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?
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 voice, touch, 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.
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.