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Use of Medical Scribes to Reduce Documentation Burden: Are They Where We Need to Go With Clinical Documentation?
Abstract
Physician burnout is epidemic today in health care. For example, Shanafelt et al¹ found in a 2012 national sample that 46% of physicians reported at least 1 symptom of burnout. In that study, burnout was more frequent in frontline practitioners. Although there are many contributors, one of the most important ones may be the use of the electronic health record (EHR).
... 1,2 However, EHRs have also led to some unintended consequences like provider burnout, overdocumentation, and stress. [3][4][5][6] Health care professionals have some of the highest levels of burnout compared to other professions and the use of EHRs has been implicated as one of the possible factors contributing to burnout. [7][8][9][10][11][12] Because of the EHR and documentation requirements, many providers experience EHR fatigue and note bloating. ...
... Medical scribes are one proposed way to alleviate physician documentation burden. 4 Scribes have been aiding in documentation for centuries, but were not part of the medical field until 1975 when they were deployed as nursing scribes. 19 With the massive increase in EHR use in the early 2000s, the scribing industry has risen in popularity. ...
... It should be noted that clinical documentation in the United States is, on average, almost four times as long as those in other countries; an important factor that has driven the utilization of scribes. 4,27,47 This work also brings to the fore a larger issue of institutional and regulatory requirements for documentation. Organizations must consider how matching physician-scribe dyads will achieve the overall goal of scribe implementation, while also recognizing the limitations that scribes will have in altering poor EHR users' underlying behavioral deficits. ...
Medical scribes have become a widely used strategy to optimize how providers document in the electronic health record. To date, literature regarding the impact of scribes on time to complete documentation is limited. We conducted a retrospective, descriptive study of chart completion time among providers using scribes at our organization. A total of 148,410 scribed encounters, across 55 different clinics, were analyzed to determine variations in chart completion time. There was a significant variance in completion time between specialty groups and clinics within each specialty. Additionally, chart completion time was highly variable between providers working in the same clinic. These patterns were observed across all specialties included in our analysis. Our results suggest a higher level of variability with respect to chart completion when utilizing scribes than previously anticipated.
... There has, however, also been debate about the unintended consequences of scribes, which might include stifled EHR innovation because using scribes is a workaround indicative of problems inherent in EHRs. [29][30][31] A second unintended consequence might be decreased note quality. 32 Finally, expansion of the scribe role has also been cited as a concern. ...
... There have been some skeptical discussions in the literature about the wisdom of using scribes, [29][30][31] and a preliminary study we conducted indicated that scribes do make errors associated with EHR documentation. 32 However, in this study, subjects in all roles told us that if best practices are followed, scribes make few errors, and careful oversight avoids patient harm. ...
Objective:
Hiring medical scribes to document in the electronic health record (EHR) on behalf of providers could pose patient safety risks because scribes often have no clinical training. The aim of this study was to investigate the effect of scribes on patient safety. This included identification of best practices to assure that scribe use of the EHR is not a patient safety risk.
Materials and methods:
Using a sociotechnical framework and the Rapid Assessment Process, we conducted ethnographic data gathering at 5 purposively selected sites. Data were analyzed using a grounded inductive/hermeneutic approach.
Results:
We conducted site visits at 12 clinics and emergency departments within 5 organizations in the US between 2017 and 2019. We did 76 interviews with 81 people and spent 80 person-hours observing scribes working with providers. Interviewees believe and observations indicate that scribes decrease patient safety risks. Analysis of the data yielded 12 themes within a 4-dimension sociotechnical framework. Results about the "technical" dimension indicated that the EHR is not considered overly problematic by either scribes or providers. The "environmental" dimension included the changing scribe industry and need for standards. Within the "personal" dimension, themes included the need for provider diligence and training when using scribes. Finally, the "organizational" dimension highlighted the positive effect scribes have on documentation efficiency, quality, and safety.
Conclusion:
Participants perceived risks related to the EHR can be less with scribes. If healthcare organizations and scribe companies follow best practices and if providers as well as scribes receive training, safety can actually improve.
... There has, however, also been debate about the unintended consequences of scribes, which might include stifled EHR innovation because using scribes is a workaround indicative of problems inherent in EHRs. [29][30][31] A second unintended consequence might be decreased note quality. [32] Finally, expansion of the scribe role has also been cited as a concern. ...
... There have been some skeptical discussions in the literature about the wisdom of using scribes, [29][30][31] and a preliminary study we conducted indicated that scribes do make errors associated with EHR documentation. [32] However, in this study, subjects in all roles told us that if best practices are followed, scribes make few errors, and careful oversight avoids patient harm. ...
Objective:
Predictive analytics are potentially powerful tools, but to improve healthcare delivery, they must be carefully integrated into healthcare organizations. Our objective was to identify facilitators, challenges, and recommendations for implementing a novel predictive algorithm which aims to prospectively identify patients with high preventable utilization to proactively involve them in preventative interventions.
Materials and methods:
In preparation for implementing the predictive algorithm in 3 organizations, we interviewed 3 stakeholder groups: health systems operations (eg, chief medical officers, department chairs), informatics personnel, and potential end users (eg, physicians, nurses, social workers). We applied thematic analysis to derive key themes and categorize them into the dimensions of Sittig and Singh's original sociotechnical model for studying health information technology in complex adaptive healthcare systems. Recruiting and analysis were conducted iteratively until thematic saturation was achieved.
