Medical Scribes: The History of Present Illness is Now a Narrative

Scribe“We are again at a time of great change. The doctors of medicine long have been revered like priests of old; scribes copied their words as a holy writ that the public could not easily access. Then came the electronic medical record. Now patients, doctors, nurses and scribes are trying to find their way in this new world.  Each has a place in the system of care and scribes are walking a new path.” – Regina Holliday, “The Scribe”

I had a chance to talk with Dr. Luis Saldaña about the benefits of “medical scribes”, and how the role has evolved and exploded in the age of EHRs. Dr. Saldaña is an emergency physician whose group was among the first to use medical scribes – way before the introduction of the Electronic Health Record. Even in the paper world, scribes were found to increase efficiencies by 25 percent while improving the patient experience.

Dr. Luis Saldana

Luis Saldaña, M.D.

Today, medical scribes are a growing trend, and Dr. Saldaña is uniquely poised to speak to the value of medical scribes in our digital world. He also serves as chief medical information officer (CMIO) of Texas Health Resources, one of the largest faith-based, nonprofit health systems in the United States. In 2012, Dr. Saldaña co-authored HIMSS’ Book of the Year: “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide.”

What is a Medical Scribe?

medical scribe is a trained medical information manager who specializes in charting physician/patient encounters in real-time during medical exams. A scribe follows a physician through his or her work day and documents information in the Electronic Health Record so that the physician can focus on patient care.

Interview with Luis Saldaña M.D., CMIO of THR

How did you get started with scribes? 

Our group, which contracts with our hospital – and we staff all the THR hospitals, except maybe one or two – has used scribes for many, many years. One of the group’s owners came from a military background where corpsmen acted as scribes in the emergency department. He brought something similar to our emergency practice.

We started with our own scribes but that later morphed into a totally separate company, PhysAssist, with whom we contract today.

What are the benefits of medical scribes?

Scribes let me focus on the patient. I don’t see any other way than a third party being in the room to capture the patient’s voice. That is a narrative. The history of present illness is now a narrative.

It has a huge value to me. As a busy physician, you may have heard one thing, but the patient may have told you something in addition. Scribes capture all the elements, and that is key.

Even with voice recognition, you can’t capture the whole physician/patient encounter as well…I’d have to leave the room to dictate…or try to type and capture in the room which would be very awkward.

The process allows our physicians to be more productive and efficient because they can parallel task.

What is the process?

  • Typically, I go in to do my interview, with the scribe and the Electronic Health Record. The scribe has the computer. I don’t.
  • I stay focused on the patient, and examining and interviewing the patient. I tell my scribes this needs to be exactly what the patient told us. I call out my abnormals. They do the documentation.
  • We go out of the room to discuss the differential diagnosis, and note it.
  • I go in and put in my orders. The scribe is not entering the orders.
  • Then it becomes an iterative process with the scribe making sure all the elements are there.
  • We work through it together, and decide on the level of care.
  • During the patient’s stay, as I get the results back, I am working off the EHR screen. The scribe has theirs.
  • When labs or key elements come back, I’ll go back and interview the patient with the scribe.
  • We’ll reevaluate the patient, and give them an update. The scribe captures the reevaluation, and really provides a narrative of the patient’s stay.
  • At the end of the encounter, I will do the prescriptions, and I’ll tell the scribe the followup and narrative I want for the patient’s discharge instructions.
  • The scribe is capturing everything, while I am writing prescriptions – we are parallel processing.
  • Then, I’ll do my exit interview with the patient.

Do scribes add a human element to the machine?

You need both. It allows us to focus and be more patient-centered. Am I meeting the patient’s needs? Have I given the proper discharge instructions for followup? Have I told the patient what they need to look for?

Do patients mind if there is a scribe in the room?

I’ve never once had a patient have an issue with it. I make sure to introduce the scribe. The patient sees that I am talking directly with them, and the scribe is capturing the information.

What advice do you have about medical scribes and EHRs?

What bothers me is that people describe scribes as workarounds for EHR shortcomings, and for some people, that may be how they look at it.

But regardless of what setting you are in, you have to think about how the work is done, and how it can be done more efficiently and effectively.

Our vendor has been very good adopting to the workflow, so you can use a scribe or not. A vendor has to understand the workflow, that’s critical in any Electronic Health Record. As much as we like standardization, in different settings, there are different workflows. And in physicians’ offices, there are also different models of care. You have to be cognizant of all these various workflows, and be flexible to allow for those differences.

Should primary care doctors use scribes?

Because of the nature of parallel processing, scribes are a great fit in the emergency department. It’s not the same for a primary physician where adding a separate person to serve just as a scribe wouldn’t work. Again, you have to look at workflow, and maybe the role of the medical assistant on the team.

Is being a scribe an advantage for getting into medical school?

Our program is really like an apprenticeship. Almost all of our scribes are pre-med students. They commit to doing a year or two working all the shifts with us – nightshifts, weekends, holidays. We’re teaching them, and telling them what we’re thinking.

Many of the scribes end up working with us after medical school. They’re now emergency physicians or other physicians on staff. Every one of the scribes has told me that when they did their residency, they were far ahead of their colleagues in terms of understanding the patient encounter because they saw many, many patient encounters.

They were also ahead in understanding medical terminology and in decision-making skills.

It’s a reward to see these students come back as colleagues and peers.

Demand for scribes is growing 46 to 50 percent every year according to PhysAssist, which employed 35 scribes in 2008, and now has over 1400.

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HealthIsCool

HealthIsCool writes for HL7standards.com on health innovation, wearable tech, Quantified Self, IoT, mHealth, and future trends. Follow on Twitter at @HealthIsCool.

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