Where EHRs, Scribes, and Patient Interaction Intersect

April 9, 2015

One physician explores the "dance of documentation" between physician, patient, and EHR; and a potential new partner: the medical scribe.

In a report released late last year in the Journal of the American Medical Association, a group of physicians from a Texas-based health system made the case that the use of medical scribes was allowing physicians to see more patients, but also impeding the development of EHRs

Part of their case was that without physicians actively engaged with EHR systems - and instead delegating EHR navigation and documentation to scribes due in part to their dissatisfaction with the technology - significant improvements to the market would never come to fruition.

At Sparrow Health System, one of Michigan's largest health systems, scribes play an active, yet limited and specific role in the emergency department, according to Michael Zaroukian, a primary-care physician as well as Sparrow's vice president and chief medical information officer.

"They are purely what we call 'clerical scribes,'" he told Physicians Practice. "They are allowed to literally transcribe what the physician said and use the EHR to the extent that it reflects, virtually, the same words and meaning, but they are not allowed to enter orders at all."

Zaroukian will deliver one of the preconference symposia opening keynote sessions, "Diverse Roles of Physicians in Health IT," scheduled for Sunday, April 12, from 8:15 to 9:15 a.m. CT at the Healthcare Information and Management Systems Society (HIMSS) Annual Conference in Chicago.

He recently spoke to Physicians Practice about the wider use of scribes in healthcare, their pros and cons when it comes to EHRs, and how both "tools" affect patient interaction.

Physicians Practice: What are your thoughts on the use of medical scribes: Good or bad for EHR use?

Michael Zaroukian: Scribes are not inherently good or bad for EHR use, but just as the EHR is a tool for the documentation and delivery of healthcare, scribes function as efficiency tools for EHR documentation of care delivered by providers.  Even for physicians who are very proficient in EHR use, having a scribe can allow the physician to interact with the patient without the potential distraction of the computer, with the scribe acting as the recorder. So there are definitely potential strengths. The key issues there are:

• How well does the scribe function in that role? How accurately and completely does the scribe document what was actually said and done?

• How appropriately are scribes used as required for payment? For example, having a scribe get history independent of the provider is not permissible, even if the history is later reviewed and confirmed by the physician.  It is important to ensure that the scribe's role is limited to true scribing.

The other part, as you might guess, is that we build clinical-decision support (CDS) into EHRs that physicians will not see if they are not interacting with the system at the time, and the scribe does not alert them to a CDS prompt that appears.  For example, an evidence-based history form might remind a physician to ask important questions they might otherwise forget to ask and could make a difference in the care of that patient. The scribe may or may not appreciate the importance of the question or be comfortable suggesting that the information also be gathered and recorded.   

And then there is the question of the impact of the scribe on the physician-patient relationship or the information the patient decides do disclose.  We seem to be highly sensitive to the possibility that the EHR might interfere with our relationship with the patient, but we may be underestimating the impact the presence of the scribe may have on what the patient might be willing to share with the physician.  Remember that the scribe may be a stranger and may influence the sharing of sensitive information. I think this is an important area for further study.

PP: How do you balance EHR use and patient interaction?

MZ: What I find useful is to use the EHR with the patient.  When the conversation is logical, as opposed to emotional, I use the EHR in a manner where the patient can see the screen along with me and use the EHR to facilitate data gathering and recording, and to review the information we are using to make decisions. Not all patients will elect to watch along with me but they do so with some regularity and ask to see specific information when it is relevant to them.  I find that my patients become more engaged when I show them relevant information and help interpret it for them, including verifying that I have documented their history and examination findings correctly and reviewed their problem assessments  and plans correctly.

I liken this process to driving down the road together on the way to a shared destination, but with more ability to make eye contact with the patient.  When the conversation is logical and the patient and I agree that looking at the EHR is important to make sure we are going in the right direction, we can both look through the EHR "windshield" to make sure we're on track and not missing anything that matters.  When the conversation becomes emotional or the patient otherwise requests, I do the EHR equivalent of "pulling off the road," turning completely away from the computer and focusing my entire attention on the patient. It is in this situation where even having a scribe could be detrimental to the patient feeling comfortable enough sharing sensitive information.  

It has been my experience that learning to do this "dance of documentation" in the exam room has improved both my efficiency and task completeness during office visits compared to previous paper work flows or using the EHR only outside the exam room.