Results:
Forty-nine interviews were conducted in 3 healthcare organizations. Technical components of the implementation (hardware and software) raised fewer concerns than alignment with sociotechnical factors. Stakeholders wanted decision support based on the algorithm to be clear and actionable and incorporated into current workflows. However, how to make this disease-independent classification tool actionable was perceived as a challenge, and appropriate patient interventions informed by the algorithm appeared likely to require substantial external and institutional resources. Stakeholders also described the criticality of trust, credibility, and interpretability of the predictive algorithm.
Conclusions:
Although predictive analytics can classify patients with high accuracy, they cannot advance healthcare processes and outcomes without careful implementation that takes into account the sociotechnical system. Key stakeholders have strong perceptions about facilitators and challenges to shape successful implementation.
... Some tasks may simply be redundant (see [30]), others, such as dealing with insurance companies, but also documentation tasks, might be taken over by specially trained nurses or administrative staff (see [30]). Programs employing scribes, who take over much of documentary tasks, have been shown to have positive effects [31], including reduced physician pre-session and post-session time and time spent in visits, while increasing patient satisfaction [32] and efficiency [33]. Furthermore, improving the usability of electronic health records (EHR) deserves attention [31]. ...
... Programs employing scribes, who take over much of documentary tasks, have been shown to have positive effects [31], including reduced physician pre-session and post-session time and time spent in visits, while increasing patient satisfaction [32] and efficiency [33]. Furthermore, improving the usability of electronic health records (EHR) deserves attention [31]. ...
Background:
Many surgeons report passion for their work, but not all tasks are likely to be satisfying. Little is known about how hospital surgeons spend their days, how they like specific tasks, and the role of core tasks (i.e. surgery-related tasks) versus tasks that may keep them from core tasks (e.g., administrative work). This study aimed at a more detailed picture of hospital surgeons' daily work - how much time they spend with different tasks, how they like them, and associations with satisfaction.
Methods:
Hospital surgeons (N = 105) responded to a general survey, and 81 of these provided up to five daily questionnaires concerning daily activities and their attractiveness, as well as their job satisfaction. The data were analyzed using t-tests, analysis of variance, as well as analysis of covariance and repeated measures analysis of variance for comparing means across tasks.
Results:
Among 14 tasks, surgery-related tasks took 21.2%, patient-related tasks 21.7% of the surgeons' time; 10.4% entailed meetings and communicating about patients, and 18.6% documentation and administration. The remaining time was spent with teaching, research, leadership and management, and not task-related activities (e.g. walking between rooms). Surgery was rated as most (4.25; SD = .66), administration as least attractive (2.63; SD = .78). A higher percentage of administration predicted lower perceived legitimacy; perceived legitimacy of administrative work predicted job satisfaction (r = .47). Residents were least satisfied; there were few gender differences.
Conclusions:
Surgeons seem to thrive on their core tasks, most notably surgery. By contrast, administrative duties are likely perceived as keeping them from their core medical tasks. Increasing the percentage of medical tasks proper, notably surgery, and reducing administrative duties may contribute to hospital surgeons' job satisfaction.
... Prior efforts to minimize medication errors have involved color coding medications 26 , using tall man style lettering on labels 27 , standardized safety protocols 28,29 , additional observers 30 , prefilled syringes 31 and barcode scanning 32,33 . While some of these mitigation strategies are passive, methods like barcode scanning require active participation by clinical providers prior to medication administration, and compliance with these safety mechanisms can be problematic [34][35][36] . Busy clinicians often develop 'workaround' techniques to decrease their workload up to 62% of the time during medication administration tasks, often administering a drug first before entering the drug name manually into the clinical record 37 . ...
Drug-related errors are a leading cause of preventable patient harm in the clinical setting. We present the first wearable camera system to automatically detect potential errors, prior to medication delivery. We demonstrate that using deep learning algorithms, our system can detect and classify drug labels on syringes and vials in drug preparation events recorded in real-world operating rooms. We created a first-of-its-kind large-scale video dataset from head-mounted cameras comprising 4K footage across 13 anesthesiology providers, 2 hospitals and 17 operating rooms over 55 days. The system was evaluated on 418 drug draw events in routine patient care and a controlled environment and achieved 99.6% sensitivity and 98.8% specificity at detecting vial swap errors. These results suggest that our wearable camera system has the potential to provide a secondary check when a medication is selected for a patient, and a chance to intervene before a potential medical error.
... However, the implementation of comprehensive approaches is challenging [65,66,[71][72][73]. More small-scale interventions aiming to reduce illegitimate tasks, such as relieving physicians from administrative duties by employing scribes [74,75], should not be neglected, although such approaches also require careful implementation [76]. ...
Objectives: The current study investigates the prevalence of illegitimate tasks in a hospital setting and their association with patient safety culture outcomes, which has not been previously investigated.
Methods: We conducted a cross-sectional survey in a tertiary referral hospital. Patient safety culture outcomes were measured using the Hospital Survey on Patient Safety Culture questionnaire; the primary outcome measures were a low safety rating for the respondent’s unit and whether the respondent had completed one or more safety event reports in the last 12 months. Analyses were adjusted for hospital department and staff member characteristics relating to work and health.
