SOAP to EHR to Scribe: What's Next?

L. Gregory Lawton, MD


February 23, 2018

Too Much of a Good Thing?

There are too many clicks now. There is too much data entry. With the 20-inch screen in the exam room, all eyes are on it. Clinicians are spending more time looking at the screen. Patients, left to their own devices for more of the time when the clinician is in the room, are more likely to be using their own devices.

At CHOP, I am involved in a number of initiatives to increase clinician efficiency with the EHR. We are in the process of implementing several different pilots. One is a class on awareness of EHR functionality and showing "tips and tricks" to decrease hapless clicking and mousing. A second pilot is more of an immersion experience, with "at the elbow" personalized support for all staff and clinicians at a given site, with an emphasis on workflow analysis.

The third pilot is a new approach to notes and harkens back to the good old days. It is a scribe pilot.

Enter the Scribe

Here is how a scribe works. The clinician enters the exam room; greets the patient; introduces the scribe (holding a laptop already opened to the patient encounter); and, while maintaining eye contact throughout the entire encounter, conducts a conversational history and physical exam. No turning one's back to the patient. No "please hold on while I type." No "hold on a sec while I find that." Meanwhile, the scribe is taking that encounter and turning it into a clinical document of history and physical.

Outside the exam room, the clinician reviews the scribe's note, makes any necessary adjustments, and signs it. Other documents, such as referrals, letters, forms, orders, and patient instructions, can all be initiated by the scribe. The clinician just needs to approve and sign.

The pilot is intended to determine how this will work in an ambulatory pediatric practice. Will clinicians like it? What will patients think? Will it make clinicians more efficient or more productive? Although I am a touch-typist and very facile with our EHR, I am rather keen to make use of a scribe. Some clinicians have expressed reluctance to engage a scribe, citing such reasons as a desire to personalize their notes, concerns over privacy, or an aversion to deviating from a long-held workflow or habit.

In the world of EHR, notes are still about communication, but with an emphasis on data.

Alternatively, there have been a number of very enthusiastic responses to the pilot, somewhat analogous to a willingness to part with a loved first-born child in exchange for a scribe (and assuming that the physician really does love the EHR!).

As I look back over my career of 20 years and think about my progress notes, I can make out different seasons. My first notes were truly a personal expression, scratched out with a fountain pen, complete with initialed cross-outs, double underlines, exclamation points, and written so as to leave a physical imprint on the page. They could be copied or faxed, but essentially, they were physical notes, a means of communication as a solitary but unified collection of information.

When the EHR came, notes lost the components of a physical entity. Letters were but pixels on a screen, pecked out between hitting the tab, enter, or backspace key. No more cross-outs. No more smeared ink. No more coffee stains. The notes, no longer physical in nature, could have certain parts or words or options (template-enabled) flagged for archiving, mining, and analysis.

In the world of EHR, notes are still about communication, but with an emphasis on data. And data, to be useful, need to be collected in a certain way. Too much of what a clinician does today is less SOAP note and more data entry.

The pediatrician in me hopes that the scribe will enable clinicians to take a step back in time, to the mindset of a SOAP note written with emphasis on eye contact between the clinician and the patient. The clinical informaticist in me hopes that this will ensure that the very real benefits of data generated during the course of patient encounters will still be possible.

From SOAP note to EHR to scribe. Personal, physical notes to collected data elements. All in 20 years. What's on the horizon? Stay tuned.


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