It’s not quite the world’s oldest profession.
More like civilization’s.
It predates EHRs, paper, papyrus…even clay.
So long as there has been writing, even on stone tablets, there have been scribes.
Folks trained to commit words to a more durable medium than fallible memory.
Folks who did nothing else besides that special act of translation.
Because the movers and shakers who were actually talking, doing, or thinking the important stuff were busy with the important stuff — and were unable to scribe simultaneously, and too busy to learn.
Sound familiar?
It Sounded Like A Bad Joke, Actually
The idea first came to my attention from one of The EHR/EMR Show’s readers in 2008. At the time, I thought it was a step backwards: another layer between the physician and the medical record, like a court stenographer with one of those cryptic keypads.
Now, I’m not so sure.
No question this is a niche market occupation, like personal shopping. But if a physician is either too busy or just plain unable to learn to use his EHR to document efficiently — yet has no choice but to use it in order to continue medical practice — how outlandish an idea is it, to have a scribe as the human interface to that digital system?
Many ERs currently use medical scribes for their emergency room physicians — not for EHR interfacing, but simply to navigate their walk-in, critical care shifts. The physicians see the patients and call out the key notations to their scribes, never having to take their eyes off the patients, and the scribes dutifully note the history and observations, order what they’re told to order, and collate the results and notes for the final doctor’s review before the patient leaves.
For an EHR-challenged physician, a medical scribe might work similarly. Such a physician may have a hard time learning an EHR’s clicks and checkboxes — or in some cases, even how to type — but every doctor knows how to talk. And the scribe knows where the buttons, checkboxes, and on-screen order forms are. The doctor can look sage and speak freely, and the medical scribe transcribes all that info into the discrete clicks and data fields that healthcare systems love.
Blasphemy, Dr. Langdon
If you’re reading this blog, you’re hopefully among The Illuminati, and beyond needing such assistive services.
Or at least an initiate, soon to join the ranks of those who can finish notes by the time you walk out of the exam room, run reports against your patient data, and otherwise
- see a few more patients than before
- do so more safely than before
- legitimately code higher than you did before
- go home earlier than you did before
- in an office that runs 3 times more efficiently than it did before
But in case it isn’t obvious by now, attaining this state takes a village, and the majority of American physicians haven’t gotten here, yet.
EHRs are evolving fast, and ease of use and customizability — convenience, even — will become major differentiators in a field of similar feature sets. But as of today, they still demand a fair amount of patience, diligence, and networking to successfully implement. Higher brain functions, all.
Front line physicians function more as solitary operators, taking all comers and fighting to survive the day. From the lizard brain, if you will. And the lizard brain is stronger and louder than the superego, as we all know.
In an environment where you hit the ground running from your first day on the wards and never stop, and are incentivized both by training and by reimbursement to provide a critical service as your sole means of purely active income, is it any wonder that it’s an uphill battle to teach doctors a fundamentally different way of doing things?
Can Doctors Learn To Do It?
Of course…but “doctors” aren’t a homogeneous monolithic group, any more than “overweight patients” are. And in the same way, some will get the message immediately and turn their lives around. Some will maintain their set points with some degree of struggle. And some will get steadily worse.
Psychology 101 (and Marketing 301) spell it out: it’s easier to play to someone’s point of view than to turn it around. If the success of your venture depends on Making A New Man out of your prospects, you’d better be prepared to for a siege: tech support, help desks, educational materials, physician advisors…or a really big stick.
Changing a worldview isn’t impossible, it just takes work.
What If You’re Not One Of The Elect?
The whole premise of this blog — and indeed, the business models of most EHR vendors out there — is that you can turn your attitude around once you see the light, via the carrot or the stick. Enlightenment is grand, but Survival is a marvelous motivator, so to speak. I’ve seen it work time and time again: you accept the reality, do what it takes, and move on.
What about those struggling colleagues who can’t make the switch, no matter what the incentive, rationale, or threat?
Imagine that 3 years from now, the prevalent medical business model still demands that doctors see more patients, in less time, just to break even. And that tort reform is still a happy hour joke, and EHRs still aren’t as easy to use as Google’s Gmail. How can your challenged colleagues, doing the best that they can, bridge the too wide gap between their mounds of medical work and how to translate that into their EHRs?
Enter the medical scribe.
Caveats
This wouldn’t even be a discussion worth having, were it not for a basic concept called evolution.
Doctors evolve, EHR systems evolve, and the healthcare system is evolving. And each, while intertwined with the others, is evolving at a different rate.
Most of the focus on adapting has been on physicians and their offices: small groups of humans can change faster than organizations (EHR vendors) and the entire U.S. healthcare system.
That balance sheet is changing, with the incredible selection pressures being brought to bear with healthcare as the primary focus of the nation’s economy. But substantive change in the next few years will still be up to physicians — and as the still low EHR adoption numbers show, some doctors and local healthcare systems just can’t adapt.
Scribes cost. As Gugliemo points out in his Medical Economics article, it requires time — about 2 years of commitment from the scribe — as well as training in the EHR and the physician office workflow. You have to pay the scribe, too, although the balance sheets can look good (a modest cost, for moderately increased efficiency, patients per day, and doctor satisfaction).
We don’t use scribes any more for everyday information processing, because as a society we’ve evolved to make them superfluous. But EHRs are still early in their evolutionary cycle, while the pressures to use them are high and immediate.
It took 8,000 years to go from royal scribes to everyday reading and writing without them — requiring a groundbreaking invention called the printing press and a little social reform called, oddly enough, The Reformation. Things move a lot quicker in the digital age, but if the gap is just too wide for you, medical scribes might be a useful alternative to an epic fail.
