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Friday, July 23, 2010

EHR's, scribes, and the purpose of the record

Ever since I can remember I recall learning that one of the most important skill sets which follows from a good education is the ability to communicate using the written word. In virtually all realms of human endeavors, we place a premium on the ability to write and to write well. Why do we value this skill so highly? There are many different takes on this question but certain themes are consistent across authors. First, most organizations rely on effective written communication to operate. Assuming that coordinated human activity is important to accomplish a particular task or tasks, unambiguous communications (generally written since they are more enduring) are absolutely essential for the functioning of operating units. Writing is also an effective tool for organizing your thoughts when face with a problem which requires analysis. It is particularly important when one is trying to extend and test one's initial gut impressions.

It seems to me that these aspects of writing SHOULD be relevant to the practice of medicine. What we do as individual practitioners should be effectively communicated to other members of a greater team caring for the same patient and the written word is the gold standard for communication. Furthermore, physicians are by definition problem solvers, faced with a steady stream of patients who present with a constellation of signs, symptoms, and other data. The gold standard for reflection and analysis is to collect your thoughts, put them down and paper and organize them into a document that conveys as reasonable hypothesis and plan for analysis and treatment.

However, the written record in medicine has been completely high jacked. The elements which must be included are elements needed to justify billing. Everything else is secondary. Coordination of health care activity..what's that? Organization of thoughts..endangered species. Perhaps the best evidence of how unimportant written communication in the form of office notes have become is the task is increasingly being delegated to scribes. In my community, these are generally individuals with high school educations who operate off macro menus in EHRs. Thus they are essentially working off a medical mad-libs menu piecing together documents that are designed solely to contain verbiage that optimizes billing. Each note looks eerily like the previous one, filled with words but no actual information or analysis.

The origins of the present state are obviously in the past. Historically, physicians in the outpatient world operated by themselves. Their notes served their own purposes and even very brief notes may have been adequate to communicate back to themselves at a later date when the patient returned. Furthermore, medicine was simply less complex. There were fever options and the pace of practice was generally less hectic. Fast forward to the present and the world has changed but how we operate has not. We have tried to apply an old practice model to new circumstances where volume and acuity is increased. However, the model is neither functional nor scalable.

The problem is all about essential tasks and workflow. Part of that workflow is collection of data which includes information collected from patients as history and physical exam. After essential information is collected, it needs to be synthesized, an impression created followed by a plan for further evaluation and treatment. In the current state, all of this is jam packed into a time constrained slot which is the face to face encounter (appointment). It creates time pressures where none is really required. Our payment system has created artificial time constraints which prompted physicians to create useless notes. We have become so focused on the use of the medical record to maintain our revenue stream that we have missed its transition to a state where it actually serves no other useful purpose.

Ultimately, we need to change the workflow to encourage better analysis and communication of that analysis. We need to ask what data do we need to guide patients and their physicians to make the best decisions and how and where to collect this? Technology and scribes are fine for recording data. Premium value for physicians can only be justified by unique skills which require intelligence, drive, and years of training and experience. This generally falls into unique technical skills and problem solving skills. Those focused on the former may not require the same analysis and communication skills and their practices may not require dramatic changes in workflow. Medicine is pretty good in this value added realm. However, for those physicians who operate in the realm of solution shop and chronic care models, we need to change the workflows first to collect data first in a non-time constrained fashion and place highest value on our abilities to define and solve problems and communicate our analysis in precise terms using the written word. This is not something can be delegated to those with nominal training nor is it something that can (or should) be done is those fleeting moments before the next patient get roomed.


  1. you post on this topic is very nice, It had been a while since I visited website with such high quality EHR Scribes information. Thanks loads for the helpful information.