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Do We Need Stricter Scribe Standards?

Posted on June 9, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

As most readers will know, scribes have gone from a neat idea to a fixture in many clinical settings. Though the long-term effect of their participation has yet to be determined, so far it seems that scribes have been proven to be quite useful. Not only are they saving time, they’re helping physicians connect with patients again, rather than their computer screen.

That being said, when you hire a scribe you don’t always know what you’re getting. After all, there’s no such thing as a scribe certification accepted by the healthcare industry as a whole. There are schools which offer aspiring scribes a thorough education in the essentials of medical terminology and practice, but they don’t need to adhere to a single national standard.

This lack of standardization could turn out to be a problem, according to Dr. Jeffrey Gold. In an article for The Doctor Weighs In, Dr. Gold concedes that scribes seem to be offering real benefits, noting that researchers have found that scribes can enhance physician efficiency, boost physician satisfaction and even increase billing. And he notes that scribes may improve patient satisfaction, as they make it easier for physicians to connect with patients during visits.

But despite the benefits they offer, Dr. Gold says he’s concerned about the lack of regulation concerning how scribes participate in healthcare. For example, he notes that researchers haven’t yet assessed scribes’ ability to interface safely with the EMR.

His concerns seems to be shared by the Joint Commission, which requires that providers signed all scribe-generated orders prior to implementation, that healthcare organizations document the ability of scribes to perform their assigned tasks. These concerns arise because scribes aren’t held to a common standard, Dr. Gold contends.

“Scribes have a wide variety of backgrounds, including premed students and certified medical assistants,” he notes. “…Unfortunately, few rules or standards currently exist that designate appropriate scribe activities.”

Scribe training varies a great deal as well, he notes. To make his point, Dr. Gold cites a study by medical malpractice insurer The Doctors Company and Oregon Health and Science University which looked at scribe capabilities and backgrounds. He notes that the survey, which had 335 respondents, found that 44% of scribes had no prior experience, and that only 22% of scribes have had any form of certification.

Under these circumstances, using scribes might come with some unexpected risks, he suggests. “The combination of rapid growth in scribe use, lack of standardized training, variability in scribe experience, and variability in both EHR exposure and EHR workflows raises the concern that scribes may introduce potential negative unintended consequences to either workflow or documentation,” he writes.

It is worth noting that another of Dr. Gold’s fears is that scribes will be asked to take on more complex EMR work which, if handled badly, could also lead to problems. He’s concerned that scribes may simply accumulate such duties due to “functional creep.”

For myself, while I understand Dr. Gold’s concerns, I don’t feel the situation is as dire as he suggests. Yes, it would probably be appropriate and beneficial to standardize scribe training, as it never hurts to boost the professionalism of any party participating in the care process. At the same time, though, with many scribes being trained largely by their employers, there will be a lot of variation in outcomes anyway.

But maybe I’m wrong. What do you think? Is it important to give scribes or standardized training and ask them to meet national certification standards? Or are they working effectively as is?

EMR Issues That Generate Med Mal Payouts Sound Familiar

Posted on February 8, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

When any new technology is adopted, new risks arise, and EMR systems are no exception to that rule. In fact, if one medical malpractice insurer’s experience is any indication, EMR-related medical errors may be rising over time — or at least, healthcare organizations are becoming more aware of the role that EMRs are playing in some medical errors. The resulting data seems to suggest that many EMR risks haven’t changed for more than a decade.

In a recent blog item, med mal insurer The Doctors Company notes that EMR-related factors contributed to just under one percent of all claims closed between January 2007 through June 2014. Researchers there found that user factors contributed to 64% of the 97 closed claims, and system factors 42%.

The insurer also got specific as to what kind of system and user factors had a negative impact on care, and how often.

EMR System Factors: 

  • Failure of system design – 10%
  • Electronic systems/technology failure – 9%
  • Lack of EMR alert/alarm/decision support – 7%
  • System failure–electronic data routing – 6%
  • Insufficient scope/area for documentation – 4%
  • Fragmented EMR – 3%

EMR User Factors

  • Incorrect information in the EMR – 16%
  • Hybrid health records/EMR conversion – 15%
  • Prepopulating/copy and paste – 13%
  • EMR training/education – 7%
  • EMR user error (other than data entry) – 7%
  • EMR alert issues/fatigue – 3%
  • EMR/CPOE workarounds -1%

This is hardly a road map to changes needed in EMR user practices and system design, as a 97-case sample size is small. That being said, it’s intriguing — and to my mind a bit scary — to note 16% of claims resulted at least in part due to the EMR containing incorrect information. True, paper records weren’t perfect either, but there’s considerably more vectors for infecting EMR data with false or garbled data.

It’s also worth digging into what was behind the 10% of claims impacted by failure of EMR design. Finding out what went wrong in these cases would be instructive, to be sure, even if some the flaws have probably been found and fixed. (After all, some of these claims were closed more than 15 years ago.)

But I’m leaving what I consider to be the juiciest data for last. Just what problems were created by EMR user and systems failures? Here’s the top candidates:

Top Allegations in EMR Claims

  • Diagnosis-related (failure, delay, wrong) – 27%
  • Medication-related – 19%
    • Ordering wrong medication – 7%
    • Ordering wrong dose – 5%
    • Improper medication management – 7%

As medical director David Troxel, MD notes in his blog piece, most of the benefits of EMRs continue to come with the same old risks. Tradeoffs include:

Improved documentation vs. complexity: EMRs improve documentation and legibility of data, but the complexity created by features like point-and-click lists, autopopulation of data from templates and canned text can make it easier to overlook important clinical information.

Medication accuracy vs. alarm fatigue: While EMRs can make med reconciliation and management easier, and warn of errors, frequent alerts can lead to “alarm fatigue” which cause clinicians to disable them.

Easier data entry vs. creation of errors:  While templates with drop-down menus can make data entry simpler, they can also introduce serious, hard-to-catch errors when linked to other automated features of the EMR.

Unfortunately, there’s no simple way to address these issues, or we wouldn’t still be talking about them many years after they first became identified. My guess is that it will take a next-gen EMR with new data collection, integration and presentation layers to move past these issues. (Expect to see any candidates at #HIMSS16?)

In the mean time, I found it very interesting to hear how EMRs are contributing to medical errors. Let’s hope that within the next year or two, we’ll at least be talking about a new, improved set of less-lethal threats!