Bartleby in the ER?

CHW LogoFavorite things about doctoring:  coming up with a diagnosis; simple but gratifying procedures like pulling random objects out of a kid’s ear; getting a high five from a four year old when she’s leaving the emergency department; working with really smart and dedicated people.

Least favorite things about doctoring: not getting to work outside; paperwork.

Now, I have nothing against paper, or work, or working with paper.  But I do have a problem with things that at best add no value, and at worst diminish it.  Paperwork too often falls into that category.  (I recognize the term “paperwork” is undoubtedly passé, as most of what we call paperwork is done on an electronic device of some sort.  But given the bureaucratic connotations of the term, I’ll stick with it.)

The EHR is rapidly becoming a prime source of dissatisfaction for providers across the spectrum of professions and specialties.  A 2013 RAND report, based on interviews and surveys of a representative sample of hundreds of physicians, found a good deal of support for EHRs in principle, and their potential to improve care and facilitate greater to access to information.  But in actual practice, the current state of EHR technology is often plain unfriendly to the provider.  As the report says, “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction.”  Providers often spend more and more time simply entering information, leaving them less time for the things they were trained for.  Less doctoring, more paperwork.

In the face of a shortage of physicians, especially those in primary care, one solution is to reduce the waste of this resource, as suggested in a recent Health Affairs article – hand off the administrative and clerical tasks to allow the provider more time to provide care.  An increasingly common solution to the inefficiency of the EHR is the use of scribes.  Several companies now supply scribes to hospitals and physician practices; primary care and emergency departments are among the heaviest users.  The scribes, who typically undergo 3-4 weeks of training in medical terminology and the use of EHRs, accompany the providers into patient rooms and transcribe the history and exam findings simultaneously with the provider’s assessment.

I’ve heard this concept before, and have to admit to being a bit of a skeptic.  First of all, our ED group has developed sufficient templates that for the overwhelming majority of my patients, the documentation is no more burdensome than it was before we installed our EHR, and perhaps less so.  I was also leery of having another person present when I am evaluating a patient.  Would people be as forthcoming?  Would patients and families worry about their privacy?

But the more I think about it, the more it seems worth trying.  I recognize that my practice is exactly that, my practice.  I’ve heard enough from enough other providers that for at least some providers or specialties, the burdens of the EHR are real.  As for having that extra person, I’ve had experience where there was a scribe for my provider, and I have to be honest, it was hard to even remember there was someone else there.  And I’ve not noticed any reticence on the part of patients when I have students or others shadowing me.

The real question is, is it worth it?  Scribes cost money.  Will any efficiencies and provider satisfaction we gain justify that cost?  What’s the value proposition?   The early evidence, albeit anecdotal, suggests it very well might be worth it.

2 Responses to Bartleby in the ER?

  1. Wyatt, David says:

    Mark – there was a semi-recent blurb on NPR Planet Money on the use of scribes. They called it Win-Win-Win … You can download the podcast from


    David T. Wyatt, MD
    Medical College of Wisconsin
    9200 W Wisconsin Ave
    414.266.6750 (office)

  2. T Derks says:

    I agree with trialing scribes. In my observations, it appears that the next generation of physicians is spending is spending far greater time on the EHR, cell phones, and I pads than being at the bedside of their patients…There have been some recent e mails within our division about scribe use as well.

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