Medical scribes to ease administrative burden

Studies show that the use of medical scribes to document details of patient visits and take on onerous paperwork has relieved physicians, freeing them up to focus on the work they do best: personalized, one-to-one patient care. In this podcast, doctors discuss the evolving role of medical scribes, training required, financial implications on a practice and their future potential both in human and an artificial intelligence form. 

Transcript

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Georgia Balogiannis: In this podcast, the Ontario Medical Association looks at current issues of interest in healthcare. Spotlight on Health gives you all the straight talk. We’re Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association. 

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Balogiannis: The ever-increasing amount of administrative tasks and notetaking that doctors have to take on in our digital age has added hours to their work week and led to widespread burnout. In this episode, physicians discuss the benefits and challenges of using medical scribes as a way to tackle the mounting clerical burden.  

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Balogiannis: Dr. Noah Crampton is a family physician with the Toronto Western Family Health team and peer leader with Ontario MD.

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Dr. Noah Crampton: The top considerations for including a medical scribe really revolves around what are the pain points you're trying to solve for yourself and your practise that the scribe may help with, and also what are the potential consequences of integrating a human scribe, both for you in terms of your workflow as well as the financial considerations. So there are a lot of dimensions that go into making an important decision like this. 

Certainly in the era of computerised electronic medical records, there's been a lot of downloading administrative work onto clinicians. So how do we relieve that burden? Hiring a human scribe who learns your particular way of doing clinical documentation and also ordering tests or sending referrals, and that tends to significantly reduce the burden of that effort.

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Dr. Crampton: The classic human scribe is actually an individual who's in the room, the exam room, with the doctor listening to potentially sensitive health matters. So it has to be very well explained to each patient why that person is there – explain their role, the training that they've received, how they're going to impact the provision of the care. This conversation can actually take a few minutes if it's the first time a patient is seeing a human scribe in the room with you. 

It's important to respect patient preference as to whether or not they want the scribe there at all. You have to respect their wishes. By and large, most patients do understand the rationale as to why it's important and why you're doing it. Privacy training for scribes is so paramount and explaining the training that was undergone by the scribe to the patient and then also the clinic's policies about how to remain adherent to strong privacy controls, the secured environment of the exam room,  and documented in a secured record. 

All those processes remain. It becomes paramount, the training of that person to be at the same level as the clinician receives it so that all risks of a breach or inappropriate release of that information gets eliminated.

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Dr. Crampton: AI technology, it's really a burgeoning field in healthcare because it's only recently in the last 10 years that the artificial intelligence has gotten sophisticated enough to really interpret complex natural language in a way that is accurate enough for it to be useful in real world context. It's trying to take two major parts of data sets, one which is the doctor-patient transcript, and understand the language nuances there, as well as the corresponding medical note that was generated from that transcript. 

The more data you have, the more accurately labelled data you have, the more high performing the machine learning model will be out of the box. An artificial intelligence tool will never quit on you, it will never leave your practise. It will continually learn so long as you decide to, that you want to pay for it and it'll continue to improve. It'll continue to become more and more tailored to your practise and be a net positive. This is not a black box that will send the data to who knows where, right? 

This is, very strict protocols are in place that are adherent to the same health information policies that every other software have to go through. The only difference is that the data is improving the, the performance of the model over time. Whether it's a human scribe or the AI scribe route, I think either, there's a real opportunity if we find a collective effort supported by governments to these types of roles, enabling clinicians the flexibility to at least pilot trial them and see if it's a good fit for their practise. I think there's a real opportunity to really revolutionise the practise of medicine.

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Balogiannis: Dr. Vandana Ahluwalia is a rheumatologist and internal medicine physician and is the past chief of rheumatology at William Osler Health System and past president of the Ontario and Canadian Rheumatology Associations.

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Dr. Vandana Ahluwalia: I was going home in the evenings. I had little sticky notes and I was recording patient's information. Still, I wasn't getting all the paperwork done. I was getting to the point where things were becoming overwhelming and what's interesting is that I've been a peer leader for Ontario MD for more than 10 years. I actually built the tools for rheumatology into the electronic medical records 10 years ago. I had all of the rheumatologists adopt emr, so I'm a super-user in terms of the emr, but even I was having trouble getting all the data into the emr. 

