An EHR System Without Scribes Is Like a Jaguar Without Tires

Jason Ruben , MD

Scribe Program Director

Published September 07, 2013

Imagine yourself buying a luxury car — for argument’s sake, a Jaguar XKR-S convertible. It's got a 385-horsepower, 5-liter V8 engine. It's got plush leather seats, OnStar and Blue Tooth for your iPhone.

But there's a problem. The tires are missing.

The dealer apologizes and offers to put some new ones on for $300.

"Are you kidding?" you say. "I just dropped $140,000 on this car." And you roll the Jag out of the parking lot — clunking, scraping and destroying your expensive rims as you go.

So what does this absurdist little sketch have to do with healthcare reform? A whole lot when you think about hospital administrators' approach to the electronic health record (EHR). All too often, they're overlooking an inexpensive program that would help them get the most out of their mammoth EHR investment: scribing.

Proprietary EHR systems — the kind used by a majority of hospitals — are notoriously pricey. So pricey that health systems are suffering operating losses in order to implement them. To give you an idea, here are a few cost statistics:

Wake Forest Baptist Medical Center: $21 million (plus an estimated $27 million in lost revenues due to decreased productivity during implementation)
Dartmouth-Hitchcock Medical Center: $80 million
University of San Francisco: $150 million
Henry Ford Health System: $356 million
Duke University Health System: $700 million

Unlike a Jaguar, EHR systems aren't luxuries. Hospitals now have meaningful use mandates to meet for government subsidies — not to mention penalties to avoid in the coming years. They're pretty much at the mercy of proprietary EHR vendors. This is now a world where Epic CEO Judy Faulkner can walk into a roomful of hospital CIOs, toss her purse on the table and tell them she's there to decide who she wants as her customers.

There's another important way that EHR systems differ from Jaguars: engineering. Most EHRs have been designed in a slapdash fashion using outdated technology. And as physicians will attest, they're a real pain to use. So to extend the Jaguar analogy, buying an EHR is a bit like buying a $140,000 car that drives like a clunky 1960s Pinto.

So where do the tires come in? Well, bear with me.

Some evidence demonstrates that EHR use can indeed improve healthcare quality, but even that's debatable. Only when physicians actually use the darn thing properly is there even a chance. To quote from a 2004 study published in Health Affairs:

"Our key insight with policy implications is that the path to quality improvement and financial benefits lies in getting the greatest number of physicians to use the EMR (and not paper) for as many of their daily tasks as possible. The key obstacle in this path to quality is the extra time it takes physicians to learn to use the EMR effectively for their daily tasks."

So how much have things improved since 2004? Have advances in technology removed the productivity barrier and paved the way for greater physician adoption?

Well, here's what some physicians are saying about EHR utilization today:

"Documenting a full clinical encounter in an EHR is pure torment."

— Steven J. Stack, MD, chair of the American Medical Association board of trustees at a 2013 Centers for Medicare & Medicaid Services listening session

"One of the major issues I face is productivity. I do not believe I would ever have reached pre-EHR productivity levels without using a scribe. After a year of getting home at 11 p.m. and when my spouse threatened to leave me, I began using a scribe real time in the room. She completes 98% of the notes, enters the visit code, updates the med list and problem list, sends the prescriptions, prints patient handouts, sends inter-office flags to call for outside reports during the visit, prints the patient summary, and even completes forms such as school physicals in the room while I attend to the patient. In short, she is the major reason that the EHR will deliver meaningful use."

— Anonymous physician responding to a 2012 satisfaction survey by American EHR Partners

Which brings us to the tires.

At a cost of $17 to $30 (fully loaded) per man-hour, medical scribing solves the number one barrier to physician adoption of the EHR. Scribes are the rubber that connects the EHR machine to the road and cushions the rims against blows. And when implemented early enough, a scribe program can help prevent operating losses during EHR implementation (as happened in the case of Wake Forest Baptist above).

Scribes are the solution to the federal government's concerns about meaningful use, quality improvement and fraud prevention. They're also a solution for most problems that keep healthcare administrators up at night.

And yet, who pays for scribes at most hospitals? Physicians.

Administrators, you know what comes from driving your car on bare rims. So when spending upwards of $150 million on an EHR system, consider adding a scribe program. For the bargain cost of just a few hundred thousand dollars a year, it will help smooth the road to implementation, cushion the organization against losses, vastly improve physician experience and provide a reliable bridge to quality.

Think of it as the $300 tires on the $140,000 Jag.

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