One day while on shift in the emergency department, I looked out into the waiting room at the dozens of people waiting to be seen. Many had been waiting for hours. Some looked bored. Others appeared agitated by the long wait time. One thing that nearly all of them had in common, though, was the presence of a smartphone within arms reach. I wondered, rather than spending their time mindlessly scrolling through their Facebook feed or playing Candy Crush, whether they might be able to somehow use their smartphones and their idle time to expedite their own care. The idea crossed my mind that there may be a way for them to actually begin writing their own charts. Could they act as their own “patient scribes,” so to speak?
What is a scribe?
Before I go any further I should define what a scribe is. I’ve written previously about scribes, but, in brief, a medical scribe accompanies a physician or other healthcare provider as they see patients and assists them by documenting the medical chart. Scribes can allow providers to see more patients, document more accurately, and free up time for more face-to-face interaction with patients by minimizing time spent on clerical work. Some potential downsides of working with scribes include cost, variability in the quality of scribes, and the necessity of having an additional staff member in the exam room.
Patient scribe model
Imagine a scenario where patients who are waiting to be seen in the emergency department are initiating their own workup, prior to being seen by a provider. After being triaged, each patient is instructed to download an app which allows them to start inputting information regarding the details of their chief complaint.
The program would use simple language to elicit details regarding their presenting issues. The layout may involve drop-down menus for each element of the specific chief complaint. For example, if someone is presenting to the emergency department for abdominal pain, they would select “abdominal pain” from a drop-down menu of chief complaint options. This would trigger a series of additional drop-down menus specific to said complaint. For this particular example, there would be a “location” tab that brings up a picture of an abdomen and asks the patient to point to the location of their pain. They would then select options from the “severity” tab, “duration” tab, etc. Once they have filled out each of the tabs they would “submit” it to the EMR. There could be an additional “free text” option where patients could write additional information they may feel is relevant.
After the patient submits their information, the EMR would construct a preliminary HPI for the provider to review. There would be an “abdominal pain” template that simply plugs in the relevant information provided by the patient.
For example (the information provided by the patient is underlined):
John Doe is a 52-year-old male who presents to the emergency department for evaluation of abdominal pain. When asked where his pain is located he notes that it is in his right lower quadrant. He states that the pain began at 8am this morning. The pain has been constant and non-radiating. He rates the pain as 7 out of 10 in severity and says that it is exacerbated by walking. The pain is associated with nausea and vomiting.
With such a system in place, the provider would have all of these details prior to walking into the exam room. The patient interaction will be streamlined as the provider only needs to confirm these details rather than having to elicit them from scratch. Once confirmed, the provider would then only need to modify or add to the HPI as necessary. In addition, the chart will be as accurate as possible, since the details are being provided directly by the patient, rather than being recalled by the provider later.
Potential pitfalls of “patient scribes”
- Lack of patient interest – It may be the case that patients would view the process of inputting their own data as a burden that they would rather not be bothered with. Maybe some would prefer to mindlessly browse their social media rather than convey the details of their complaints. However, I believe that most patients are eager to engage in their own care. Having the ability to describe their presenting issues prior to seeing their provider would allow patients to feel like they are taking a more active role in their visit. Patients may be less concerned about the harried physician missing details of the encounter if they knew that they had already communicated this information. Currently, as patients sit in waiting rooms, they are in no way contributing to their care. I have no doubt that being able to communicate via such an app would empower patients and make them feel as though they are doing something.
- Technology barriers – Without question, the more tech-savvy patients would be more apt to embrace this type of technology. To overcome this issue, such an app would need to be extremely user-friendly and intuitive to use. The language would need to be in plain English, lacking any medical jargon. Furthermore, not everyone owns a smartphone. For these patients, the department can provide tablets that would allow them to input their information.
- Cost – The cost of implementing and maintaining this type of program would likely vary greatly depending on the size of the department, logistics of EMR integration, etc. However, once it is up and running, the ongoing costs ought to be significantly less than the cost of maintaining a full staff of in-person medical scribes.
- Privacy – Obviously, such a program would need to be secure and HIPAA-compliant. Some patients may not be comfortable filling out a form with details of their condition while in a waiting room full of other people. It would be simple enough to create a separate area in the waiting room with partitions between the chairs that is designated as private space for patients to fill out their information.
A way to make EMRs more bearable
Utilizing an app that allows patients to document their own HPI could help to make the process of EMR documentation faster and more accurate. There is a growing body of literature showing that EMRs are contributing to physician burnout 1. Anyone who works with an EMR regularly can attest to this. Implementation of a program like the one I am describing will not fix our EMR debacle but may ease the burden for many providers. For many of us, every little bit helps.
CMAJ 2017 November 13;189:E1405-6. doi: 10.1503/cmaj.109-5522
Kevin Perkins says
I feel like patients will attempt to find ways to make it to the front of the line and then change their CC when in front of a doctor. Also, could this information be used against the doctor in court? What if the patient doesn’t know how to accurately describe something and instead puts a more severe issue that wasn’t really the problem? Does that get deleted from the EMR?
Efficient MD says
Thanks for the question, Kevin.
Here is how I imagine the process: The patient is first evaluated by a triage nurse. The RN would document vital signs, chief complaint, etc as they normally would. This would determine their triage priority. After this initial evaluation, the patient would then fill in the details regarding their complaint(s). Once they submit their information it would not be uploaded directly to the chart but to file that allows the provider to review and accept the information prior to it being part of the actual chart. This would allow the provider to review, clarify and confirm what was written by the patient.
It may make more sense to make this type of program completely separate from the EMR, allowing providers to review, edit, then copy-and-paste the information into whichever EMR they happen to use. This would minimize the chance of information inadvertently being uploaded to the chart. What do you think?
I think this model would work well for straightforward complaints. Complex presentations with multiple complaints would be difficult to convey with this type of program and would likely rely on the patient communicating directly with the provider.