Why have scribes become so pervasive in health care?

You may have already seen them — medical scribes hunched over tablets in hospitals and doctors’ offices, working away like Kim Jong-Un’s omnipresent cadre of note takers (though in this case, they’re actually getting things done). Recently, this piece about the phenomenon was making the rounds in my corner of the Twitterverse. In a conversation with a reach so high that it at one point drew in Dr. Farzad Mostashari (former National Coordinator for HIT), the question was raised: Why have scribes become so pervasive in health care? Why is a practice that most of us associate with feather quills and dimly lit rooms suddenly reasserting itself in our collective vocabulary?

EHR’s role

Many have suggested that “inefficiencies of poorly designed” electronic health records are to blame (or perhaps, from the scribes’ perspective, to thank). Undoubtedly, even the best EHR could stand to be streamlined, and many would benefit greatly from more intuitive design. In the age of Siri and CandyCrush, integration of voicetouch, and mobile provider portals are also key to bringing EHR into closer alignment with clinicians’ needs and expectations. To make the switch a success we must recognize that less tech-savvy providers will need more training and support.

Piling on: Beyond EHR

Fully a-scribing (pardon the pun) this surge in professional note-taking to poor UI, however, seems to me to miss several other important stories that define modern health care. We all know that the length of a patient visit is shrinking. But also, as this is happening, more demands are being placed on that shorter increasingly precious time.

Some of these new tasks are extrinsic to the core of patient care. The outrageous amount of time today’s providers spend coding encounters and managing insurance claims has truly created new areas of full-time employment, for example. With ICD-10, we can expect that this will only become more pronounced. An abundance of caution surrounding medico-legal concerns, too, slows us down. As we all know, “if it isn’t documented, it didn’t happen,” so it had better be documented. There are more central requirements, too, such as the growing number of performance metrics necessitated by new guidelines and accountability models. (These offer the possibility of higher quality care,  to be sure, as long as the EHR reminders are well-designed and deployed judiciously to avoid alert fatigue.)

Trade-offs: Better documentation is not a systemic failing

But these systemic challenges, too, miss the full story. In their heyday, paper charts had a little secret: Their context allowed them to be faster.

As Dr. Romaine Johnson commented on Twitter under the hashtag #tradeoffs, “SOAP notes were very brief. EMRs want a lot more data.” Anyone who has spent time doing chart reviews knows well that the quality of documentation was often not so hot. I have spent hours scrutinizing illegible scrawls, trying to piece together complex case histories from a few words, and attempting to divine undocumented findings for retrospective research. These notes may have been so messy, in part, because they were typically meant to be quick. For years, medical shorthand rested on two assumptions — that there was one provider (with a stellar memory), and that the patient had no plans to transfer care or read his/her own chart. In the days when a physician’s notes were just that, notes to herself, presumably this system worked.

We no longer live in that time. Notes are still taken by the provider, but they belong now to the patient. They no longer serve only to jog the solo private practitioner’s memory, but to communicate with a whole cadre of other interested parties, including coders, insurance companies, researchers, other doctors, and the patients themselves. This shift brings with it additional work and complexities (particularly for mental health providers), but it is nonetheless essential to offering care that is high-quality and transparent, and for which patients will be covered and physicians (somewhat) fairly compensated. These are all things that suggests meaningful documentation should be considered a step forward – a new core responsibility of the modern clinician, not a place to cut corners.

Are scribes the only answer?

We’re still left, however, with the fact that even after stripping away the unnecessary systemic hooey, there’s still more documentation and less time. This is where scribes become an option — a good one if hiring a professional is in the budget, or if the provider wants to mentor a medical student eager for experience. Importantly, though, scribes are not the only choice. Technology is developing to meet our needs and save us time. Some professional transcription services can still be prohibitive, yet several pieces of excellent software (like Dragon Medical) can do the job beautifully for a fraction of the cost.

Silver linings

Far from being a barrier between patient and provider (as one often hears of digital and paper charts), scribes and dictation systems free the provider’s eyes for the patient. Beyond the myriad benefits of that small act of attention, dictation also offers a fantastic opportunity in patient education and empowerment: When a doctor articulates thoughts and observations in front of a patient, the doors open to another level of discourse. For many, documentation may feel like a last vestige of control in their once-vast domain – but all the more reason to do it right, with greater quality and efficiency.