Results: A total of 2,276 respondents answered the survey (participation rate: 35.0%). Overall, 26.2% of respondents perceived illegitimate tasks to occur frequently, 8.1% reported a low level of safety in their unit, and 60.3% reported having completed one or more safety event reports. In multivariable analyses, perception of a higher frequency of illegitimate tasks was associated with a higher risk of reporting a low safety rating and with a higher chance of having completed event reports.
Conclusion: The prevalence of perceived illegitimate tasks was rather high. A programme aiming to reduce illegitimate tasks could provide support for a causal effect of these tasks on safety culture outcomes.
... [14][15][16][17][18][19] Despite these advantages, some critics argue that scribes are merely a "workaround" for coping with EHR usability. [20][21][22] Further, there is a growing concern regarding the wide range of variability that has been reported based on the outcomes and performance of providers who use scribes. 19,[23][24][25][26][27] Scribed notes can highly vary in length, structure, and content. ...
Background
The use of electronic health records has generated an increase in after-hours and weekend work for providers. To alleviate this situation, the hiring of medical scribes has rapidly increased. Given the lack of scribe industry standards and the wide variance in how providers and scribes work together, it could potentially create new patient safety-related risks.Objective
The purpose of this paper was to identify how providers can optimize the effective and safe use of scribes.DesignThe research team conducted a secondary analysis of qualitative data where we reanalyzed data from interview transcripts, field notes, and transcribed group discussions generated by four previous projects related to medical scribes.ParticipantsPurposively selected participants included subject matter experts, providers, informaticians, medical scribes, medical assistants, administrators, social scientists, medical students, and qualitative researchers.ApproachThe team used NVivo12 to assist with the qualitative analysis. We used a template method followed by word queries to identify an optimum level of scribe utilization. We then used an inductive interpretive theme-generation process.Key ResultsWe identified three themes: (1) communication aspects, (2) teamwork efforts, and (3) provider characteristics. Each theme contained specific practices so providers can use scribes safely and in a standardized way.Conclusion
We utilized a secondary qualitative data analysis methodology to develop themes describing how providers can optimize their use of scribes. This new knowledge could increase provider efficiency and safety and be incorporated into further and future training tools for them.
... The use of medical scribes can cut physician EHR time and boost productivity and satisfaction; therefore, expanding the use of medical scribes to telehealth use possibly will have similar effect. 34 Following the federal telehealth expansion on March 6, our data demonstrated a substantial increase in the uptake of virtual care visits among urban patientsand among the number of virtual visits occurring by video. We found that telehealth visits from more vulnerable regions substantially decreased post the expansion. ...
Introduction:
The coronavirus 2019 pandemic (COVID-19) has resulted in major changes in lifestyle practices and healthcare delivery. The goal of this study was to examine changes in practice and service outcomes in a telehealth program before and after the federal and private telehealth policy expansion during the COVID-19 pandemic. These findings are particularly useful to understand what may be needed to overcome telehealth challenges in future disasters.
Methods:
We conducted a cross-sectional analysis of virtual visits through a statewide telehealth center embedded in a large academic healthcare system. Primary outcomes of this study were changes in telehealth visits pre- and post-policy expansions among at-risk populations.
Results:
A total of 2,132 telehealth visits were conducted: 1,530 (71.8 percent) patients were female, 1,561 (73.2 percent) were between the ages 18-50, 1,576 (74 percent) were uninsured, and 1,225 (57.5 percent) were from rural regions. The average number of telehealth visits per day increased from 14 to 33 visits post-expansion. A significant change in patient characteristics was found among senior, uninsured, and rural patients after the telehealth expansion.There was an 11 percent decrease in telehealth visits from very high vulnerability regions post-expansion compared to pre-expansion. There was a 15 percent decrease in visits resulting in prescription post-expansion (p-value<0.01).
Conclusions:
COVID-19 policy expansions expanded telehealth utilization among at-risk populations such as senior, uninsured, and rural patients while decompressing hospitals and emergency rooms and maintaining positive patient experiences. Further regulations are needed around virtual visits unintended consequences, software certification, and guidelines for workforce training.
... 3,4 Stringent documentation policies, prolonged time and effort fetching for information, and work out of work hours are the main contributors to EHR-related fatigue. [5][6][7] Additionally, inadequate EHR interface design hinders the physician-EHR experience that leads to exhaustion. 8 Evaluations of the physician EHR experience have heavily relied on objective and subjective responses. ...
Prior authorization is an approval process to ensure that services provided by healthcare organizations will be reimbursed by insurance carriers. Prior authorization denials can result in revenue loss. Due to multiple prior authorization issues, over 291,217.63 was ultimately written off as uncollectible in a one-year period at the Department of Surgery at Hospital X. This paper aimed to design an improved process to reduce, or eliminate, the issues causing charges to be written off. Three divisions with the most prior authorization denials within the department were identified. A comprehensive review of the current prior authorization process was conducted. Each division was found to have a unique prior authorization issue that was causing charges to be written off. Barriers were identified, educational training was provided accordingly, and process changes were implemented thereafter. When comparing the results pre- and post-interventions, these interventions resulted in these charges no longer being denied or written off. The processes utilized here can be easily replicated for organizations with similar barriers.
... impact on provider workflow due to documentation burden, which is driven by a combination of EHR design and regulatory requirements [2]. Documentation burden is substantial: provider notes in the United States (U.S.) are nearly four times longer than in other countries [3]. ...
