Can EHR Scribes Create Consistent and Accurate Healthcare Data?

Can EHR Scribes Create Consistent and Accurate Healthcare Data?

The EHR is expected to ease processes such as medical chart reviews. EHR scribes are increasingly used by physicians now but is the data produced reliable?

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In any industry, easy access to the required information is vital for timely and appropriate action. In the health sector, processes such as medical chart reviews can be speeded up only if the medical records are retrieved quickly and with minimum effort. This ease of access and use is what the EHR or electronic health record promises. Unfortunately, this new system presents many challenges for which it is being criticized from all quarters. The EHR is charged with distracting physicians from their patients, creating physician burnout, and extending work days. We find many healthcare organizations increasingly relying on EHR scribes who are specially trained in transcribing clinical discussions into digital documentation, much like what a medical transcriptionist would do.

Essentially, scribes assist physicians with EHR navigation, documentation, retrieving diagnostic results, and coding. The physician in turn gets time for patient care. The issue here is that the position of the scribe remains minimally regulated – for instance, there are no requirements for certification. Any certification scribes receive is voluntary, and the minimum qualification to work as a scribe is a high school diploma.

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CMS doesn’t provide official guidelines on the use of scribes, and does not bar nonphysician providers such as physician assistants, clinical nurse specialists, and nurse practitioners from using the service of scribes.

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The Joint Commission doesn’t endorse or prohibit the use of scribes. They permit scribes to document the previously determined physician’s dictation and/or activities. Scribes are not permitted to act independently, with the exception of obtaining past family social history and a review of systems (technique providers use to obtain the patient’s medical history.)

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A scribe doesn’t necessarily be employed by the hospital they work at. Hospitals can use scribes to bridge volume gaps, which would enable a smaller number of physicians to treat a greater volume of patients.

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The provider is required to add and sign an addendum to the scribe’s note when the scribe makes an entry on a paper medical record and correction is needed, rather than alter/cross out what the scribe has written.

The important question is whether scribes produce accurate health data. A study conducted by the Oregon Health & Sciences University has found that there is significant variation in the length, accuracy, and comprehensiveness of the clinical notes EHR scribes create for physicians. Five scribes participating in sample OB-GYN encounters were provided the same information to transcribe into an EHR system. Only 17% of data elements were in agreement across all of the resulting notes. This indicates that

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subjective interpretation may vary the accuracy and usefulness of EHR documentation.

Other findings of the study are as follows: •

Individual scribe accuracy fell in the range 50 to 76% when compared to “gold standard” notes for 3 different scenarios that were generated from a simulated, videotaped, patient-physician interaction.

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The standard notes comprised 118 – 150 distinct data elements the scribes had to capture.

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More than a quarter of all data elements created by scribes were unique to individual scribes.

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Less than 40% of the documented diagnoses and plan items were found to be in common across all the five scribes.

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There was a two-to four-fold difference in the number of data elements present for each scribe.

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Marked differences were seen in length of content, language choice, style, and structure.

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Errors of omission and errors of commission were quite frequent.

This study is very significant because it clearly shows that proper education and training, along with regulatory guidance, and certification are indispensable when it comes to EHR scribes.

As of now, physicians are responsible for signing off on a scribe’s work before adding the note to the patient’s EHR. So ultimately they are accountable for the patient’s treatment outcome. With uncertified and untrained scribes, physicians may find that they spend large amounts of time correcting the documentation made by the scribe or trying to remember whether the scribe has accurately captured the consultation. The study authors mentioned above emphasize that scribes should be given appropriate training that directly links their learning needs with measured outcomes, and this can be accomplished via good training regimens that assess individual competencies that are relevant to accurate EHR documentation.

www.mosmedicalrecordreview.com

(800) 670 2809