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Invited Commentary
November 2018

Use of Medical Scribes to Reduce Documentation BurdenAre They Where We Need to Go With Clinical Documentation?

Author Affiliations
  • 1Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
  • 3Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Intern Med. 2018;178(11):1472-1473. doi:10.1001/jamainternmed.2018.3945

Physician burnout is epidemic today in health care. For example, Shanafelt et al1 found in a 2012 national sample that 46% of physicians reported at least 1 symptom of burnout. In that study, burnout was more frequent in frontline practitioners. Although there are many contributors, one of the most important ones may be the use of the electronic health record (EHR).

A significant time-consuming component of EHR use for practitioners is documentation.2 Notes have a variety of purposes, but arguably their most important one is to adequately document what is occurring to make available to other practitioners the information they need to care for the patient. Another use that they have is to help patients understand their care. Patients increasingly have ready access to their notes through initiatives such as OpenNotes and find them remarkably useful despite the concerns that physicians had about making them available. Notes are also the basis for generating and substantiating the legitimacy of bills.

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    2 Comments for this article
    Transcriptionist or scribes?
    John Gray, MD |
    Physician dictation with a transcriptionist has many advantages over a scribe.
    1. A transcriptionist can record for multiple doctors and is thus much less costly than a scribe for each one.

    2. A physician dictated note can reflect much more completely a doctor's thoughts about the patient, the patients problems, his/her concerns, the decision making, and plans. A one to two page dictated history and physical can communicate better than a scribes comments and far better than many pages of template verbage designed for the insurance company.

    3. Dictating with the patient present (which
    I always did) lets the patient know exactly what will be in their record. It reinforces what you have told them and allows them to correct, explain, or expand on anything in the record. And it sometimes reminded me of something more that needed to be added, clarified or done.

    4. While dictating I can look at the patient and have further discussions which enhances communication and relationship.
    Thinking it, saying it, then writing it helps me do it
    John Clark, MD | Alaska Native Medical Center
    Flannery O'Connor said "I write because I don't know what I think until I read what I say". Einstein did not "dictate" his theorems - he worked them out with a pencil. Copying and pasting "potassium 2.1" in the chart alongside a "scanned review of systems" sheet circled yes for "cramps" and "palpitations" does not carry the same weight as writing in narrative form "the patient is experiencing leg cramps, and palpitations. Labs are notable for potassium low at 2.1". Those who take the time to study EMR's should place more weight on the quality and accuracy of the assessment, and the timeliness and outcomes of treatment and less weight on physician "efficiency". To the extent that physician notes play a role in communicating important information to other providers and the patient, we should also study whether notes are "lucid". To communicate effectively notes need to be concise, clear, accurate, relevant and internally consistent - i.e. the information in the note must logically support the assessment and plan. My experience is the EMR has failed miserably in this regard. My worry is that while we worship at the alter of information and documentation, we are losing our ability to think.