Kaylan Baban is a preventive medicine resident and can be reached on Twitter @KaylanBaban. This article originally appeared in The Doctor Blog.

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  • NPPCP

    Your article emphasizes how far health care has fallen. There will never be a scribe in my patient room. This whole concept and the presumption there is even a need for it is utterly ridiculous. To even think that healthcare documentation has opened up the need for a “new profession” is disgusting and unbelievable. I’ll document what I can within the confines of my workday and that’s all you get.

    • Dr. Drake Ramoray

      If you read the whole thing you got farther than I did. I stopped after the section titled: Better documentation is not a systemic failing. EMR notes are full of so much gobbledy gook and garbage that has no clinical relevance for caring for the patient.

  • Dr. Drake Ramoray

    “Better Documentation is not a sysetmic failing”

    Let me share an edited for privacy example of a referral note that I received. Now keep in mind the note is 10 pages long. I’d scan it if I could but I don’t want to violate any HIPAA even with removing info without discussing with the patient first. Most of the wording is verbatim where possible although I leave some comments in parentheses.

    History of Present Illness:
    Patient is seen in the office today for annual exam. Pt’s past meidical hx, family hx, and social histories are reviewed without changes.
    [Patient name] was seen in the office today for her annual GYN examination. She has the following complaints: none. [Patient Name] medical history was reviewed with no changes.
    [Individual citation with times stamped signature that the above histories were reviewed by the provider.

    Past Medical History:
    1/2 a page of pap smear history, immunizations, screening tests, seatbelt, fiream in the home etc.

    Family History:
    One disease state for each parent.

    Social history:
    No smoker, working, married, social alcohol

    Medication List:
    Reviewed with time stamp by the provider:
    There is no actual listing of the patients medications.

    Drug Allergies:
    Codiene
    Non-Drug Allergies:
    None Known

    ROS:
    This is a page and half long that no physician ever reads but not surprisingly has been templated in such a way to maximize billing.
    Physical Exam:
    Also a page and a half, I admittedly at least read the pertinent points, although in this case I still have no idea why the patient is being referred so I don't know what I am looking for.

    Diagnosis:
    V72.13 (Some gyn diagnosis routine exam code that does'nt tell me anything.)

    Plan:
    The level of diagnosis or management options of this case is limited (I'll say other than develop a templated note I have no idea what you are actually doing for this patient or why they are being referred.)
    This involved the following management options: 1. breast self exam reviewed. 2. Discussion of diet (Not included in this section but the patient had a BMI of 19, is she planning on having children, general diet counseling?.) 3. Exercise routines 4. lab order (no specific labs are indicated in the note as being ordered or reviewed).
    The level and amount and/or complexity of data to be reviewed is limited. (I'll say)

    The chart data reviewed included the following. 1. reviewed medical history. 2. reviewed medical records. The risk of complications (of what????) is low. The patient is to return in 1 year for an annual exam. Should the paient have any porblems she is to call. This chart has been electronically signed by [Provider name]
    (this is then followed by compute spit out path results, screening check lists, patient demographics and insurance information.)
    =====================================================
    I have no idea why this patient is being referred to me. The information that I have for my review isn’t worth the paper and ink that its printed on. Sure I can read it, although most docs can read other docs bad handwriting but it literally tells me noting other than I’m getting a referral from another practice that has drank the EMR kool-aid.

    Sure the patient may have access to this, not that it tells them anything either. EMR notes are a joke. They have turned into a vehicle for billing, meeting regulatory mandates, and as a treasure trove of time stamped information for malpractice attorneys. They do nothing to improve patient care; quite frankly they make it more difficult with or without a scribe (who doesn’t work for free to document on the EMR that a small pracice would spend 10′s of thousands of dollars to obtain.)

    This note is not the exception but now the rule. I get several just like this almost every day.

    • DeceasedMD1

      Drake thank you for writing this. It is a perfect example. As every chart and pt are being turned into pages of meaningless data. It is much more than stupid. It is a deliberate attack on the very heart of HC and form of communication. It is very creepy.