Background
With the use of electronic health records (EHRs) increasing and causing unintended negative consequences, the medical scribe profession has burgeoned, but it has yet to be regulated. The purpose of this study was to describe scribe workflow as well as identify the threats and opportunities for the future of the scribe industry.
Methods
The first phase of the study used ethnographic methods consisting of interviews and observations by a multi-disciplinary team of researchers at five United States sites. In April 2019, a two-day conference of experts representing different stakeholder perspectives was held to discuss the results from site visits and to predict the future of medical scribing. An interpretive content analysis approach was used to discover threats and opportunities for the future of medical scribes.
Results
Threats facing the medical scribe industry were related to changes in the documentation model, EHR usability, different payment structures, the need to acquire disparate data during clinical encounters, and workforce-related changes relevant to the scribing model. Simultaneously, opportunities for medical scribing in the future included extension of their role to include workflow analysis, acting as EHR-related subject-matter-experts, and becoming integrated more effectively into the clinical care delivery team. Experts thought that if EHR usability increases, the need for medical scribes might decrease. Additionally, the scribe role could be expanded to allow scribes to document more or take on more informatics-related tasks. The experts also anticipated an increased use of alternative models of scribing, like tele-scribing.
Conclusion
Threats and opportunities for medical scribing were identified. Many experts thought that if the scribe role could be expanded to allow scribes to document more or take on more informatics activities, it would be beneficial. With COVID-19 continuing to change workflows, it is critical that medical scribes receive standardized training as tele-scribing continues to grow in popularity and new roles for scribes as medical team members are identified.
... Preliminary evidence suggests the use of scribes saves time and may even improve doctor-patient interaction [32], but there are problems associated with them. There is considerable variation between scribes in the accuracy and content of what they enter into EHRs [33], concerns about patient confidentiality in the presence of scribes [34], about the impact of scribes on patients' willingness to be honest with their physicians [35], and about the affordability of scribes, particularly for physicians who specialize in family practice and internal medicine [36]. Alternatively, patients may be given the option to self-report personal health information in writing or electronically. ...
Background
This study assessed direct and indirect associations between problems with electronic health records (EHRs) and physician distress via problems encountered during the day-to-day practice of medicine and access to social support.Methods
One-hundred and ninety physicians in the state of Nevada completed an online survey in spring of 2019 regarding problems with EHRs, their medical practice, social support, and mental health. A parallel mediator model was tested with 10,000 bias-corrected bootstrap samples to assess associations between EHRs and distress directly and indirectly via medical practice problems and social support.ResultsFrequency of EHR problems was positively associated with problems with the day-to-day practice of medicine, and negatively associated with access to social support. Medical practice problems were positively associated with physician distress, and social support was negatively associated with it. Mediation analyses suggest that EHR problems indirectly affect physician distress via problems encountered during the practice of medicine and social support.Conclusions
Physician wellbeing is a critical priority for health care. This study suggests that reducing EHR problems may improve physician well-being directly and indirectly by addressing problems in the practice of medicine that compound mental health effects of EHRs. Suggestions for improving the integration of EHRs into medical practice are discussed.
... There are attempts where AI-based chatbots are used for collecting medical histories (e.g. Ana) [21], or the development of digital scribes to reduce clinical burden using speech recognition and natural language processing [22,23]. However, there are still some challenges [24]. ...
Research on artificial intelligence (AI) for healthcare gained interest in recent years. However, the use of AI in daily clinical practice is still rare. We created and distributed an online survey among professionals working within the health informatics field to explore their views. The provided answers were classified into referring or not to: 1) Application areas; 2) Medical specialities; 3) Specific technologies; 4) Use cases; 5) Citizens involvement; and 6) Challenges. We received 42 valid responses. With regard to the sentiment of the answers, 71,4% were classified by the AFINN tool as being positive. In light of the open question, 76,2% of the respondents referred to possible applications areas. They think the most frequent uses will be for diagnostic, decision making and treatment. 54,8% of respondents referred to use cases, being personalized care and daily practice the most popular scenarios. 28,6% mentioned citizens’ involvement, and 23,8% medical specialities in which AI might be used. There is a mostly positive attitude towards the application of AI in healthcare, in particular regarding its future use for realising routine tasks. From these results, we conclude that research should further focus on realising AI-based applications for relieving health professionals from repetitive tasks and optimize healthcare processes.
... However, these approaches are limited in that most are in a prototype phase and are unlikely to be ready for implementation in the near future. Although it has been shown that using medical scribes (individuals who specialize in transcribing information during encounters into EHRs in real time) can reduce the documentation burden for physicians [16,17], scribes require a significant amount of training and clear coordination with physicians. In addition, the presence of a scribe might cause uncomfortable conversations during physician-patient encounters. ...
Background:
Documentation burden is a common problem with modern electronic health record (EHR) systems. To reduce this burden, various recording methods (eg, voice recorders or motion sensors) have been proposed. However, these solutions are in an early prototype phase and are unlikely to transition into practice in the near future. A more pragmatic alternative is to directly modify the implementation of the existing functionalities of an EHR system.
Objective:
This study aims to assess the nature of free-text comments entered into EHR flowsheets that supplement quantitative vital sign values and examine opportunities to simplify functionality and reduce documentation burden.
