Response: Re: The Use of Medical Scribes in Health Care Settings: A Systematic Review and Future Directions
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* Cameron G. Shultz
* Heather L. Holmstrom

*To the Editor:* We thank Dr. Martel and Mr. Imdieke for their comments.1 We agree that 1 potential benefit of medical scribes is improved documentation of a patient's medical complexity. The stakes for improved documentation are growing notably higher as more patients are enrolled in health plans that factor medical complexity into their reimbursement models. Martel and Imdieke cite the hierarchical condition categories risk adjustment model used by the Centers for Medicare and Medicaid Services to adjust capitation payments for Medicare Advantage (Part C) enrollees. Such models are designed to mitigate the effect of adverse selection, whereby high-cost patients enroll disproportionately. In 2010 Part C enrollees accounted for just under a quarter of all Medicare beneficiaries; in 2015 the fraction had grown to nearly one-third.2 Suffice it to say, risk adjustment models are here to stay, and the pressure on physicians to (accurately) report the requisite data are likely to become more intense.

Martel and Imdieke note that using medical scribes at their institution has led to modest improvements in documenting hierarchical condition category–related diagnoses within the primary care population. We applaud the effort they describe, and in the spirit of scholarly debate challenge them to measure and report their findings in the peer-reviewed literature. In this era of evidence-based decision making it is not enough to merely proclaim an improvement; one must make the case empirically using methods that hold up under scrutiny. As stated in our review, “Given the nascent state of the science, methodologically rigorous and sufficiently powered studies are greatly needed.”3 We sincerely hope Martel and Imdieke take their work to the next step by reporting their findings in the scientific literature, and we look forward to learning more about their exciting outcomes.

## References

1.  1.Martel ML, Imdieke BH. Re: the use of medical scribes in health care settings: a systematic review and future directions. J Am Board Fam Med 2016;29:423.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjkvMy80MjMiO3M6NDoiYXRvbSI7czoyMjoiL2phYmZwLzI5LzMvNDIzLjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  2.Jacobson G, Damico A, Neuman T. What's in and what's out? Medicare Advantage market entries and exits for 2016. Menlo Park, CA: Kaiser Family Foundation; 2015. Available from: [http://files.kff.org/attachment/issue-brief-whats-in-and-whats-out-medicare-advantage-market-entries-and-exits-for-2016](http://files.kff.org/attachment/issue-brief-whats-in-and-whats-out-medicare-advantage-market-entries-and-exits-for-2016). Accessed January 8, 2016.
    
    

3.  3.Shultz CG, Holmstrom HL. The use of medical scribes in health care settings: a systematic review and future directions. J Am Board Fam Med 2015;28:371–81.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjgvMy8zNzEiO3M6NDoiYXRvbSI7czoyMjoiL2phYmZwLzI5LzMvNDIzLjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9)