Make room for the scribe

In some exam rooms and hospital rooms, there’s a third person these days – a scribe whose task is to record all the notes for the visit between patient and physician.

The use of medical scribes isn’t particularly widespread. But as the paper trail for patient care becomes increasingly complex, some health care practices are bringing scribes on board to handle all the note-taking and documentation. And there’s a chance this trend could grow with the adoption of electronic medical record systems.

What does a scribe do, anyway? He or she might take the patient’s medical history, document the exam and any procedures that are done, transcribe orders for tests or prescription drugs, and record the patient’s diagnosis, followup instructions and other pertinent information dictated by the physician. Although medical scribes work in a clinical setting, they generally don’t do any hands-on patient care.

A rather detailed article from the Physicians Practice journal explains how an emergency practice in Fresno, Calif., benefited from hiring scribes:

With clerical duties relegated to dedicated “apprentices” rather than clinically trained, overworked medical personnel, workplace satisfaction has gone up across the entire staff. A scribe’s full concentration on creating a complete chart results in improved compliance, more accurate (read: higher) coding, and, therefore, increased reimbursements – both on a per-patient basis (less under-coding) and a patient load basis (more patients seen per day).

From the patient’s point of view, the presence of a scribe also can mean the physician is free to concentrate on patient care and having a two-way conversation vs. spending part of the visit taking notes.

The introduction of the electronic medical record seems to be upping the ante. I think it’s safe to say the medical community has found it challenging to enter the digital age. Many practices are struggling with how to incorporate the EMR at the bedside or in the exam room in a way that’s seamless rather than clunky. The transition can take time, and productivity can drop while frustration rises.

Bringing in scribes is one way that some practices are managing this transition, as this article, which appeared last fall in USA Today, makes clear:

Instead of pens, scribes… use laptops as they trail doctors from bed to bed, taking detailed notes that will form part of each patient’s electronic medical record. Experts say the scribes’ peculiar role – with one foot in 2009 and one in 2000 B.C. – illustrates hospitals’ often bumpy transition from clipboards and closets of paper charts to digital records.

Uberblogger Dr. Kevin Pho published a guest post just this week that illustrates how awkward it can be to manage a patient encounter while simultaneously trying to document for an EMR:

It’s relatively easy to write with pen and paper while listening and explaining. It’s far harder to keep two hands on a keyboard, a third hand on the mouse, one eye on the screen and another eye on the patient and his family. And the fact that most EMRs and user interfaces are designed by computer geeks with no knowledge of clinical care or workflow certainly doesn’t help matters.

I suspect there’s another factor at work as well: Many doctors aren’t good typists. I learned these basic skills in Mrs. Perry’s ninth-grade typing class (back then it was called “typing”; nowadays I suppose it would be called “keyboarding”) and they’ve been seriously honed by years of daily use. This isn’t necessarily the case for other people, though, whose keyboard experience might have focused more on the Internet and e-mail. It takes time to build up proficiency, and time is what busy medical practices simply don’t have.

This is the up side to medical scribes. The down side? There’s an added cost to hiring scribes. Presumably it can be offset by improved reimbursement and increased productivity, but the introduction of another category of employee can be rather challenging for a medical practice to manage and the payoff might not be immediate. There doesn’t yet appear to be any standard training or qualifications for becoming a medical scribe, so quality is at risk of being hit-or-miss. Adding this third layer to the doctor-patient encounter also can increase the possibility of errors and miscommunication in the record and differing interpretations of what happened in the exam room.

So far, I’ve heard little of the patient perspective regarding scribes. One of the commenters at Kevin MD took a rather dim view of the concept, calling it “creepy.” More than a few patients might find it inhibiting to have a scribe in the room, especially if they’re already stressed about their doctor visit or if they need to have a conversation about something that’s awkward or sensitive. From a practical standpoint, many exam rooms aren’t very large and a third party can make for rather crowded quarters. The constant clickety-click-click of a laptop keyboard also can be unnerving for patients.

If a patient really didn’t want to have the scribe in the room for part of the visit, could they ask to have the scribe step out into the hall? Would providers be willing to accommodate this, or would it brand the patient as uncooperative? If the scribe isn’t physically present in the room but is observing the encounter through a two-way monitor or some other means, are patients made aware of this fact?

There seems to be a lot to sort out yet about the best way to incorporate scribes in clinical care. In the meantime, consumers shouldn’t be too surprised if one of these days their appointment with the doctor also includes a scribe.

2 thoughts on “Make room for the scribe

  1. Pingback: Rx for primary care | HealthBeat

  2. As a scribe myself, I have noticed that patients feel a little extra comfortable knowing they are getting more one on one time with the doctor. As far as some patients exhibiting anxiety having an extra set of eyes and ears in the room, it’s usually a younger female patient anxious over the fact that a younger person (scribe) in the room for her vaginal issues or the pelvic exam in which case the scribes leave the exam room during anyway, having the Doctor finish the clinical impression. On a side not most patients fail to realize that the scribes are not residents or nurses and see us as just an extra professional there documenting the exam.

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