So that's when I said I gotta make a change. So this friend of mine said, let me see what I can do. She called up a friend whose son was looking for a job, came to my office the next week. I hired him. He's been with me for the last three years and it's been a fantastic relationship. I started from scratch. I did not have any training programme for my scribe. I trained him myself. It took time, took a long time, took probably a year, maybe even more, to get him to the point where I felt that he was doing a pretty good job. 

In the last couple of years, we've still been fine tuning all the work that we do. Every day I give him feedback, every patient, because at the end of the day we go over all the notes and anything that I think could be done better, we talk about it and he incorporates it into the next day. The thing about the scribe training is that scribes can be, for example, pre-med students. They're looking for a transition year. Some of them are post-grad students, sometimes they're just at a high school. 

We had a scribe that had just finished high schools thinking about going to medical school. They all come from different backgrounds and they need to have some resources in order to get them to where they need to be. The thing is that they're sometimes there for a year and so if you can't get them up and running in about three months, then it's going to be really hard. If it takes six months to train them and then they're only there for another three to six months, you're not getting the benefit. 

You need a lot of resources. You need medical terminology. You need to understand the diseases that you treat. You need them to understand how clinics work, how hospitals work, how emergency departments work. You also need them to understand how to record medical information because there's a certain way that physicians talk and record and then we've been taught that for a decade. 

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Dr. Ahluwalia: If I want to have a life, then I want to finish all my work during daytime hours. And I'm willing to pay for that. So it's going to cost me a little bit of extra. On the other hand, if I want to break even, I have to see two more patients in a specialty practise to pay for a scribe. It's a no-brainer. If I want it to be profitable, I can see four more patients. Within the first hour I had already paid for the scribe because I had better documentation, I had better notations of physical examination, I did more for the patient, I had better quality of care, and in fact that paid for the scribe. 

I'm sure that physicians would be interested in discussing that considering what is going on these days in the healthcare crisis and people are leaving the profession and so forth. There are so many different stressors, whether it's systemic stressors or patient care stressors. If we can reduce some of that documentation burden, we can make a difference to physicians' lives. They also can have a longer career life. Many physicians want to retire because they're burnt out. So if we can keep physicians in the system longer doing a better job than we've made a difference.

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Dr. Ahluwalia: We have to find ways to improve efficiencies in our office and there are many ways to do that. There are physicians that use team-based care and so this is just another member of the team. For example, they could be remote, they don't have to be necessarily in the office, so then you don't have an extra person in the office. Because some of my colleagues said, “well, I don't actually have space in my exam room for an extra person to be in there”. 

The important thing is a lot of times now we are dealing with the technology, and the technology to a certain extent is still not user friendly. Because, when I'm doing rheumatology sometimes I'm counting 30 or 40 joints. I have to label all the joints, I have to click on the joints, I have to say whether they're tender or swollen or damaged. If we had a much better user interface that was supported and built by physicians for their use, then we may be in a different situation. But until then I think that we do need somebody else to help support the documentation.

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Balogiannis: Stephen Graves is a healthcare consultant and the co-founder of Medical Scribes of Canada with his father, Dr. Peter Graves, an emergency physician at Ottawa’s Queensway Carleton Hospital.

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Stephen Graves: It was in 2014 that we started the medical scribe programme and it was initially started out after hearing about medical scribes in the United States, wanted to get a bit of a feel for whether a similar program might be feasible in Canada. So it began with him as the sole physician in the program and myself as the sole medical scribe. It was pretty quickly demonstrated that it was successful. 

Shortly thereafter, we secured some funding to have a bit more of a uh, established pilot program, bringing in a few additional medical scribes as well as a few more physicians to really feel out what sort of improvements in efficiency and quality we could impart by having a scribe program up and running. And within a period of about four months, we were able to demonstrate around a 15% improvement in efficiency in uh, patients seen for each of those physicians – not to mention a complete offloading of their administrative tasks that really were contributing to the burnout that they were experiencing on shift. 

By and large who we hire are medical school keeners. Those that are in either their late undergrad or Master's programs that are ambitious and looking to find their way into medical school in a short period of time.

Dr. Peter Graves: If you're working in another department, there's definitely a learning curve within that specialty. Our basic core training program was designed for emergency departments, but a lot of that is transferrable. But then the learning directly for those specialties would typically happen on site with that other individual physician being part of the teacher.

