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.