology clinics requires effort from both physicians and scribes. For physicians, it means developing best practices and a clear outline of roles, requirements and basic templates that every member of a clinic will use. Scribes “require training by someone who is savvy with the EHR and who has an understanding of best practices that cascade to the multiple providers they work with,” says Gluckman.

Westcott has no plans to hire a scribe, but his thoughts on process and teamwork parallel Gluckman’s. In his practice, Westcott has tackled the challenges of EHR documentation with modifications to how he and his team work and by ensuring that all team members are rigorously trained on EHR documentation. Before Westcott sees each patient, a nurse or PA fills in specific areas of the EHR and distills key data about each patient onto a single page that Westcott reviews before the visit starts. Then, after each visit, it takes only minutes for him to record notes in the EHR.

This system might not work in high-pressure emergency and ambulatory environments, Wescott says. In those settings where he doesn't have "an established relationship with a patient, [EHR documentation] would get in the way of getting my work done," he explains. “To have a scribe follow me around so I could spend more time with the patient would be great.”