Thursday, November 12, 2009

Moving Transcription Back Into the Hospital

What's old is new again......A recent article in USA Today (High-tech 'scribes' help transfer medical records into electronic form) highlighted the latest innovation in healthcare documentation - "High-Tech Scribes" who help "transfer medical records into electronic form. Is it just me or does that sound like something that is already going on in the electronic documentation industry with medical transcription and editing for the last 20+ years?

The challenge of capturing clinical documentation in digital format have remained the same and the continued struggle of adoption is highlighted by the poor adoption rate of electronic medical record systems
Today, only 1.5% of hospitals have a "comprehensive" electronic health record, and 8% have a basic version, according to Jha's March study in The New England Journal of Medicine. Most hospitals are intimidated by the cost, which can range from $20 million to $200 million.
Pretty poor given how long the industry has been working on this and despite the length of time still no clear exchange format or standard to facilitate the sharing of information
because there are no common standards for these records, doctors who do implement electronic charts may not be able to share them with a hospital across the street
But the value of digitizing medicine and implementing these systems has been clearly established and the terrifying level of errors that do occur as detailed in the landmark "To Err is Human - Building a Safer Health System" published in 2001 and many follow on reports and studies including he 2005 Health Affairs study that reported:
The country could eliminate 200,000 drug mistakes and save $1 billion a year if doctors in all hospitals entered their orders on computers
Despite these drivers we are still languishing in single digits of adoption and continue to struggle to roll out healthcare technology that effectively improves quality and safety without crushing efficiency and effectiveness of clinicians. So the University of Virginia Doctors elected to employ "scribes" to document the clinical encounter and these individuals such as:
Leiner, 22, a University of Virginia graduate who plans to apply to medical school
Who follow the doctors around and capture the clinical interaction on laptops. The consensus appears to be this will not catch on although a recent debate on the AMDIS list server offered some differing opinions that included some potential to reduce mistakes given the second set of eyes reviewing the documentation and the capture of the information real time with the patient. There is complexity in this approach made worse with gender conflicts (female patient and male scribe for example) but this approach appears to represent a modification of the current documentation process that uses dictation and transcription and perhaps offers some potential to free up clinicians to interact with patients rather than focusing on the clinical documentation and the electronic health record.

Moving the medical editor out of the bowels of the hospital just formalizes one of the well known methodologies in many transcription departments that attempts to link doctors to the same transcriptionists so they learn to "work together" (albeit remotely). This would make the bond stronger, the connection greater and the opportunity for error reduction using a trained and qualified "scribe" to document with the clinician. The medical editor is qualified, experienced and a highly knowledgeable resource that is currently disconnected from the clinical process.

Technology just becomes a facilitator in this process with speech understanding and speech recognition providing tools that can be used by one or both of the documentation team. The electronic medical record becomes integral to the documentation process. And although the real time aspects of alerts, evidence based medicine and the application of real time clinical knowledge to the interaction is still once removed from the physician the real time team documentation can provide direct access to the clinician through a combined approach to the capture and recording of the patient encounter.

How would you feel about a scribe being part of the clinician patient interaction - as the patient, as the clinicians or as the scribe?


Nick van Terheyden, MD said...

An interesting commentary on the use of scribes in a local hospital that added 20 - 25% efficiency for this Emergency Room Doctor

moviedoc said...

I can see problems with the scribe concept (and I'm a double UVa grad myself). The doc is the one who (thinks she) knows what is important to capture. Most docs don't even review their own transcribed records. For them to take the time to review what will probably be even longer scribe records would add a huge amount of wasted time. And we haven't even talked about who pays the scribe how much. It's yet another HIPAA question. Scribes will certainly be regulated like everyone else in medicine. They will require certification; standards must be developed. Medical documentation is a moving target. The sad thing is the degree to which it is driven by attempts to document what the doc will need to defend against a malpractice suit where it should serve to enhance clinical pursuits.

Lynn said...

The inefficiency and un-scalability of this solution is almost mind boggling. A one-to-one match between physician and "scribe"? Really, rather funny considering that hospitals have been using technology to eliminate transcription costs - who is paying for the scribes? What we're hearing is even more evidence that technology such as speech understanding or speech recognition, when coupled with a skilled medical transcription editor, is a viable, cost efficient way to allow physicians to capture clinical information while keeping their attention where it belongs - on the patient.

moviedoc said...

(sheepishly) I told this story to an ophthalmologist Friday. He said one of his colleagues has been very happy with using a scribe in his practice, that it has allowed him to see more patients. Go figure.

Cary Deshazer said...

I would love to be the "scribe" for some docs! I've been a transcriptionist for 22 years and an editor for the last 2. It would be great to actually capture their visit with the patient in real time, without the usual problems of a doc's dictation.