Scribes can help transform health care by creating better clinical data

“Insurers, drug companies and large HMOs are mounting an extensive effort to use medical data to decide which treatments are best, which doctors are best and which plans keep people the healthiest.”

That quote, seemingly ripped from today’s headlines, was published in the New York Times 25 years ago this month. I know because I was featured in the story, which began my (mostly) friendly jousts with regulators, administrators, and even some physicians fighting externally driven change — a group I refer to as the High Priests of Status Quo.

A medical scribe takes notes on a laptop at Beth Israel Deaconess Medical Center in Boston. Kayana Szymczak for STAT

Robert Merold, STAT August 7, 2019

Since that article appeared, health care has seriously lagged behind in its use of analytics, which has transformed every other major industry, even as health care spending grew from 10% of gross domestic product to 20%, adding a $1.7 trillion burden on our nation.

Today, at long last, we are on the verge of realizing the article’s promise. I believe that wider use of medical scribes will get us there.

In 1994, I was part of a forward-looking team building new generations of health data in the commercial sector. Policy experts, understanding that analytics were the key to improving health care, sought our real-world knowledge. I still have a cool bag with a hand-embroidered Secret Service logo, my reward after a particularly long and painful session explaining what does and doesn’t work in the world of collecting data. The Health Insurance Portability and Accountability Act of 1996, about which I testified as an expert witness, was as much about permitting data collection as it was protecting privacy.

During the 1990s, my colleagues and I, along with many others, built amazing detailed databases on prescriptions and medical claims. While those databases have many important uses, they lack the clinical data essential to understanding patient outcomes.

After a lull during the administration of President George W. Bush, policy experts turbocharged clinical data collection via the Affordable Care Act’s sister, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. It provided a brilliant carrot-and-stick incentive that migrated almost all physicians to electronic medical records that capture clinical data digitally, providing the foundation to enable analytics.

Today, large repositories of clinical data are being assembled in many places by many different types of companies and organizations. Largely unseen is innovation at medical specialty societies, where members contribute data from electronic medical records into quality registries. Dozens of registries exist, some for major diseases like addiction, Alzheimer’s, cancer, and heart disease, that will soon contain clinical data on more than half of all patients nationwide, almost in real time. This electronic information provides robust fuel to power artificial intelligence engines for health care.

Many large tech-savvy firms have jumped into health care only to quickly discover, painfully, that health care is unique. First, it’s not just about efficiency — the priority is better patient outcomes. Second, as Uwe Reinhardt, the legendary Princeton economist, famously observed, “Every dollar of health care spending = Someone’s health-care income,” and the High Priests of Status Quo protect their position.

But in the end it’s mostly about the data. And the quality of clinical data is abysmal. Hardly a week passes without a tech company or private equity firm calling me, desperate to find better data for their cool new AI engines.This could have been, and should have been, foreseen: Physicians are not data-entry clerks. Electronic medical records require more entry time than physicians have, so important clinical information is often entered as typed or dictated notes. This unstructured data isn’t usable analytically. There also is a cultural disincentive: Many physicians regard electronic medical records only as a necessary evil to get paid, and see little clinical value for them in a work flow that’s closer to Marcus Welby than a 21st-century operation.

We will never achieve much-needed health care efficiencies until we get serious about fixing the data. Technology is helping, but not fast enough. Voice recognition is getting good, but it doesn’t yet produce structured data. Natural language processing and machine learning are reducing the time it takes to abstract medical records, but are still too imprecise and expensive. Besides, any quality expert would say fixing the data is inefficient; it’s more important to get it right from the start.

Fortunately, there is an answer we can implement now: partner physicians with medical scribes who enter information as structured data into electronic medical records.

I can hear the High Priests screaming, “That would be a huge new cost.” So let’s do the math: There are effectively 400,000 physicians who handle more than 85% of all patient visits. At $50,000 per scribe that’s $20 billion annually, which represents only 0.6% of health care spending. The savings in physician time alone is justification for the addition of scribes, especially with growing concerns about burnout. Better data quickly will pay back in a system in which 200 million insurance claims, about 1 in 7, are initially rejected every year, according to the Department of Labor.

Then there is the benefit of powering transformative analytics to deliver better, more personalized diagnostics and care, predictive analytics to prevent problems, and Six Sigma improved work lows to promote best practices and avoid waste.

What are we waiting for? Fix the data now!

Scribes are the last piece in the 25-year puzzle to remake health care. The data will power analytics to drive the final step necessary in any transformation: overthrowing the High Priests of Status Quo.

Physicians have more power over what they do than factory workers, supply-chain managers, or cashiers. But they are no less immunized against the use of data-driven outcomes and best-practice algorithms. Some denigrate this as “cookbook medicine,” but Betty Crocker gives me great cakes every time.

Robert Merold is managing director at Execullence, a health care consulting firm.

Source STAT

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