Ever wonder how EHRs developed? How did anyone ever think of using a medical scribe? Here’s an outline of the history, beginning with the ancient Greeks.
Development of Medical Records
• Earliest medical records by ancient Greeks documented successful cures, observations about symptoms and outcomes, and case studies for teaching purposes
• In 1928, the American College of Surgeons set standards for record-keeping and established what is now the American Health Information Management Association
• Computers came into use for data collection as early as the 1960s
• Record-keeping gradually became more and more computerized, with recognition developing in the 1990s of the need for easier electronic sharing of information
Development of electronic health records
• 2004 – President George W. Bush called for computerized health records
• 2009 – Health Information Technology for Economic and Clinical Health (HITECH) Act provided financial incentives to encourage the adoption of EHRs and the interoperability necessary to share data among providers
• HITECH also established meaningful use standards to use as criteria for receiving the financial incentives and penalties for not adopting EHRs
• 2014 – Government mandate fully in place
Development of Medical Scribing
• As charting in EHRs became more detailed and time consuming, physicians found themselves focusing on their computers rather than their patients during encounters, and they spent more time outside the encounters updating their records.
• Physician burnout increased in direct proportion to the time requirements of working in EHRs.
• Physicians began using scribes to assist with EHR documentation, freeing them to focus more on patients and spend less time after hours working on charts.
• Industry growth began in emergency departments, with proven efficiency and results
• Scribing soon spread into other aspects of healthcare such as inpatient and ambulatory settings.
• Multiple studies have documented the benefits of using medical scribes.
The rise of virtual medical scribes
• Remote scribing has grown rapidly
o Rural communities with limited workforces can receive scribing services
o Many patients find it less intrusive than having a 3rd person in the room during the encounter
o Virtual scribe services are often more cost effective for providers
o Scribes can be located anywhere
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