Monday, September 06, 2010

The Ultimate Workaround To Mission Hostile Health IT: Humans (a.k.a. "Scribes")

"Gentlemen, we can rebuild him. We have the technology. We have the capability to build the world's first bionic doctor. Dr. Data will be that doctor; better worse than he was before. Better, stronger, faster Worse, weaker, slower." -- parody of Oscar Goldman from the 1970's scifi series The Six Million Dollar Man.

"Gentlemen, we can rebuild him."

The EMR is a technology that was supposed to improve clinical medicine (revolutionize it, some say). It was supposed to facilitate clinical medicine. It was not supposed to slow physicians and others down to the point of impairing their ability to practice medicine.

However, the rosy predictions are not proving to be the case. Instead, we have the ultimate workaround to the health IT mission hostile user experience:

Los Angeles Times
September 6, 2010

This brings real meaning to the observation that "you should not have to work around something that is not in the way."

Just one screen from a Cerner product (from a presentation touting recent addition of a simple database "search" feature that should/could have been present eons ago). Each menu item leads to even more screens, subscreens, menus and pick lists, in labyrinthine fashion. Click to enlarge.

In a domain as complex as medicine, ever-increasing demands for fine grained data on clinical encounters now outstrip the 2010-style human-computer interface's abilities to allow capture of the data without massive interference in the process of medicine itself.

This mismatch is due largely to the limitations of the GUI as the primary user interface (UI) metaphor, especially the widget-centric UI currently in vogue, characterized by massive numbers of screens and GUI widgets, labyrinthine navigation, and forced data entry of artificially and needlessly "atomized" data through interaction with multiple widgets.

CPOE as an example has become a Rube Goldberg contraption (def: "deliberately over-engineered machine that performs a very simple task in a very complex fashion"), the furthest thing from a straightforward "typewriter for orders" as can be.

For instance, a simple order requires interaction with search boxes, multiple drop down lists, scroll bars, check boxes, and other widgets to capture each micro-component of the order, wasting much time compared to writing "Sotalol hydrochloride 120 mg PO BID, first dose now." There are alternatives to "data atomization" and "widget-centricity" in the health IT user interface, apart from simply cleaning up the current interaction disorganization and other weaknesses, but the health IT industry seems largely oblivious to alternatives.

Professor Butts and the Self-Operating Napkin: EMR's have become machines that perform simple tasks in a very complex fashion

Unfortunately, it's difficult to show this complexity using actual EMR images, as most health IT vendors avoid posting screen images and user manuals online, and forbid customers from doing so. They are excessively secretive about their products. Try a Google image search on 'Cerner Millenium' as an example (click here), then compare to an image search on, say, Microsoft Word (click here).

The inappropriate-for-medicine, management information systems (MIS)-derived business model of the healthcare IT vendors and HIT ecosystem also contributes to the, at best, stuck-in-the-1980's health IT user interface. (As an example of these issues, the industry wouldn't even listen to aforementioned UI alternatives even if I served them up on a silver platter, because using the advice would require significant investments on their part to incorporate alternative UI approaches into their products, meaning lower short and medium term profits. Unlike pharma and tangible medical devices, interest in advanced R&D in the health IT industry seems nil. Instead, complacency rules.)

An important question to ponder is whether the dream of the health IT pioneers back in the 1950's and 1960's was too idealistic and indeed unrealistic to begin with. Was it based on "2001, A Space Odyssey"-style overoptimism, and the lack of foreknowledge of how little true progress would be made in the commercial IT market in human computer interaction, artificial intelligence, natural language processing, voice recognition, and other innovations by the 21st century?

Doctors have embraced the scribes as well. "The physicians were spending too much time documenting and not enough time with the patient," said Dr. Robert Steele, chief of Loma Linda's emergency department, which began using scribes in November. "The solution was to take the doctors off the computer, put them at the bedside, and let the scribe do the transcription. It's been a huge success. The physicians love it.

It is not hard to understand why physicians, with their years of training and expertise, would welcome relief from extremely tedious clerical tasks.

Leaders of the three biggest companies providing scribes estimate that about 200 emergency departments in community hospitals and academic medical centers currently use them. More scribes are on the way. Ronald Reagan UCLA Medical Center, Emory University Hospital in Atlanta and Beth Israel Medical Center in New York City said they are exploring the idea. Physicians in other specialties, including urology and family practice, also are starting to adopt scribes.