Methods:
We evaluated 209,055 vital sign comments in flowsheets that were generated in the Epic EHR system at the Vanderbilt University Medical Center in 2018. We applied topic modeling, as well as the natural language processing Clinical Language Annotation, Modeling, and Processing software system, to extract generally discussed topics and detailed medical terms (expressed as probability distribution) to investigate the stories communicated in these comments.
Results:
Our analysis showed that 63.33% (6053/9557) of the users who entered vital signs made at least one free-text comment in vital sign flowsheet entries. The user roles that were most likely to compose comments were registered nurse, technician, and licensed nurse. The most frequently identified topics were the notification of a result to health care providers (0.347), the context of a measurement (0.307), and an inability to obtain a vital sign (0.224). There were 4187 unique medical terms that were extracted from 46,029 (0.220) comments, including many symptom-related terms such as "pain," "upset," "dizziness," "coughing," "anxiety," "distress," and "fever" and drug-related terms such as "tylenol," "anesthesia," "cannula," "oxygen," "motrin," "rituxan," and "labetalol."
Conclusions:
Considering that flowsheet comments are generally not displayed or automatically pulled into any clinical notes, our findings suggest that the flowsheet comment functionality can be simplified (eg, via structured response fields instead of a text input dialog) to reduce health care provider effort. Moreover, rich and clinically important medical terms such as medications and symptoms should be explicitly recorded in clinical notes for better visibility.
... To counter this impost, the implementation of human or non-human scribing to accommodate the needs of the EMR has been suggested (Doval 2018;Bates and Landman 2018). Medical scribes demonstrably increase physician productivity (Walker et al. 2014) and increase hospital revenue over and above the costs of scribes (Slomski 2019). ...
The rapid adoption and implementation of artificial intelligence in medicine creates an ontologically distinct situation from prior care models. There are both potential advantages and disadvantages with such technology in advancing the interests of patients, with resultant ontological and epistemic concerns for physicians and patients relating to the instatiation of AI as a dependent, semi- or fully-autonomous agent in the encounter. The concept of libertarian paternalism potentially exercised by AI (and those who control it) has created challenges to conventional assessments of patient and physician autonomy. The unclear legal relationship between AI and its users cannot be settled presently, an progress in AI and its implementation in patient care will necessitate an iterative discourse to preserve humanitarian concerns in future models of care. This paper proposes that physicians should neither uncritically accept nor unreasonably resist developments in AI but must actively engage and contribute to the discourse, since AI will affect their roles and the nature of their work. One’s moral imaginative capacity must be engaged in the questions of beneficence, autonomy, and justice of AI and whether its integration in healthcare has the potential to augment or interfere with the ends of medical practice.
... 28,29 In the United States, this has led to a growing industry of medical scribes who document in the EHR while the clinicians focus on the patient, although this is not always advisable. 30 Yet, the academic literature shows that the issue is more complicated and that EHRs affect the patient-clinician interaction in multiple ways, both positive and negative. Through the literature and our own research, we identified some of the challenges involved in integrating the EMR into the clinical consultation, as well as best practices to minimize the negative impact and maximize the benefits. ...
The benefits of Health Information Technology (HIT) depend on the way they are being used. Education and training are often needed to move from basic to advanced, value-adding, use. In this article, we describe three educational approaches that can help in achieving this goal: “productive failure,” video tutorials, and simulation. We describe the rationale behind these approaches, their strengths, and limitations and illustrate their application, respectively, to three problems associated with the use of HIT in clinical practice: improving data quality within Electronic Medical Records (EMRs) at the point of data entry, use of advanced EMR features for chronic disease management, and impact of the EMR on patient-clinician communication. We conclude that, while these approaches are promising, there is a need for innovation and diversity of educational approaches to address use of advanced HIT features, identified challenges with HIT, and usage in context—as well as for rigorous evaluation.
Background There are limited objective studies regarding the effectiveness of strategies to alleviate the documentation burden on resident physicians.
Objective To develop and implement diagnosis-specific templates for the plan of care section of inpatient admission notes, aiming to reduce documentation time.
Methods Twelve templates for the plan of care section of admission notes were written by the study authors, reviewed by attending physicians, and shared with the residents through the electronic health record (EHR) on September 23, 2022. EHR audit log data were collected to examine admission note writing times, supplemented by resident feedback on acceptability via an anonymous survey. Feasibility measures included time investment, experience with the EHR, and resident training.
Results Between July 1, 2021 and June 30, 2023, 62 pediatric residents contributed 9840 admission notes. The templates were used in 557 admission notes. The mean total time spent on an admission note decreased from 97.9 minutes pre-intervention to 71.0 minutes post-intervention with the use of a template; an adjusted reduction of 23% (95% CI 16%-30%; P<.001). The mean attending time spent editing an admission note was unchanged. The survey results underscored wide acceptability of the templates among the residents. Feasibility data showed that the project required minimal time investment from the health care informatics team and minimal resident training.
Conclusions Using templates in the care plan section of admission notes reduces the time residents spend writing admission notes.
Importance
Time on the electronic health record (EHR) is associated with burnout among physicians. Newer virtual scribe models, which enable support from either a real-time or asynchronous scribe, have the potential to reduce the burden of the EHR and EHR-related documentation.
