How Providers Can Optimize Effective and Safe Scribe Use: a Qualitative Study.

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. DESIGN: The 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. PARTICIPANTS: Purposively selected participants included subject matter experts, providers, informaticians, medical scribes, medical assistants, administrators, social scientists, medical students, and qualitative researchers. APPROACH: The 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 RESULTS: We 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.

Translating ethnographic data into knowledge, skills, and attitude statements for medical scribes: a modified Delphi approach.

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.

Early Intervention Referral Information, Transmission, and Sources-A Survey of State Part C Coordinators and Analysis of Referral Forms.

OBJECTIVE: Early Intervention (EI) referral is a key connector between health care and early childhood systems serving children with developmental risks. This study aimed to describe the US network of EI referrals by answering the following: "What information is sent to EI?", "Who sends it?", and "How is it sent?" METHOD: This study combined an analysis of national document-based and website-based referral forms with a survey of state Part C Coordinators (PCCs). Data on referral forms were systematically collected from state agency websites. PCCs from 52 jurisdictions were surveyed to assess current EI referral practices. Descriptive statistics were used for responses to multiple-choice items; free-text answers were condensed into key study themes. RESULTS: EI referral forms came as e-documents (81%) or websites (35%), and 72% were in English alone. They emphasized family and referral source contact information and reason for the referral. The survey results indicated that health care (45%) sends the most referrals, followed by families (30%). EI agencies received referrals by phone (38%), electronically (23%), e-mail (17%), and fax (17%), and PCCs valued this diversity of methods. Few states received referral data directly from electronic health records (EHRs); however, PCCs hope to eventually receive referrals through websites, mobile devices, and EHRs. CONCLUSION: EI referral data flow is complex, with opportunities for loss of children to follow-up. This study describes how EI referrals occur and provides examples of how communication and access to information may be improved.

A qualitative study of provider burnout: do medical scribes hinder or help?

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.

The future of medical scribes documenting in the electronic health record: results of an expert consensus conference.

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.

Priorities of Hybrid Clinician-Managers: A Qualitative Study of How Managers Balance Clinical Quality Among Competing Responsibilities.

OBJECTIVE: Oversight of clinical quality is only one of physical therapy managers' multiple responsibilities. With the move to value-based care, organizations need sound management to navigate this evolving reimbursement landscape. Previous research has not explored how competing priorities affect physical therapy managers' oversight of clinical quality. The purpose of this study was to create a preliminary model of the competing priorities, motivations, and responsibilities of managers while overseeing clinical quality. METHODS: This qualitative study used the Rapid Qualitative Inquiry method. A purposive sample of 40 physical therapy managers and corporate leaders was recruited. A research team performed semi-structured interviews and observations in outpatient practices. The team used a grounded theory-based immersion/crystallization analysis approach. Identified themes delineated the competing priorities and workflows these managers use in their administrative duties. RESULTS: Six primary themes were identified that illustrate how managers: (1) balance managerial and professional priorities; (2) are susceptible to stakeholder influences; (3) experience internal conflict; (4) struggle to measure and define quality objectively; (5) are influenced by the culture and structure of their respective organizations; and (6) have professional needs apart from the needs of their clinics. CONCLUSION: Generally, managers' focus on clinical quality is notably less comprehensive than their focus on clinical operations. Additionally, the complex role of hybrid clinician-manager leaves limited time beyond direct patient care for administrative duties. Managers in organizations that hold them accountable to quality-based metrics have more systematic clinical quality oversight processes. IMPACT: This study gives physical therapy organizations a framework of factors that can be influenced to better facilitate managers' effective oversight of clinical quality. Organizations offering support for those managerial responsibilities will be well positioned to thrive in the new fee-for-value care structure.

Safe use of the EHR by medical scribes: a qualitative study.

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.

Do You Know What Your Scribe Did Last Spring? The Impact of COVID-19 on Medical Scribe Workflow.

OBJECTIVE: To understand the impact of the shift to virtual medicine induced by coronavirus disease 2019 (COVID-19) has had on the workflow of medical scribes. DESIGN: This is a prospective observational survey-based study. SETTING: This study was conducted at academic medical center in the United States. PARTICIPANTS: Seventy-four scribes working in ambulatory practices within an academic medical center. INTERVENTIONS: All medical scribes received a survey assessing their workflow since beginning of COVID-19 restrictions. PRIMARY AND SECONDARY OUTCOMES: To assess the current workflow of medical scribes since transition to virtual care. Secondary outcomes are to assess the equipment used and location of their new workflow. RESULTS: Fifty-seven scribes completed the survey. Overall 42% of scribes have transitioned to remote scribing with 97% serving as remote scribes for remote visits. This workflow is conducted at home and with personal equipment. Of those not working as scribes, 46% serve in preclinic support, with a wide range of EHR-related activities being reported. The remaining scribes have been either redeployed or furloughed. CONCLUSION: The rapid transition to virtual care brought about by COVID-19 has resulted in a dramatic shift in scribe workflow with the adoption of a previously unreported workflow of remote scribing for virtual care. Additional work is now needed to ensure these new workflows are safe and effective and that scribes are trained to work in this new paradigm.

