Scribes in 2014

I’ve written about scribes in the ED before (here’s one from 2007) and continue to utilize their services. Did I say utilize? Wrong thought: enjoy and marvel in their help is more my experience. I’m spurred to extoll their virtues and my experience after reading “Attack of the Scribes” by the great twitterer @SkepticScalpel  (he also blogs at SkepticalScalpel.blogspot.com ).

Read the article, it’s well written though more than a touch odd; why’s a doc who’s never worked with scribes editorializing on their pluses and minuses? The literature review is fair, and there probably isn’t enough scholarship on the issue of whether scribes can have a measurable impact on physician productivity. I think we’ve only scratched the surface with scribing in the hospital, as I think every nurse should have a scribe. Imagine, nurses nursing rather than staring at screens, checking boxes! It would be hugely liberating for them.

I’m going to insert some quotes from the article then answer them:

“The emergence of the electronic medical record (EMR) has spawned a new occupation—the scribe.”

No, scribes have been around since ink and paper, and maybe before. I would accept that the EMR has spawned a new medical occupation, though we used scribes in the paper chart world before the EMR. It is certainly true the EMR has facilitated the explosion of scribe utilization (and companies to fill that need).

“I have no personal experience with scribes, but I suspect their notes would tend to be too long rather than too short. Do we really need longer notes in charts? No. Residents need to learn how to write concise progress notes that do not duplicate what is already in the chart. This would require a culture shift by faculty and senior residents who tend to expect voluminous notes.”

Scribes document something like doctors without scribes: all over the map for volume. Some distill the history in a few sentences, some type verbatim, and there’s a mixture between. In the ED, as the note is pretty heavily templated, and so much fluff and junk are automatically stuck in there, an extra sentence or three isn’t contributing to note bloat. I would never scribe any other than a Senior resident, as learning what and how to document is part of the education.

Additionally, docs 40 and above didn’t grow up with keyboards like our scribes did; that means less information added by poor typists, which isn’t good for the patient or the documentation.

The presence of a third party during the doctor-patient interaction has not been an issue so far, but it is conceivable that some patients might feel uncomfortable.”

I’ve had one patient ask the scribe to leave the room. I introduce myself, introduce the scribe as ‘my assistant’, and it’s not an issue otherwise. (We do excuse them for the more intimate exams).

“When a scribe enters a note in an EMR, it must be cosigned by the physician. Experience with dictated H&Ps, notes, and operative reports shows that most of these entries are not carefully proofread before they are signed. Using scribes opens up new vistas for plaintiffs’ attorneys if patients experience bad outcomes.”

I disagree; the issue is the quality of the documentation, and it’s irrelevant who pushes the keys. The name at the bottom of the chart is responsible for the content. Before Texas’ Prop 12 several of us were sued, and the use of scribes never came up as a problem in depositions or trials.

True story. I know someone who had pain in her arms. The scribe documented the doctor as saying “consider a mass” instead of what he actually said, “consider MS.””

Professional transcriptionists get words wrong frequently, and the speech-to-text used by our radiologists is often inadvertently hysterical (‘Sono: Renal and Nasal’ was a recent report header), so communication errors happen. That’s why we read and edit charts.

 

I don’t need a study to tell me scribes make me more efficient, but we did one anyway. We were very efficient on paper charts, with scribes, and the EMR showed up. We went through the training, and had people time scribe-on-paper vs the EMR for time; the EMR was tremendously slower (40% more time required), which was a big hit in an efficient system. We’ve gotten better, but several of our docs use two scribes to get their speed back (and more; I now see more per hour than I did on paper). We didn’t publish our data. Maybe we should have.

Our scribe company* has gotten a whole lot bigger, and a lot more corporate for better and worse. They turn out trained and enthusiastic scribes, and they’re still wonderful to work with. I showed up very early for work the other day and decided to start early, which reinforced that I can manage the EMR and do my own documentation, and I’m terrifically glad I don’t have to.

Here’s Greg Henry (ACEP past President and EM lecturing fixture) being interviewed about scribes by Nick Genes (genius and blogger/twitterer):


ACEP 2012: Greg Henry v. Nick Genes Part 3 – Scribes from Logan Plaster on Vimeo.

Dr. Henry has  also been quoted (though I cannot find it) as saying ‘the ER doctor should be a free floating brain’, meaning let the doctor do the thinking they’re trained to do and let anything that not that be done by someone else. It makes zero sense for the highest compensated in the department to be the typist (not a slam on typists, it’s about the best use of time and talents).

Scribes. If you use an EMR, or don’t, get them. They’ll make you money, and they’ll make your day way, way better.

*Full disclosure: I independently contract with a CMG that supported and then spun off our scribe company. I’m also friends with the scribe company senior management, and they’re good folks. I’d say nice things about our scribes if none of that were true, but don’t want my relationship to be an issue.

 

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Comments

  1. Nice post. It’s good to hear the other side of the story. It sounds like you have a highly tuned setup at your hospital. The scribe literature that I found starts in 2008. I wasn’t aware that the concept started with paper charts.

    Just one point. My blog is at SkepticalScalpel.Blogspot.com. That’s Skeptical with a “k.” Thanks for the link anyway.

  2. Great article and good points. The only way I would want scribes to go away is if the EMR went away and half of the old paper chart burden went away. Your point about transcriptionists making mistakes is spot on. I once read a dictated note on a female patient that said, “Patient has a very large penis.” Turns out the doctor who dictated the note actually said, “pannus.”

  3. As an ER Nurse I have not been impressed with the scribe programs I have seen. It’s a steep learning curve and most Doctors I have seen liked the idea but gave up on it after trying it. Some use the scribes as a buffer between them and the nurses. Others never read nursing or anyone else’s documentation because they reply on their scribe to filter information and present only abnormal values. I have heard that the Texas Hospital where the Ebola case was missed on initial presentation uses ED Scribes. Could that have been a factor in the documented travel history have been missed?

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