      Basically that report says, you have a pt who is not very unique or important with not too much wrong. How would big business like it if we changed their record keeping involving hedge funds and mixing up their data? At least no one would die that way, just go broke.
      I wish there was a source that would listen to how destructive this is. It is far worse than annoying or a huge waste of resources. My question is how much have EMR’s increased morbidity and mortality?
      I spoke awhile ago with a NS who said he had seen a pt with h/o severe head trauma in his office. The hospital records were so bad he could not tell if she left alive let alone what her hospital course. I am sure it is worse than we even know.

      • ninguem

        There was an old-line surgeon in my town, retired now.

        His discharge summary.

        Admission diagnosis: Appendicitis

        Discharge diagnosis: same

        Procedure: Appendectomy.

        And that was it. That was his entire summary.

        You know, thing is. Unless there was a problem…..which he would document…….that’s all I needed to know.

        Administration was constantly on his case to dictate more detailed notes. Reason was something other than clarity.

    • NewMexicoRam

      Exactly. The old 3 x 5 notecards were better than this.

  • NPPCP

    Experts like us understand that. We just don’t care. My documentation gets the reimbursement – nothing more and nothing less. Without someone from a “so called new profession” hanging around for a paycheck.

    • Ava Marie Wensko George

      Patient care is primary – Your documentation relates vital information from clinician to clinician first and foremost. Billing is secondary. If your documentation cannot relate information about your patient to others, why do you do it? This all comes down to the fact that our clinicians see a lot of patients and are required to tell each patient’s story in a clear and concise manner. It takes a lot of time. Clinicians are required to wear so many more hats now. We do have to find a solution to assure quality patient care, while at the same time not burning out our providers (and get paid appropriately at the same time)….and I am not even going to get into the slang and short cuts that are used in the medical record…..

  • ninguem

    “Trade-offs: Better documentation is not a systemic failing.”

    Question is…..ARE you getting better documentation?

    Or are you just getting certain magic words put on a chart to guarantee better payment?

    A couple years ago, I got this new patient. He had been living alone in Far Away Big City. He got sick, protean cognitive and neurologic complaints. Went to local large HMO practice, seen by nurse practitioners who came to a reasonable but incorrect diagnosis. Incorrect diagnosis passed on to different nurse practitioners until it became “accepted” diagnosis sort of written in stone.

    Problem is, treatment for Accepted Diagnosis is not helping.

    Eventually referred to physician in the organization, the consultant had the correct degree of skepticism, reviewed “accepted” diagnosis and proved them incorrect, and came to correct diagnosis.

    Plan “A” didn’t work, so go to Plan “B”.

    So, Plan “B” treatment underway, and seems to be responding. Family wanted patient Brought Back Home to be cared for by relatives. He can’t live alone anymore.

    Problem is medical care in the interim. He got transferred to branch of same HMO eventually, but there was a gap of a few months. So, I’m called by relatives in my practice.

    I’m handed the person’s medical records, about a ream of papers. Nearly all of it duplicative and useless information.

    What a doctor needed, out of the ream of papers, was about four pages. I wrote a summary, and used that as a referral letter to
    get the person plugged back into the system locally. The person needed some tertiary interventions.

    Relative went with the family member to new patient visit. There were issues of competency to consent and manage finances, that sort of thing.

    Family member tells me some time later, one clinic to another, as the relative got sorted out in their system, one doc after another, gushed over my letter. How great it was.

    “What did you do?”

    Actually, all I did was a classic narrative H+P. What happened, the conclusions reached, what was proven, what remains under
    conjecture, what has been done, and what I thought needed to be done, and certain issues that the consultants needed to decide.

    The reason the new docs were so happy with my note, is I saved them from having to slog through reams of……well, trash…..to find information they can use.

    They still got the old records to slog through, in case I’d missed something; but they were given a complicated story, clearly, in a couple pages. They were so happy with my note…….because they don’t get that anymore.

    And I know that as well, because the new treating physician called me about the patient as well, and said the same thing.