One of the, the strengths of the program is also unfortunately one of the weaknesses of the program. 

Feedback from the universities is that our medical students who were previously scribes are at the top of their class. They excel in everything because of the, basically the experience they've had even before starting medical school. It's very much an apprentice program. And so we do lose them and as part of our mandate as well is we do want them to transition into the next stage of their careers and act almost like a mentoring for it. But that results in the challenges of the ongoing attrition and the needing to retrain.

Stephen Graves: The really isn't a turnkey solution at this point in time in Canada for a physician to just hire a scribe into their practise. You know, the reality is from what we've seen, uh, in establishing these programs is it really does require to gather the momentum to keep the programme running in perpetuity as there is that attrition and as physicians themselves come and go in terms of the scribe services they elect to utilise.

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Dr. Peter Graves: The difference between an AI scribe and a human scribe is with a human scribe there's also all of the other components of the executive assistant that the machine obviously can't do. So they're trained, uh, to be our chaperones as well for a sensitive physical exam. They print out documentation, they pull up old visits, other reports, comparison ECGs. They essentially manage me, which a machine couldn't do. So the role is not just the concurrent scribing of the document, it's actually a multitude of other things as well.

Stephen Graves: It's worthwhile delineating the difference between a transcription tool versus an AI scribe. There are obviously a large number of voice-to-text transcription tools already in use at this point in time. And so far as I understand the true AI scribe equivalent aren't yet really on the market. When the point comes that they are actually effective that would be fantastic because we also struggle with capacity challenges, both in terms of a staffing perspective but also in terms of demand perspective. That would be overcome with a technology solution in place. The flip side of that being, establishing a in-person program at a site is challenging enough.

Dr. Peter Graves: I think it could be a role for human scribes being a backup system as AI tries to develop, because it really needs to be concurrent. I think that may be something in the future, we're just not there yet. But technology changes.

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Stephen Graves: For a program to be sustainable enough and have the potential to scale to a point where it's adopted more broadly across the country, it would require co-pay from the three groups that are really benefiting from this – physicians themselves, from the hospitals that the efficiencies are driving downstream improvements, and from the government who are ultimately looking to have patients seen more effectively, more efficiently, and minimise the burnout that clinicians are seeing these days, especially.

Dr. Peter Graves: When we talk about what are the barriers to getting a scribe program up and running – and obviously financial is probably one of the big barriers initially. But it's funny how many of the physicians, once they've tasted having a scribe they say, “I don't care how much this costs. My god, I love my job again. I can actually focus on patient care. I'm engaged. It's revitalised me.” 

All boils down to finances. Who's going to pay for it to get these programs in place? I think a physician should be paying for this partially themselves, but they shouldn't absorb the whole cost. And so there are ways, I think, that if there is some kind of co-payment coming from hospitals and government, from both branches, education and healthcare, it might be something that'd be worthwhile.

Stephen Graves: We have clearly a critical health human resources shortage right now and a benefit of medical scribes as a support to physicians and through physicians the rest of the staff supporting the hospital, is that the people that we're looking to hire are an untapped resource. This is a capacity that isn't being taken away from any other component of the health system. The reason that we're not seeing the uptake of scribes that we could is that there isn't a model at this point in time to sustain scribe programs. 

There needs to be a buy-in from all of those that are going to be benefiting from the program and a concerted effort for it to be done in a sustainable way, which requires a critical mass of scribes, a critical mass of physicians using those scribes, to be able to support the program at the calibre that's required year over year. But when it works, you can really see the results.

Dr. Peter Graves: Because I have a bit of a hearing impairment myself, I tend to sit up on the bed beside the patient, like literally three or four feet away from them, and we have a really good conversation. And I also do my physical exam out loud, so I describe all my findings as I'm going and the scribe's documenting it. And then I say what we're going to do. So I give my impression as to what I think's going on and what tests we're going to do and why. 

So it gives the patient also an opportunity to sort of know what we're doing, why we're doing it. There's no black box anymore. It's all right out there in front. It gives them a point of conversation for them to ask questions. And the feedback I've had from the patients has been, ‘this is wonderful’. And often they'll say “Thank you to both of you. Thank you, doctor, and thank you scribe.”

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Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.

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