Objective
To characterize the association of use of virtual scribes with changes in physicians’ EHR time and note and order composition and to identify the physician, scribe, and scribe response factors associated with changes in EHR time upon virtual scribe use.
Design, Setting, and Participants
Retrospective, pre-post quality improvement study of 144 physicians across specialties who had used a scribe for at least 3 months from January 2020 to September 2022, were affiliated with Brigham and Women’s Hospital and Massachusetts General Hospital, and cared for patients in the outpatient setting. Data were analyzed from November 2022 to January 2024.
Exposure
Use of either a real-time or asynchronous virtual scribe.
Main Outcomes
Total EHR time, time on notes, and pajama time (5:30 pm to 7:00 am on weekdays and nonscheduled weekends and holidays), all per appointment; proportion of the note written by the physician and team contribution to orders.
Results
The main study sample included 144 unique physicians who had used a virtual scribe for at least 3 months in 152 unique scribe participation episodes (134 [88.2%] had used an asynchronous scribe service). Nearly two-thirds of the physicians (91 physicians [63.2%]) were female and more than half (86 physicians [59.7%]) were in primary care specialties. Use of a virtual scribe was associated with significant decreases in total EHR time per appointment (mean [SD] of 5.6 [16.4] minutes; P < .001) in the 3 months after vs the 3 months prior to scribe use. Scribe use was also associated with significant decreases in note time per appointment and pajama time per appointment (mean [SD] of 1.3 [3.3] minutes; P < .001 and 1.1 [4.0] minutes; P = .004). In a multivariable linear regression model, the following factors were associated with significant decreases in total EHR time per appointment with a scribe use at 3 months: practicing in a medical specialty (−7.8; 95% CI, −13.4 to −2.2 minutes), greater baseline EHR time per appointment (−0.3; 95% CI, −0.4 to −0.2 minutes per additional minute of baseline EHR time), and decrease in the percentage of the note contributed by the physician (−9.1; 95% CI, −17.3 to −0.8 minutes for every percentage point decrease).
Conclusions and Relevance
In 2 academic medical centers, use of virtual scribes was associated with significant decreases in total EHR time, time spent on notes, and pajama time, all per appointment. Virtual scribes may be particularly effective among medical specialists and those physicians with greater baseline EHR time.
Goal:
Administrative burden is one of many potential root causes of physician burnout. Scribe documentation assistance can reduce this burden. However, traditional in-person scribe services are challenged by consistent staffing because the model requires the physical presence of a scribe and limits the team to a single individual. In addition, in-person scribes cannot provide the flexible support required for virtual care encounters, which can now pivot geographically and temporally. To respond to these challenges, our health network implemented an asynchronous virtual scribe model and evaluated the program's impact on clinician perceptions of burnout across multiple outpatient specialties.
Methods:
Using a mixed-methods, pre-/postdesign, this evaluation measured the impact of an asynchronous virtual scribe program on physician burnout. Physicians were given the Professional Fulfillment Index tool (to self-assess their mental state) and free-text comment surveys before virtual scribe initiation and again at 3-, 6-, and 12-month intervals after program implementation. Descriptive statistics of survey results and qualitative review of free-text entries were analyzed for themes of facilitation and barriers to virtual scribe use.
Principal findings:
Of 50 physician participants in this study, 42 (84%) completed the preintervention survey and 15 (36%) completed all 4 surveys; 25 participants (50%) discontinued scribe use after 12 months. Burnout levels-as defined by dread, exhaustion, lack of enthusiasm, decrease in empathy, and decrease in colleague connection-all trended toward improvement during this study. Importantly, quality, time savings, burnout, and productivity moved in positive directions as well.
Practical application:
The cost burden to physicians and the COVID-19 pandemic inhibited the continued use of asynchronous virtual medical scribes. Nevertheless, those who continued in the program have reported positive outcomes, which indicates that the service can be a viable and effective tool to reduce physician burnout.
Objective:
While the use of medical scribes is rapidly increasing, there are not widely accepted standards for their training and duties. Because they use electronic health record systems to support providers, inadequately trained scribes can increase patient safety related risks. This paper describes the development of desired core knowledge, skills, and attitudes (KSAs) for scribes that provide the curricular framework for standardized scribe training.
Materials and methods:
A research team used a sequential mixed qualitative methods approach. First, a rapid ethnographic study of scribe activities was performed at 5 varied health care organizations in the United States to gather qualitative data about knowledge, skills, and attitudes. The team's analysis generated preliminary KSA related themes, which were further refined during a consensus conference of subject-matter experts. This was followed by a modified Delphi study to finalize the KSA lists.
Results:
The team identified 90 descriptions of scribe-related KSAs and subsequently refined, categorized, and prioritized them for training development purposes. Three lists were ultimately defined as: (1) Hands-On Learning KSA list with 47 items amenable to simulation training, (2) Didactic KSA list consisting of 32 items appropriate for didactic lecture teaching, and (3) Prerequisite KSA list consisting of 11 items centered around items scribes should learn prior to being hired or soon after being hired.
Conclusion:
We utilized a sequential mixed qualitative methodology to successfully develop lists of core medical scribe KSAs, which can be incorporated into scribe training programs.
Background:
Inadequate electronic health record (EHR) interface design hinders the physician-EHR experience, which may lead to increase physician frustration and fatigue levels.