Still, some physicians question whether college students are equipped to handle the complicated task of charting patients after only two to four months of training. Others wonder why it's necessary to hire additional staff to fill out computerized records that were supposed to be simpler and more efficient than paper.

The key phrase is "were supposed to be simpler and more efficient" than paper. I'd likely be hard-pressed to find robust research supporting that assertion in the scientific literature. I'd be more likely find the origins of this meme in vendor marketing materials.

"It will be interesting to watch whether the need for scribes goes away as the next generation of physicians who grew up with computers and electronic medical records comes in," said Dr. Ann O'Malley, a senior researcher at the Center for Studying Health System Change in Washington, D.C.

This passage implies the bottleneck is those physicians who need to "get used to the IT", whereas a major component of the problem is the health IT user interface itself. Scribes might "go away" if the health IT user experience was vastly improved. The IT needs to become more physician and medicine-friendly.

At Loma Linda [Hospital], Steele said doctors used to spend two minutes with a patient, then take four minutes typing the information into a computer. Now the doctor talks to the patient with the scribe present and summarizes the encounter to the scribe in 30 seconds. While the scribe spends three minutes entering the information into an ever-present laptop, the doctor can spend extra time with the patient.

Afterward, the doctor checks the accuracy of the scribe's chart, makes any necessary additions or corrections, and signs off. Although novice scribes sometimes need the doctor's help in understanding terminology, those with several months' experience usually are spot-on, Steele said.

Again, clerical work is a very poor use of a physician's time. Scribes are a good idea considering 2010's EMR technology, at least from the time/skills perspective.

... [Dr. Michael] Murphy of ScribeAmerica estimates that doctors can see eight additional patients over a 10-hour shift, hiking Medicare revenues alone by $91 an hour.

The companies that develop and sell electronic medical records systems are "in total denial" about how complicated they are for doctors to use, [Dr. David] Strumpf said. "They know these systems need scribes," he said. "They work with us to train our scribes on their systems, but they don't want to be public about it."

(One wonders how much in "denial" the companies are and just who is truly in denial; after all, purchase of these systems just became a governmental priority.)

Here, of course, is the major drawback to scribes: money. Scribes "typically cost $20 to $26 an hour" today, and that number is likely to rise. While the article's contributors maintain that physicians can boost their revenues by "$50 to $60 an hour" using scribes, I wonder if the overall economic impact of the generalized use of tens or hundreds of thousands of EMR scribes would be in the "wrong" direction (i.e., from the payor and government perspective). The billions spent on EMR's were supposed to reduce the costs of healthcare, not increase the expenses associated with it.

I also wonder what could happen when a scribe is not available.

At the University of Virginia Medical Center in Charlottesville, Va., emergency room physicians can complete electronic charts just as fast as scribes, most of whom are pre-med students at UVA. But doctors would rebel if the scribes disappeared, said Dr. Robert Reiser, medical director of the scribe program, which the university runs itself.

Sept. 10 Addendum:

See an interesting financial analysis by Doug Perednia here.

-- SS


Anonymous said...

There is something frighteningly pathetic about this, actually.

Hospitals have spent $ millions on C$HIT certified and Leap Frog and HIMSS promoted devices that have disrupted medical care, causing delays which have contributed to deaths and injuries of unknown numbers of patients and requiring scribes to enter the orders and information as the ultimate of the ultimate work arounds. But are they safe?

The article also reports on the vendors who support the education of the scribes (no doubt, to save their collective a$$es) but two prominent vendors would not return the calls and emails of the reporter.

Your tax dollars have been hijacked for an inferior system of care.

Adverse events are promoted by EHRs and CPOE. Report them to the FDA to be on the record.

Scot M Silverstein MD said...

Anonymous wrote:

The article also reports on the vendors who support the education of the scribes (no doubt, to save their collective a$$es) but two prominent vendors would not return the calls and emails of the reporter.

This is true, as in the article. Doing so would be admitting their P.R. on "ease of use" was not entirely accurate...

-- SS

Dixies mom said...

Given all the valid challenges of using EHRs and the volumes of data and information that RNs must enter and manage, I think nurses need scribes, too.