Many in the health field credit the general wizardry of computer engineering for innovations in electronic medical documentation that are helping ease patient flow, improve data collection, and prevent medication errors.
But emergency medicine may be solving a problem that has dogged computer science for decades: how to stay personally connected amid growing information technology. It's a challenge being addressed by institutions from Microsoft to the U.S. military.
One answer may be found in the emergency department at the University of Virginia in Charlottesville. There, emergency physicians can keep their attention focused solely on the patients rather than a keyboard or paper chart, thanks to the newest group of employees. They function for the most part like silent partners, their job only to record patient encounters.
They are medical scribes, and emergency physicians there say they are making a big difference in the ED.
How big? In a study conducted on scribes, undertaken to determine whether they were cost-effective and accurate, significant improvements in documentation were shown in completion of coding and in bolstering revenue. The average charge for visits increased by $42, a 15 percent boost. (Acad Emerg Med 2008;15:S216.)
The program appears to be mutually beneficial. It pays for itself by saving time and increasing productivity while affording pre-med students a way to earn money and gain clinical experience. “They are smart people, and it has gotten harder to give [undergraduate] students valuable experience in medicine” due to patient-privacy concerns, said Scott Syverud, MD, a professor of medicine at UVA and a co-author of the study. “It is a win-win.”
Dr. Syverud also helped shepherd the program, which began 18 months ago. One nice side effect also seems to be enhanced workplace satisfaction, at least for some physicians. Llike any new system, though, scribes take some getting used to, said Claire Plautz, MD, an assistant professor of emergency medicine at the University of Virginia Health System. “I don't know what others have done, but I had to re-sequence my way of seeing patients since I did not need to sit down and do documentation,” she said. “It took about a week for me to get accustomed.”
The time that documentation takes can be fairly variable depending on the demands of the entry system, according to published time-motion evaluations. When the state of California examined how health IT was being used by physicians and in community clinics, the findings indicated that while most physicians thought health IT was a helpful advance, the electronic medical record in particular, about 30 percent of them resisted the change. This was the same group that overwhelmingly agreed health IT and the EMR helped them provide better care. (California Health Care Foundation 2008).
Why the discrepancy? Surveys from KPMG, an international business consulting firm, show that careful planning, ease of use, and supplier responsiveness help pave the way to IT success. Beyond that, however, hard-to-forecast human factors govern acceptability.
Most accounts on health IT show increased time expenditure for electronic entry by health care providers compared with paper charting. Moreover, those extra minutes can be precious ones; they often are spent without human interface, to put it in the lexicon of organizational psychology.
The computer engineering literature has started labeling this as the “connectedness” question: Just how much do state-of-the-art communication tools detract from human interaction?
Human distraction by IT systems may be perceived by medical users to include deterrence from patients and interference with autonomy, say some military-based studies, such as one by the Veterans Affairs Medical Centers. When the Agency for Healthcare Research and Quality looked at why VA doctors overrode alerts on potential drug interactions—arguably the most important error-prevention feature to come from electronic order entry systems—the findings showed that physicians became annoyed with insignificant prompts, even taking time to type in sarcastic reasons for using the override feature. (Am J Manag Care 2007;13:573.)
This past November, Robert Half Technology of Menlo Park studied connectedness by surveying more than 4,100 chief information officers. As it turns out, even among these IT professionals, the personal touch is essential. A third of the respondents felt no more connected despite all the new technology. When asked how staff liked to communicate, 43 percent listed e-mail, but a fairly close second, at 35 percent, was in-person conversation.
The finding prompted Katherine Spencer Lee, the executive director of Robert Half Technology, to assert in a prepared statement that “when conveying potentially sensitive information, nothing can replace the value of face-to-face communication.” In a study commissioned last year by Microsoft to determine what a national cross-section of executives thought were essential employee skill sets, a majority of them listed “people skills” as more important than IT knowledge.
It would probably come as no surprise to many IT experts that by employing scribes to collect data, documentation isn't the only thing enhanced, so is employee morale.
“We have a small minority of docs who like to do their own documentation, and they are good at it, so they tend to go without using scribes,” Dr. Syverud said. “But the majority does use scribes, and many of them actually want more time with them.”
So does documentation truly interrupt the patient-physician relationship, or is that just a perception? “That is an interesting question,” said Phillip Asaro, MD, an assistant professor of emergency medicine and informatics at Washington University School of Medicine in St. Louis. A study he and his colleagues did suggested computerized provider order entry only negligibly affected patient time with caregivers. And the trade-offs are likely worth it, or they will prove to be down the road, he predicted.
“Although both nurses and physicians experienced a significant shift toward tasks on computers from other activities, this was not primarily at the expense of face-to-face time with patients,” he said. For nurses, the percent of time spent in direct patient care was 56.9 percent before implementation of the system and 55.3 percent after it. For physicians, the percent of direct care time was 36.8 percent before and 29.1 percent after, a difference that did not quite reach statistical significance at the 95% confidence level. (Acad Emerg Med 2008;15:908.)
Most of the increase in time on computers came as a direct shift from time spent working on paper forms, he noted. “With regard to provider order entry in and of itself, there are reports in the literature of significant increases in time requirements for electronic versus paper orders,” he said. “Our data are not inconsistent with this conclusion. However, as we point out in the paper, we see evidence of improved workflow, enabled by electronic orders, which appears to offset the added burden.”
Moreover, the lack of “apparent detrimental effect on throughput in the ED is further evidence that this implementation did not tie up providers, keeping them away from necessary patient care tasks,” he added.
In addition, there is likely “improved information flows and streamlined workflow,” he observed. To date, certain potential benefits have not been fully measured about the EMR, such as potential improvements in patient safety. “Nor do our data provide insights into potential adverse effects of the electronic system,” he said, noting that both beneficial and adverse effects of electronic ordering systems have been reported. “Having said that, I of course believe that, with further development of EMR systems, the benefits will far outweigh the adverse effects,” said Dr. Asaro.
When asked whether scribes might increase those benefits, Dr. Asaro said although he doesn't have direct experience with scribes, he said he understands the use of scribes can be very beneficial, he said. A scribe can improve workflow by removing much of the burden of documentation and order writing, freeing the physician to interact with patients.
“It seems to me that this would be just as true with electronic order entry and electronic documentation systems as it is with paper,” he added. It might be argued, however, that the greatest patient benefit to come from the EMR will be in clinical decision support, but much of this benefit is as yet unrealized in current commercial systems, he pointed out.
In the University of Virginia ED, scribes so far document about a third of the patient encounters, Dr. Syverud said. They are screened by academic resume and interview, and trained to be “flies on the wall,” as he puts it. Unlike other programs that have had a hitch or two with such personnel intruding on the patient-history process being conducted by the physicians, that particular problem has not happened.
Dr. Syverud credits Courtney Terry, a fourth-year medical student, with much of its early success. “She was a scribe, then a chief scribe, so she really understood how this would go,” he explained.
Dr. Plautz agreed, noting that the scribes make her more efficient and increase her billing with more thorough documentation. “But, in exchange, you have to review what they have written,” she said. Physicians also have to keep in mind that scribes may “have no clinical training, and there are plenty of things that may require clarification.”
“Consider the scribe as a personal tape recorder,” Dr. Plautz advised. “They only write what they hear from you, and in most cases, we say more than we document about the patient encounter.”
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