Objectives:
The objective of this study was to examine the physician EHR experience by evaluating the congruency between actual and perceived measures among physicians with different EHR expertise and utilization levels.
Methods:
We conducted a cross-sectional EHR usability study of intensive care unit (ICU) physicians at a major Southeastern medical center. We used eye-tracking glasses to measure provider EHR-related fatigue and three surveys to measure the perceived EHR experience.
Results:
Of the 25 ICU physicians, 11 were residents, nine were fellows, and five were attending physicians. No significant differences were found between actual fatigue levels and their perceived EHR usability (p=0.159), workload (p=0.753), and satisfaction (p=0.773).
Conclusion:
We found that there was low congruency between physicians' EHR-related fatigue and the perceived ratings for usability, satisfaction, and workload, which suggests using actual and perceived measures for a comprehensive assessment of the user experience. EHR-related fatigue may not be instantly felt by some physicians, hence the similar rating of perceived EHR experience among physicians.
This article addresses ethical concerns with the use of electronic health records (EHRs) by physicians in clinical practice. It presents arguments for two claims. First, requiring physicians to maintain patient EHRs for medically unnecessary tasks is likely contributing to increased burnout, decreased quality of care, and potential risks to patient safety. Second, medical institutions have ethical reasons to employ medical scribes to maintain patient EHRs. Finally, this article reviews central objections to employing medical scribes and provides responses to each.
Introduction:
The electronic health record (EHR) has become an integral part of modern medical practice. The balance of benefit versus burden of a required EHR remains inconclusive, with many studies identifying increasing physician burnout and less face-to-face patient contact because of increasing documentation demands. Few studies have investigated EHR burden in orthopaedic surgery practice. This study aimed to characterize and compare EHR usage patterns and time allocation within EHR between orthopaedic surgeons, other surgeons, and medicine physicians at an academic medical center.
Methods:
EHR usage was digitally tracked within a large academic medical center. EHR usage data were compiled for all physicians seeing outpatients from April 2018 to June 2019. The tracking metrics included time spent answering messages, typing notes, reviewing laboratories and imaging, reading notes, and placing orders. Physicians were subdivided between orthopaedic surgeons, other surgeons, and nonsurgeon/medical specialties. Statistical comparisons using a two-sample t-test were done between orthopaedic surgeon EHR usage patterns and other surgeons, in addition to orthopaedic surgeons versus nonsurgeons.
Results:
One thousand sixty physicians including 28 full-time orthopaedic surgeons, 134 other surgeons, and 898 nonsurgical medicine physicians met inclusion criteria. Orthopaedic surgeons saw on average 31 patients per office day compared with other surgeons at 18 patients per office day (P < 0.01) and nonsurgeons at 12 patients per office day (P < 0.01). Orthopaedic surgeons received more EHR messages while also being more efficient at answering EHR messages compared with other surgeons and nonsurgeons (P < 0.01). EHR tasks, including answering messages, placing orders, chart review, writing notes, and reviewing imaging, consumed 58% of an orthopaedic surgeon's scheduled office day with the largest contribution from required note writing.
Discussion:
In academic orthopaedic practice, EHR use has surpassed face-to-face patient time, consuming 58% of orthopaedic surgeons' clinical days. With the previously shown correlation between EHR burden and physician burnout, targeted interventions to increase efficiency and off-load EHR burden are necessary to sustain a successful orthopaedic practice.
Objective
Provider burnout is a crisis in healthcare and leads to medical errors, a decrease in patient satisfaction, and provider turnover. Many feel that the increased use of electronic health records contributes to the rate of burnout. To avoid provider burnout, many organizations are hiring medical scribes. The goal of this study was to identify relevant elements of the provider–scribe relationship (like decreasing documentation burden, extending providers’ careers, and preventing retirement) and describe how and to what extent they may influence provider burnout.
Materials and Methods
Qualitative methods were used to gain a broad view of the complex landscape surrounding scribes. Data were collected in 3 phases between late 2017 and early 2019. Data from 5 site visits, interviews with medical students who had experience as scribes, and discussions at an expert conference were analyzed utilizing an inductive approach.
Results
A total of 184 transcripts were analyzed to identify patterns and themes related to provider burnout. Provider burnout leads to increased provider frustration and exhaustion. Providers reported that medical scribes improve provider job satisfaction and reduce burnout because they reduce the documentation burden. Medical scribes extend providers’ careers and may prevent early retirement. Unfortunately, medical scribes themselves may experience similar forms of burnout.
Conclusion
Our data from providers and managers suggest that medical scribes help to reduce provider burnout. However, scribes are not the only solution for reducing documentation burden and there may be potentially better options for preventing burnout. Interestingly, medical scribes sometimes suffer from burnout themselves, despite their temporary roles.
Objective
The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework.
Materials and Methods
In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system.
Results
Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record.
Discussion
Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses.
Conclusion
Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.
Because of increased electronic health record use, many organizations are hiring medical scribes as a way to alleviate provider burnout and increase clinical efficiency. The providers and scribes have unique relationships and thus, this study's purpose was to examine the scribe-provider interaction/relationship through the perspectives of scribes, providers, and administrators utilizing qualitative research techniques. Participants included 81 clinicians (30 providers, 27 scribes, and 24 administrators) across five sites. Analysis of the scribe-provider interaction data generated six subthemes: characteristics of an ideal scribe, characteristics of a good provider, provider variability, quality of the scribe-provider relationship, negative side of the scribe-provider relationship, and evaluation and supervision of scribes. Future research should focus on additional facets of the scribe-provider relationship including optimal ergonomic considerations to allow for scribes and providers to work together harmoniously.