  • Bradford Lacy

    The scribe profession may not work for every medical practice and particularly for outpatient practices it may not be financially viable. However, every single Emergency Medicine physician that I have spoken to loves the scribe service. In hospitals where we don’t have scribe service they are even beginning to demand it.

  • SteveCaley

    I note ” The scribe documents a more thorough and higher billing chart and learns invaluable skills while earning income….Ultimately the health care system wins. The scribe documents a more thorough and higher billing…. The hospital uses a portion of the increased funds to continue the scribe program and still leave with a profit.”

    Has there been a large outcry in public for higher billing payments, or encouraging more people to earn income through the medical system? It’s the opposite. All this extraneous detail has been added onto the simple notes, in hopes that physicians will not take a twelve-system ROS, but bill at a lower rate. The game has been to make the patient encounter impracticable, so it will occur less often.

    I hope you don’t take it personally, but the “scribe fix” is just the latest countermove in the long modern saga of deconstructing healthcare. It is only the broken window fallacy in economics – if you throw a rock through someone’s window and break it, he pays for a glazier to repair it, who in turn pays for glass and putty and such – broken windows are therefore desirable as they help the economy. It’s easily refuted. Adding more people to bill for more money for charts isn’t contributory to the principle of decreasing money spent on healthcare; it will be squeezed out of someplace else.

    • Arby

      “The game has been to make the patient encounter impracticable, so it will occur less often.”

      Do you mean the game is on to reduce patient encounters with a physicians as in giving the patient the illusion of healthcare with any number of other elements but a physician? Or all encounters?

      • SteveCaley

        For thirty years, the prejudice has been that doctors will just “see too many patients” for profit, rather than practicing good and ethical medicine. This prejudice has been turned into a cat-and-mouse game with coding and billing; and also with scribes and ICD-10 and all that; all to MINIMISE the number of patient encounters so that physicians “don’t make so much money.”
        We could make sure that “airline pilots don’t make so much money” by capping their annual salary at $25,000 per year, yes, that will save money. And we trust our lives to pilots as well. Why do we have the prejudice that physicians will see too many patients?

  • buzzkillerjsmith

    One of the local family docs here hired a scribe a while back. He likes working with the scribe–saves him hours daily.

    Sure, scribes are a workaround, but the charting requirements are now so toxic that that something has to give.

  • Kaya5255

    I am personally offended by the invasion of privacy of these non-licensed personnel.
    I refuse to have anyone other than the PCP in the exam room, unless I invite my husband to be present.
    I would never speak in front of these people.
    So please tell me how that situation provides optimal care for the consumer?

    • buzzkillerjsmith

      You are not a consumer. You are a patient. Patiens is suffering in Latin.

      If you want to be a consumer, go to Walmart or buy some grain at the local elevator.

      Optimal care? When you find that let me know so I can change to that clinic.

      Think second or third order, not first order. What the the implications of docs having to input all that data? Not just for you, but for everyone, and across the country?

      I did not make this EHR mess, but I have to live with it. So do many of our pts.

    • Anne-Marie

      I had the experience of a scribe in the room a few years ago. I accompanied a relative to a post-surgery appt to deal with an unexpected complication that took place during the surgery.

      It was not a happy situation but we were trying to be cordial about it – no one was to blame. I found it frankly a little intimidating when the surgeon came parading in with the scribe, like he needed reinforcement or an extra witness in case things went south.

      The exam room was small and once the scribe was seated at the desk with her laptop, there weren’t enough chairs so I had to stand during the entire appt. The scribe was not introduced nor was her role explained. I found myself thinking, “OK, so we’re here for a sensitive conversation – who are you, exactly, and why are you here?”

      I felt inhibited by her presence (and note that I wasn’t even the patient). It was like having a Greek chorus in the background, not saying anything but just sort of there, tap-tap-tapping away at her little keyboard and documenting everything. I’ll add here that the clicking of the keys got distracting at times.

      Maybe it was helpful to the surgeon to have a scribe present. Maybe it allowed him to concentrate more fully on the patient, although I’m not sure how I would have been able to measure this. But the bottom line is that I was uncomfortable with it.

      If it became the norm for every appt, I suppose I would have to get used to it. I would resent it like hell, however, and I probably would hold back on how much information I’m willing to share.