Clinical Decision Support for Worker Health: A Five-Site Qualitative Needs Assessment in Primary Care Settings.

BACKGROUND: Although patients who work and have related health issues are usually first seen in primary care, providers in these settings do not routinely ask questions about work. Guidelines to help manage such patients are rarely used in primary care. Electronic health record (EHR) systems with worker health clinical decision support (CDS) tools have potential for assisting these practices. OBJECTIVE: This study aimed to identify the need for, and barriers and facilitators related to, implementation of CDS tools for the clinical management of working patients in a variety of primary care settings. METHODS: We used a qualitative design that included analysis of interview transcripts and observational field notes from 10 clinics in five organizations. RESULTS: We interviewed 83 providers, staff members, managers, informatics and information technology experts, and leaders and spent 35 hours observing. We identified eight themes in four categories related to CDS for worker health (operational issues, usefulness of proposed CDS, effort and time-related issues, and topic-specific issues). These categories were classified as facilitators or barriers to the use of the CDS tools. Facilitators related to operational issues include current technical feasibility and new work patterns associated with the coordinated care model. Facilitators concerning usefulness include users' need for awareness and evidence-based tools, appropriateness of the proposed CDS for their patients, and the benefits of population health data. Barriers that are effort-related include additional time this proposed CDS might take, and other pressing organizational priorities. Barriers that are topic-specific include sensitive issues related to health and work and the complexities of information about work. CONCLUSION: We discovered several themes not previously described that can guide future CDS development: technical feasibility of the proposed CDS within commercial EHRs, the sensitive nature of some CDS content, and the need to assist the entire health care team in managing worker health.

How can we partner with electronic health record vendors on the complex journey to safer health care?

The Office of the National Coordinator for Health Information Technology released the Safety Assurance Factors for EHR Resilience (SAFER) guides in 2014. Our group developed these guides covering key facets of both electronic health record (EHR) infrastructure (eg, system configuration, contingency planning for downtime, and system-to-system interfaces) and clinical processes (eg, computer-based provider order entry with clinical decision support, test result reporting, patient identification, and clinician-to-clinician communication). The SAFER guides encourage healthy relationships between EHR vendors and users. We conducted a qualitative study over 12 months. We visited 9 health care organizations ranging in size from 1-doctor outpatient clinics to large, multisite, multihospital integrated delivery networks. We interviewed and observed clinicians, IT professionals, and administrators. From the interview transcripts and observation field notes, we identified overarching themes: technical functionality, usability, standards, testing, workflow processes, personnel to support implementation and use, infrastructure, and clinical content. In addition, we identified health care organization-EHR vendor working relationships: marine drill sergeant, mentor, development partner, seller, and parasite. We encourage health care organizations and EHR vendors to develop healthy working relationships to help address the tasks required to design, develop, implement, and maintain EHRs required to achieve safer and higher quality health care.

Essential activities for electronic health record safety: A qualitative study.

Electronic health record-caused safety risks are an unintended consequence of the implementation of clinical systems. To identify activities essential to assuring that the electronic health record is managed and used safely, we used the Rapid Assessment Process, a collection of qualitative methods. A multidisciplinary team conducted visits to five healthcare sites to learn about best practices. Although titles and roles were very different across sites, certain tasks considered necessary by our subjects were remarkably similar. We identified 10 groups of activities/tasks in three major areas. Area A, decision-making activities, included overseeing, planning, and reviewing to assure electronic health record safety. Area B, organizational learning activities, involved monitoring, testing, analyzing, and reporting. Finally, Area C, user-related activities, included training, communication, and building clinical decision support. To minimize electronic health record-related patient safety risks, leaders in healthcare organizations should ensure that these essential activities are performed.

A Sociotechnical Multiple Perspectives Approach to the Use of Medical Scribes: A Deeper Dive into the Scribe-Provider Interaction.

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.

Best practices for preventing malfunctions in rule-based clinical decision support alerts and reminders: Results of a Delphi study.

