The current approach to EHR implementation, in which the physician is supposed to document the encounter on a computer, is, Oates said, “complete insanity, turning doctors into data-entry clerks. We're going to look back on these days the way we look back on bloodletting with leeches."
Instead, what's needed is a way to revolutionize healthcare, Oates said. “There's no choice. You look at reimbursement and primary care and it's going to be dead if there is not a fundamental change and the fundamental change is to become good businesses.”
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.
“Both the scribe and the physician have to be able to control the desktop,” Oates said. “The scribe is creating the documentation, but most of the documentation is already collected before the doctor ever gets in the exam room. If the patient is in for hypertension, the scribe will know to automatically pull up the vital signs in a view. The doctor should not have to do that navigation. The doctor should be able to be empowered to do the high-touch patient care."
The system radically accelerates patient throughput, according to Oates.
“They're scheduling eight an hour with very high patient satisfaction, structured data entry and the note is completed at the end of the encounter,” Oates said.
Oates said the first scribe used in the experiment was a computer “geek” with no medical background, “but we needed a geek to help us make this technology work,” he said. After that, the practice trained “a highly intelligent former waitress” and “three burned-out medical transcriptionists.” Oates predicted there is “a whole community of unemployed medical transcriptionists that I think will jump on this.”
Todd Guenzburger is a hospitalist and medical director of information services at the five-hospital Legacy Health System in Portland, Ore.
In all, 38 physicians, maybe 30% of all physicians in the medical group working in the emergency departments at the five-hospital system, use scribes, Guenzburger said. The program began with scribes using the templated, paper-based, T-System, for charge capture and has been moving to an EHR over the past five years, he said.
At the one paperless hospital in the system, 139-bed Legacy Salmon Creek Hospital, Vancouver, Wash., scribes and ER physicians have been charting with the electronic version of the T-System, but entering orders with the hospital's Cerner EHR, Guenzburger said. “I think the success of the scribe program depends on the quality of the individual and the training,” Guenzburger said. “A lot of the scribes enter on into medical school. The training and experience has helped them.”
Physicians who do use scribes, “use them a lot and have favorite scribes,” Guenzburger said.
Going forward, as Legacy implements a new EHR systemwide, it remains to be seen whether any more physicians will be using scribes, since the system is trying to customize and improve the new vendor's emergency department module, Guenzburger said.
“We have about eight to 10 docs working on that to make it more robust,” Guenzburger said. “I think the people who are using scribes will continue using the scribes. I think scribes have their place. We definitely would not let them do order entry. It completely defeats the purpose of physician order entry, to my frame of mind, and it is beyond their professional scope. The whole point to me of computer order entry, if you're going to buy the argument that it is a safer way to provide care, is you get rid of the middle man and you increase the efficiency by making sure it gets done right the first time.”
Guenzburger, a primary-care physician by training, said, in his view, only the higher-paying, office-based specialties can afford to use scribes. Meanwhile, “It's just a little irritating to me that the little GP really can't afford to get a scribe” and keep a normal pace in which both the patient and the physician benefits.
“I couldn't imagine a worse thing to happen to primary care than doubling your practice from 30 patients a day, which I already think is too much,” Guenzburger said.
“It is everything about destroying the primary-care relationship when everything is about productivity,” he said. “People want that relationship,” he said, but “there is no place for the doc and the patient to have a relationship. That's why I left primary care. I didn't have the patience to try to change that and it probably won't change anytime in my professional career.”