Background:
Little is known about how physician time is allocated in ambulatory care.
Objective:
To describe how physician time is spent in ambulatory practice.
Design:
Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours).
Setting:
U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington).
Participants:
57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries.
Measurements:
Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work.
Results:
During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks.
Limitations:
Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics.
Conclusion:
For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.
Primary funding source:
American Medical Association.
Importance
Widespread adoption of electronic health records (EHRs) in medical care has resulted in increased physician documentation workload and decreased interaction with patients. Despite the increasing use of medical scribes for EHR documentation assistance, few methodologically rigorous studies have examined the use of medical scribes in primary care.
Objective
To evaluate the association of use of medical scribes with primary care physician (PCP) workflow and patient experience.
Design, Setting, and Participants
This 12-month crossover study with 2 sequences and 4 periods was conducted from July 1, 2016, to June 30, 2017, in 2 medical center facilities within an integrated health care system and included 18 of 24 eligible PCPs.
Interventions
The PCPs were randomly assigned to start the first 3-month period with or without scribes and then alternated exposure status every 3 months for 1 year, thereby serving as their own controls. The PCPs completed a 6-question survey at the end of each study period. Patients of participating PCPs were surveyed after scribed clinic visits.
Main Outcomes and Measures
PCP-reported perceptions of documentation burden and visit interactions, objective measures of time spent on EHR activity and required for closing encounters, and patient-reported perceptions of visit quality.
Results
Of the 18 participating PCPs, 10 were women, 12 were internal medicine physicians, and 6 were family practice physicians. The PCPs graduated from medical school a mean (SD) of 13.7 (6.5) years before the study start date. Compared with nonscribed periods, scribed periods were associated with less self-reported after-hours EHR documentation (<1 hour daily during week: adjusted odds ratio [aOR], 18.0 [95% CI, 4.7-69.0]; <1 hour daily during weekend: aOR, 8.7; 95% CI, 2.7-28.7). Scribed periods were also associated with higher likelihood of PCP-reported spending more than 75% of the visit interacting with the patient (aOR, 295.0; 95% CI, 19.7 to >900) and less than 25% of the visit on a computer (aOR, 31.5; 95% CI, 7.3-136.4). Encounter documentation was more likely to be completed by the end of the next business day during scribed periods (aOR, 2.8; 95% CI, 1.2-7.1). A total of 450 of 735 patients (61.2%) reported that scribes had a positive bearing on their visits; only 2.4% reported a negative bearing.
Conclusions and Relevance
Medical scribes were associated with decreased physician EHR documentation burden, improved work efficiency, and improved visit interactions. Our results support the use of medical scribes as one strategy for improving physician workflow and visit quality in primary care.
Electronic medical records (EMRs) have resulted in increased documentation burden, with physicians spending up to 2 hours on EMR-related tasks for every 1 patient-care hour.¹ Although EMRs offer care delivery integration, they have decreased physician job satisfaction and increased physician burnout across multiple fields, including dermatology.²,3 Employing medical scribes has enhanced clinical documentation, improved revenue collection, increased physician satisfaction, and reduced burnout in other specialties⁴- 6; however, dermatology-specific data are lacking. We implemented a multipractice quality improvement pilot program evaluating medical scribe impact on dermatologist documentation time and physician satisfaction.
Purpose:
Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non-face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours.
Methods:
We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from "event logging" records over a 3-year period for both direct patient care and non-face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours.
Results:
Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%).
Conclusions:
Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation.
This study uses data reported by electronic health record (EHR) vendors to the US Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology to determine whether usability certification requirements and testing standards were met.Many electronic health records (EHRs) have poor usability, leading to user frustration and safety risks.1 Usability is the extent to which the technology helps users achieve their goals in a satisfying, effective, and efficient manner within the constraints and complexities of their work environment.2
Background:
Despite extensive data about physician burnout, to our knowledge, no national study has evaluated rates of burnout among US physicians, explored differences by specialty, or compared physicians with US workers in other fields.
Methods:
We conducted a national study of burnout in a large sample of US physicians from all specialty disciplines using the American Medical Association Physician Masterfile and surveyed a probability-based sample of the general US population for comparison. Burnout was measured using validated instruments. Satisfaction with work-life balance was explored.
Results:
Of 27 276 physicians who received an invitation to participate, 7288 (26.7%) completed surveys. When assessed using the Maslach Burnout Inventory, 45.8% of physicians reported at least 1 symptom of burnout. Substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine). Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both). Highest level of education completed also related to burnout in a pooled multivariate analysis adjusted for age, sex, relationship status, and hours worked per week. Compared with high school graduates, individuals with an MD or DO degree were at increased risk for burnout (odds ratio [OR], 1.36; P < .001), whereas individuals with a bachelor's degree (OR, 0.80; P = .048), master's degree (OR, 0.71; P = .01), or professional or doctoral degree other than an MD or DO degree (OR, 0.64; P = .04) were at lower risk for burnout.
Conclusions:
Burnout is more common among physicians than among other US workers. Physicians in specialties at the front line of care access seem to be at greatest risk.