Medical scribes: The history of present illness is now a narrative

By Angela Dunn
09:45 AM

“We are again at a time of great change. The doctors of medicine long have been revered like priests of old; scribes copied their words as a holy writ that the public could not easily access. Then came the electronic medical record. Now patients, doctors, nurses and scribes are trying to find their way in this new world.  Each has a place in the system of care and scribes are walking a new path.” – Regina Holliday, “The Scribe”

I had a chance to talk with Dr. Luis Saldaña about the benefits of “medical scribes," and how the role has evolved and exploded in the age of EHRs. Dr. Saldaña is an emergency physician whose group was among the first to use medical scribes – way before the introduction of the Electronic Health Record. Even in the paper world, scribes were found to increase efficiencies by 25 percent while improving the patient experience.

Today, medical scribes are a growing trend, and Dr. Saldaña is uniquely poised to speak to the value of medical scribes in our digital world. He also serves as chief medical information officer (CMIO) of Texas Health Resources, one of the largest faith-based, nonprofit health systems in the United States. In 2012, Dr. Saldaña co-authored HIMSS’ Book of the Year: “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide.”

What is a Medical Scribe?

medical scribe is a trained medical information manager who specializes in charting physician/patient encounters in real-time during medical exams. A scribe follows a physician through his or her work day and documents information in the Electronic Health Record so that the physician can focus on patient care.

Interview with Luis Saldaña M.D., CMIO of THR

How did you get started with medical scribes? 

Our group, which contracts with our hospital – and we staff all the THR hospitals, except maybe one or two – has used scribes for many, many years. One of the group’s owners came from a military background where corpsmen acted as scribes in the emergency department. He brought something similar to our emergency practice.

We started with our own scribes but that later morphed into a totally separate company, PhysAssist, with whom we contract today.

What are the benefits of medical scribes?

Scribes let me focus on the patient. I don’t see any other way than a third party being in the room to capture the patient’s voice. That is a narrative. The history of present illness is now a narrative.

It has a huge value to me. As a busy physician, you may have heard one thing, but the patient may have told you something in addition. Scribes capture all the elements, and that is key.

Even with voice recognition, you can’t capture the whole physician/patient encounter as well…I’d have to leave the room to dictate…or try to type and capture in the room which would be very awkward.

The process allows our physicians to be more productive and efficient because they can parallel task.

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