To Lift EHR Burden, Doctors Live-Stream Patient Exams to Remote Scribes

The familiar phrase, “The doctor will see you now,” is not what it used to be.

That's because during most exams, physicians are spending a good chunk of time not looking at the patient, but at the patient's electronic health record on a computer screen.

A 2016 study in the Annals of Internal Medicine found that physicians spent 37 percent of their time on a computer during exams.

The situation can be frustrating for patients, who don't think they are getting the doctor's full attention.

"That most fundamental aspect of human communication, which is eye contact, now is being robbed from the medical encounter because of the electronic health record," says Dr. Lloyd Minor, dean of Stanford's medical school.

While acknowledging the benefits of EHRs, which are meant to improve patient care by providing an easily accessible health history, physicians have also railed against the heavy amount of data entry they require. Physicians spend an estimated one to two hours after work completing EHRs and other "desktop medicine" requirements, according to the study in Annals of Internal Medicine.

But now Dr. Albert Chan, the chief of digital patient experience for the Sutter Health Network, thinks he has a solution for the burden of EHRs. Chan uses Google Glass, with its tiny camera mounted on a device worn like eyeglasses, to stream audio and video of the patient to an offsite medical scribe. The scribe sees and hears what the doctor does, writing the notes that go into the electronic health record. This frees up the physician to give the patient her full attention. Doctors can communicate with their note-takers through a headset, asking them to retrieve test results and other data. The scribe responds via text message, which the physician sees in the Glass lens.

“For patients, it’s better care because the doctors focus on them, and the doctors spend more time with them," Chan says. He says that because the doctor’s attention is not divided between the computer and the patient, records of the visit are more accurate.

The system is provided by a company called Augmedix, of which Sutter Health is an investor.

Currently about 100 Sutter doctors are using the system. After first deploying it among physicians in internal medicine, Sutter is now expanding it for use by specialists like dermatologists, podiatrists and orthopedists across its Northern California network.

“I mean, we have invested a lot of time to train physicians, so why not have them use their expertise in the most efficient way possible?” says Chan.

Encounter at Dolores Park

Augmedix was founded in 2012, by Ian Shakil and Pelu Tran. Shakil, who is the CEO, says he got the idea after a chance encounter at San Francisco's Dolores Park with some Google employees who were working on Glass. "They had Glass in their backpacks. And they let us try it on," he says.

After the Google crew explained the product was intended for consumers, "I got into a big argument with the group that this was really meant for doctors." (Glass was a notorious bust with the public, but is now hitting its stride as a workplace tool.)

Shakil, who knew from media reports and his own encounters with physicians that they were beleaguered with documentation requirements, says he became obsessed with the idea of using Glass as a solution. "I couldn't sleep; I couldn't stop talking about it. I literally quit my job."

He then reeled in his friend Tran, who dropped out of his fourth year at medical school, and the two formed the company. Shakil says more than 1,000 doctors are currently using Augmedix across the U.S. , with the largest deployment by Sutter.

Besides Sutter, investors include health services company McKesson and Dignity Health network.

Sutter's Dr. Chan says the scribes provide a number of benefits, including reminding physicians to address issues they might otherwise miss.

“If you have shoulder pain and chest pain, for instance, well, if I forget to address the shoulder pain during the exam, I can get a subtle hint from the transcriptionist -- ‘Hey, you may want to address the shoulder pain, too.’ ”

Because doctors use shorthand when entering information in an EHR, Chan says, they often have to go back hours later and fill in the gaps; that isn't necessary when a third party is taking the notes in real-time.

'Oh, I Can See My Kid's Soccer Game'

About two-thirds of Augmedix's note-takers are located overseas, in India, the Dominican Republic and Sri Lanka, says CEO Shakil. But Adeeba Hasan, a full-time scribe for the company, works out of headquarters in San Francisco. Hasan says she's able to take 80 percent of the EHR workload off a doctor's hands. "My doctors  are able to leave and get home about two or three hours early," Hasan says. "They definitely thank for me for little things like, 'Oh, I can see my kids' soccer game.'  "

She has scribed for 20 doctors, whose predominant perspective, she says, is that while EHRs are important, they don't require a medical degree to complete. She herself is applying to medical school and finds the experience valuable. "I'm learning all about different medications and illnesses and how you talk to patients," she says.

A Doubter

So is this the future of medicine as we know it?

“Oh my God, I hope not,” says David Lansky, executive director of the Pacific Business Group on Health, a nonprofit consortium of private companies and public agencies working toward greater health care affordability and quality.

The Augmedix service generally ranges from $1,500 to $3,500 per physician, per month, according to Shakil. Lansky says fixing the dysfunctional health care system requires putting the brakes on runaway costs, and using expensive scribes does just the opposite.

“You’re just adding more layers of cost and people to assist in the exam room,” Lansky says.

He thinks the solution to the burden of EHRs is to lessen reporting requirements, from quality measures to insurance coding to language intended to fend off lawsuits.

“The real problem is that administrative requirements are uncoordinated and useless," Lansky says. "I mean, no one’s even looking at the quality measures physicians are required to key in."

“The two paths we want to pursue are to reduce reporting and improve EHR function. If everything’s in front of you, you can use your face time [with the patient] to really do face time.”

What About the Creepiness Factor?

Might some patients, especially women, not take too kindly to having something as intimate as a medical exam observed by someone they don't know and can't see?

"To be honest, when we first founded the business, we had no idea if this issue was going to be a show-stopper or not a big deal," says Shakil. "We’ve since grown and we’ve learned that it’ s not actually a big deal." 

He says only 2 percent of patients have opted out so far, a rate that remains steady across all demographics, including sex.

Shakil says the audio-video stream is encrypted, so hacking is not an issue. "We've penetration-tested it, and it's Fort Knox, basically." The scribes sit in what he calls an "ultra-secure environment," with nothing in their pockets, video monitoring, and computers that can only run the company's application.

The doctor can also temporarily switch off the Glass feed by swiping or verbal command if there's something occurring the patient doesn't want transmitted. The light on the device changes color to indicate its no longer active, which the patient can see.

Interestingly enough, there is one small sub-group of patients who are opting out at a slightly greater rate.

"It's a little bit higher around the Google campus than anywhere in the country," Shakil says.

Make of that what you will.