What a Scribe Taught Me About the Future EHR

The Era of Summarized Living will drive a new EHR format

I recently came across a Substack essay by entrepreneur Scott Belsky predicting what he calls The Era of Summarized Living, a future in which nearly everything we say and do is captured, compressed, and stored as part of a permanent memory.

Slowly but surely, we’re entering a world where every discussion and interaction we have will be part of a permanent intelligent memory that is always accessible and unlocks all kinds of insights and connections.

I came on this post (via the unflappable Spencer Dorn) as I’ve been hammering out my relationship with an AI scribe. Sorting that out and reading Belsky’s idea has me seeing the future of the medical record.

Let me unpack two elements of Belsky’s argument about summarized living that feels relevant to medicine.

1. Summarized living will remove bias from work and life

Can you imagine how many experiences in daily life — from employment interviews and performance reviews to team meetings and spousal debates (uh oh) — are riddled with biased and bad recollections? Perhaps relying on our natural memory will someday become unthinkable, much like navigating the world in the era before anything was written down.

This is spot-on for me.

Reading the AI summaries of my patient encounters has made it clear to me that I’m unable to recall some of the details even if I sat myself down in the workroom immediately after the visit. Maybe more importantly, my 24-year-old self probably wouldn’t do any better.

Belsky makes the point that when we compare what we remember to a factual record of what actually happened we can begin to recognize our own biases.

2. We will converse differently for better summarization

I’m already doing this, although I didn’t expect to.

I’ve fulfilled the promise of the AI scribe by pushing my keyboard aside and simply talking to patients. But the conversation isn’t what it used to be. I find myself asking questions differently, deliberately summarizing aloud, and subtly nudging parents toward phrasing that I know will translate cleanly. I am, in subtle ways, shaping the encounter for the summary.

As I steer the dialogue toward something the system can digest, I feel a kind of complicity with the scribe.

This isn’t a criticism. The scribe just isn’t that smart. I think of our scribe as like a good sub-intern from a mid-tier medical school who thinks she’s a little better than she actually is. So I have to gently help her along.

This kind of behavior is seen in the early iterations of new technology where we compensate for what it can’t do. This has been called fauxtomation. This is when humans quietly cover for what automation cannot yet do.

He says some other stuff in his essay, but I’ll leave those for the moment.

A renewed focus on the impression

So how has AI enabled summarization tech changed where I spend my time?

True to what’s been shown in scribe studies, summarization technology creates more satisfaction than bottom-line time savings. For me, the benefit not captured in these value studies is a better note because I’m able to prioritize what referring doctors want when they send a patient my direction.

And some of this relates to the kind of work I do in my north Houston healthcare ecosystem, so your mileage may vary. But my day job centers on 1) identifying unknowns, and 2) managing chronic disease.

For example, accounting for an asymptomatic preteen with dramatic weight loss and is not just a data problem. It’s physiology, psychology, maternal anxiety, and referral expectations glomed together.

So, the impression is where I work this through. This involves not only the likely pathophys, but the outcome of shared decision making and the thick layer of psychosocial goo around mothers and their ailing children.

While I’ve always found the impression to be my most important deliverable, I now have the bandwidth for really nailing the impression. And this is what I’m trying to do

I do it with straight dictation — I don’t use the scribe software. I also now put my impression at the top of my note.

Summary and synthesis | The two parts of the record

Looking ahead, I see two distinct modes emerging in the medical record: summary and synthesis.

Summary is what AI does well. And this is what a scribe does. It compresses, extracts, and reduces. It takes a meandering history from an exhausted mother and makes it legible. This is the creation of signal.

But summary won’t stop with the history.

The EHR is evolving as the exhaust pipe of the human health experience: labs, genomics, sequential imaging over decades, message threads, device data, ambient transcripts, etc. So, as our system collapses under its own data weight, information summarization will become critical. Belsky’s summarization is the only viable response to that kind of scale.

Synthesis, by contrast, is totally different.

Synthesis is what I do in the impression. It is where all of the far reaching stuff is integrated into meaning and direction. For that boy with unexplained weight loss, it’s the integration of physiology, family dynamics, probability, ambiguous celiac serology, and risk tolerance into a coherent approach. Synthesis is less about what happened and more about what it means — and what we are going to do.

As the EHR evolves into a clinical operating system, summary may become its dominant function. And synthesis will be its interpretive core.

The rise of the interpretive core

Until we have fully autonomous clinical systems (ie, end-to-end clinical experiences navigated with bots and agents, independent of human involvement), there will be a uniquely human interpretive core.

Sure, AI can simulate synthesis rhetorically. And synthesis by humans can involve the help of smart machines. That’s good. It can surface associations, challenge anchoring, and broaden a differential.

And for the foreseeable future, the physician owns the consequences and the interpretive core.