American Academy of Emergency Medicine

In the Pit: Scribes

When road-blocks are placed in our paths, most of us are good at finding work arounds. Physicians are being forced to pay for the privilege of beta-testing software for the profits of second tier companies that have ingratiated themselves with the federal government. Thus, I would not describe being forced to pay for a scribe to make the use of a poorly designed product as a win-win situation. Charting is the responsibility of the physician. That record is the only real link you have to prior patient encounters. You may choose to use a scribe or a dictation service, but in the end you must proof-read and correct every piece of information placed in the chart under your name. We cannot simply delegate that responsibility and assume that it is carried out properly.

I tried using a scribe. I measured, with a stopwatch, the time charting versus a chart done by a scribe. I found that I spent longer proof-reading and correcting the note than if I had done it right the first time myself. I have trouble getting third year residents to document properly, let alone someone with no medical training. If you use a scribe, you generally need to see an extra three to four patients a shift to make a scribe pay for themselves. If you are relatively slow using an EMR, then this may make since. However, if I am already seeing three to four patients an hour, there is not a lot of room left to safely increase productivity. When I compare the time I am able to spend at the bedside against my colleagues using scribes, there is no difference. To boot, CPOE takes longer than charting and scribes cannot enter orders.

What we need is a less cumbersome way to chart. Charts now do not reflect our care of patients. Just try reading a chart from an EMR; it is easier to read JAMA. Everything is centered around billing and CMS metrics. Had this been left to market forces, we might have something better than Pong. However, the federal government is adept at taking technology and making it dysfunctional. So, I know how we survived before scribes ... we had a better charting system. Paper ... How sad is that?

— Dave Bryant, DO FAAEM

I appreciate your letter, and I agree with you. No EMR I have seen — especially the one without voice recognition that HCA forced on me and my colleagues — is as fast, flexible, accurate, legally protective, and descriptive as dictation. An ED chart should be as unique as the patient encounter that generated it, and a point-and-click EMR can't get anywhere close. You are right about the reason for this mistake: the technology and the market for it were not allowed to evolve naturally — the federal government, with the HITECH Act, forced EMRs on us before they were ready.

As you point out, good technology doesn't require the creation of a whole new class of workers (scribes) to accomplish something that was already getting done. On the contrary, that is a sign of bad technology — very, very bad. In this case, so bad it would disappear if the doctors and nurses who are forced to use it had any choice in the matter.

There is one other thing that bothers me about scribes, and I pointed this out to my colleagues soon after we realized just how bad our EMR was. When a hospital takes dictation away from its emergency physicians and substitutes an EMR so bad that scribes are necessary, it shifts the cost of generating medical records from itself to its emergency physicians — and those records are the property of the hospital and are used by the hospital for billing, just as much as by emergency physicians. That is wrong.

— The Editor


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