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Sunday, June 24, 2012

The Scribe

Once only the wealthy, the scribes and the priestly class accessed the word of God.  The populace had to settle for images wrought within stained glass, carved within stone and painted upon walls to enlighten them.  Then the printing press was invented.  Then Martin Luther demanded change.  Then he translated a Latin Bible into the people’s German.  Nothing stood between the common man and the word. 

The world was thrown into turmoil.  Scribes wondered what they would do.  Priests felt their Godlike powers sway, as a questioning public read the word in their native tongue.  During this time the western world plunged into religious war due to a change in technology.

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 medial 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.

As an artist, I create lovely calligraphy whilst having very poor penmanship.  I can write fast and the longhand text appears as an insane scrawl, or I can write legibly at a glacial speed.  I have great respect for the scribes in our culture that can quickly write in a beautiful fashion.  That respect applies even as they embraced typing and technology.  They hear and type with great speed, making that which was illegible, easy to communicate.  My eldest son has autism so he often must use a scribe to get his thoughts quickly upon the page.  The word “scribing” is enmeshed in our daily life.  I have great respect for scribes and Kathy Nicholls is the best scribe I know.

This is Kathy Nicholl’s jacket: “The Scribe.”

The Scribe a jacket for Kathy Nicholls

Kathy Nicholls reached out to me in September of 2010.  She had stumbled across my blog while following Meaningful Use and HIPAA regulations.  She has worked in the medical transcription field for many years and was concerned that the patient story was being lost in the culture of ‘click the box’ electronic medical records.  She also explained she was caring for her grandmother and was very frustrated by records lost within EMR systems.

For the next year I read Kathy’s thoughtful and astute comments on the Society for Participatory Medicine list serve.  She brought such a grounded perspective to conversations that often were highly theoretic.  Then in the fall of 2011 she reached out again after seeing that I would be presenting as a keynote speaker at the AHDI (Association forHealth Documentation Integrity) conference in August 2012.   That was her professional organization and I asked her to join The Walking Gallery.  Kathy was torn as to which story she would tell.  Would she focus on caring for her grandmother or on her fight for patient-centered and accurate data access in the EMR for patient and caregiver?

Kathy sent her jacket to me and it would rest in the queue as her story twisted and turned as the care for her grandmother became more intense.  Much inspiration for this painting came from Kathy’s life experience in February 2012.  Her grandmother was hospitalized and records were not accessed.  Kathy’s grandmother had created an advance directive specifying no DNR prior to the onset of dementia.  Nevertheless, she was intubated upon admission to a local hospital and was asked to under go duplicate tests, as data was not transferring between EMR systems.

From the end of February through the first few days of March, hundreds of Kathy’s friends followed her care giving journey as she updated us on her grandmother’s slow decline.

In this vignette a doctor is checking on Kathy’s grandmother, while a young relative asks, “Why don’t you just clear her nasal passages so she can breathe?”  Active death is a concept not well known outside the halls of medicine.  The young and inexperienced in death cannot understand that fluid slowly fills their great-grandmother making it hard to breathe. 

Providing Care

In the background Kathy stands in her scribe’s gown.  Her hands are typing on a keyboard and holding the quill.  The paper uncoils before her saying, “This is important, this is the patient story.”  In this moment she is combining worlds; her role of scribe and caregiver become one.


Behind her the cloud and sun streaming into the room offers a promise of a new day. Only if we combine the compassion of the caring scribe, the analytical thought process of the doctor and self-reported patient data with the technological promise of the cloud will we create an EMR that truly is the patient story.  


  1. Regina, I am touched beyond words with how you captured this. I cannot wait to be able to share this jacket in person with my colleagues at the AHDI meeting this summer. Thank you for all you do and particularly for telling this story so well.

    1. Thank you Kathy for walking hand and hand with me on this path.

  2. I agree 100% with Kathy's concern for the patient's story. It is vital to the medical professional's ability to treat the patient, to give the patient the right medications, and ultimately aid the patient in healing from whatever put them in the hospital in the first place. EMR may be the up and coming way for medical records, but it is not the only way, IMHO. It needs to have a backup system in case it goes down. After all, it is essentially a computer program, and quite frankly I don't know of one program that has stayed up and operating 24 hours a day for years and years without experiencing some sort of outage or some sort of break down. People are just not thinking of that. When it works, it is great. When it doesn't, patient's cannot get the treatment that they need because records cannot be accessed.

  3. I heard a really great presentation on that by the doctors that experienced the Joplin tornado last year. They were able to get their hospital up an running b/c they had their EMR system hosted remotely. That being said in the hours the system was down patients had to be treated and we must have back up plans in place for every scenario.

  4. Regina, your emphasis on the scribe's re-emergence as an important member of the patient-doctor relationship could not be more accurate. Studies, such as the one by Dr. Montague that was published in the Journal of Medical Informatics entitled "Study Finds Computer Use Affects Patient Visits" have shown that the EHR has created a barrier between patients who need their doctors to establish some type of emotional connection during their time of need. Our company, which runs the largest medical scribe program in the nation, covering more than 350 medical locations with 3700 scribes, has long marketed the value of medical scribes as provider efficiency catalysts. However, the true value for the patient is that the medical scribe allows the physician to physically sit with the patient at the bedside; thus displaying compassion, while the scribe enters the patient encounter into the EHR. Doctors should spend this precious time with their patients, not their computers. Though scribes do not have direct patient contact, I can't imagine a more compassionate patient benefit, than that of having the scribe provide the opportunity for the doctor to build earnest rapport with the patient. I really love your painting above by the way. Excellent work!!