Pixels Over People: How the Electronic Health Record Hijacked Doctor-Patient Relations

Introducing a computer screen and the electronic health record (EHR) between physicians and patients has resulted in physicians spending far more time physically and mentally responding to those screens than patients. The loss of eye contact and the underlying loss of attention has irreversibly altered, and not in a good way, the bond between us.

Many physicians trained in an earlier era found the leap from analog to digital so disconcerting that they off-loaded the physical work of documenting a visit to another human, the medical scribe. This individual either records the visit as might a court stenographer or, more frequently, plays the computer keyboard allegro or even presto to capture all the clinical information necessary for billing. For administrators, most concerned with patient wait times, the medical scribe was the human enzyme that could speed up patient throughput, getting more patients in front of a physician every hour. How is that working out?

The Veterans Administration (VA) has been plagued with long wait times since I was a resident more than fifty years. Medical scribes were a considered solution, and a new policy paper reports on a two-year pilot study at 12 VA centers where medical scribes were deployed. Scribes were placed in the Emergency Departments or the “clinics” of two specialties, cardiology and orthopedics. Some of the scribes were VA employees; others were contracted workers. Here are the key findings.

• In the ED, using medical scribes increased the length of each visit and subsequently reduced the number of patients seen by a physician
• For the specialist office visits, medical scribes increased the number of patients seen (8 more by cardiologists, 12 more by orthopedists) but only significantly reduced the wait time in orthopedics.

From a cost perspective, the VA’s offered salary of approximately $47,000 impeded hiring compared to the contracted scribes’ salary of roughly $74,000. The VA scribes also required an additional 23% for “management” or administrative costs, while contracted workers' administrative costs were about 9%.  

At best, we might agree that in this setting, medical scribes do little to reduce wait time and may increase the number of patients seen in some circumstances. The comparison of the cost of scribes depends upon the comparator. When the comparator is a physician with a median salary of $251,000, scribes are a remarkable savings – 75% less. But if we are to replace the scribe with a nurse practitioner, with a median salary of $134,000, those savings drop by half. More importantly, replacing a scribe with a physician or nurse practitioner bolsters the professional staff while reducing the friction created by those computer screens and EHRs.

One final note: the quality of care was not considered. This is the most telling problem with all the productivity increases in medical care. After all, the EHRs were sold as a productivity increase and have yet to be a source of real quality improvement, unless you consider more reminders to physicians and patients quality.

While integrating medical scribes aimed to streamline operations and improve efficiency, the reality has been far more complex and less beneficial than anticipated. The findings from the VA’s pilot study reveal that medical scribes have not significantly reduced wait times and have, in some cases, increased the duration of patient visits. Moreover, the cost of employing scribes poses substantial financial challenges. It is imperative to prioritize genuine patient care and ensure that technology enhances rather than hinders the human connection at the heart of medicine.

Sources: The MISSION Act Scribes Pilot: Implementation and Costs A VA policy brief