OBJECTIVE: Developing effective and reliable rule-based clinical decision support (CDS) alerts and reminders is challenging. Using a previously developed taxonomy for alert malfunctions, we identified best practices for developing, testing, implementing, and maintaining alerts and avoiding malfunctions. MATERIALS AND METHODS: We identified 72 initial practices from the literature, interviews with subject matter experts, and prior research. To refine, enrich, and prioritize the list of practices, we used the Delphi method with two rounds of consensus-building and refinement. We used a larger than normal panel of experts to include a wide representation of CDS subject matter experts from various disciplines. RESULTS: 28 experts completed Round 1 and 25 completed Round 2. Round 1 narrowed the list to 47 best practices in 7 categories: knowledge management, designing and specifying, building, testing, deployment, monitoring and feedback, and people and governance. Round 2 developed consensus on the importance and feasibility of each best practice. DISCUSSION: The Delphi panel identified a range of best practices that may help to improve implementation of rule-based CDS and avert malfunctions. Due to limitations on resources and personnel, not everyone can implement all best practices. The most robust processes require investing in a data warehouse. Experts also pointed to the issue of shared responsibility between the healthcare organization and the electronic health record vendor. CONCLUSION: These 47 best practices represent an ideal situation. The research identifies the balance between importance and difficulty, highlights the challenges faced by organizations seeking to implement CDS, and describes several opportunities for future research to reduce alert malfunctions.

Texting 4 Sexual Health: Improving Attitudes, Intention, and Behavior Among American Indian and Alaska Native Youth.

PURPOSE: To design and test the effectiveness of a text messaging intervention to promote condom use and STI/HIV testing among American Indian and Alaska Native youth. METHOD: A total of 408 study participants, 15 to 24 years old, were recruited, consented, surveyed, were sent intervention messages, and were incentivized via text message over a 9-month period. Complete pre- and postsurvey data were collected from 192 participants using SMS short codes. A mixed-effects logistic regression model was used to analyze before-after change in responses assessing sexual health knowledge, attitude, self-efficacy, intention, and behavior. RESULTS: Participants' condom use attitude, condom use behavior, and STI/HIV testing intention improved after the intervention ( p < .05). Frequent condom use increased from 30% to 42% and was retained by participants at least 3 months postintervention, and the intervention improved participants' intention to get tested for STI/HIV after changing sexual partners, increasing from 46% to 58% postintervention. CONCLUSIONS: Given the widespread use of cell phones by youth, text-based interventions may offer a feasible and effective tool to promote condom use and STI/HIV testing.

Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review.

Objective: To identify and understand the factors that contribute to medication errors associated with the use of computerized provider order entry (CPOE) in pediatrics and provide recommendations on how CPOE systems could be improved. Materials and Methods: We conducted a systematic literature review across 3 large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Three independent reviewers screened the titles, and 2 authors then independently reviewed all abstracts and full texts, with 1 author acting as a constant across all publications. Data were extracted onto a customized data extraction sheet, and a narrative synthesis of all eligible studies was undertaken. Results: A total of 47 articles were included in this review. We identified 5 factors that contributed to errors with the use of a CPOE system: (1) lack of drug dosing alerts, which failed to detect calculation errors; (2) generation of inappropriate dosing alerts, such as warnings based on incorrect drug indications; (3) inappropriate drug duplication alerts, as a result of the system failing to consider factors such as the route of administration; (4) dropdown menu selection errors; and (5) system design issues, such as a lack of suitable dosing options for a particular drug. Discussion and Conclusions: This review highlights 5 key factors that contributed to the occurrence of CPOE-related medication errors in pediatrics. Dosing support is the most important. More advanced clinical decision support that can suggest doses based on the drug indication is needed.

Recognition of the Relationship Between Patients' Work and Health: A Qualitative Evaluation of the Need for Clinical Decision Support (CDS) for Worker Health in Five Primary Care Practices.

OBJECTIVE: The aim of this study was to determine the perceived value and feasibility of increased access to information about workers' health for primary care providers (PCPs) by evaluating the need for clinical decision support (CDS) related to worker health in primary care settings. METHODS: Qualitative methods, including semi-structured interviews and observations, were used to evaluate the value and feasibility of three examples of CDS relating work and health in five primary care settings. RESULTS: PCPs and team members wanted help addressing patients' health in relation to their jobs; the proposed CDS examples were perceived as valuable because they provided useful information, promoted standardization of care, and were considered technically feasible. Barriers included time constraints and a perceived inability to act on the findings. CONCLUSION: PCPs recognize the importance and impact of work on their patients' health but often lack accessible knowledge at the right time. Occupational health providers can play an important role through contributions to the development of CDS that assists PCPs in recognizing and addressing patients' health, as well as through the provision of referral guidelines.

Collaborators and Communication Channels in Eight Patient-Centered Medical Homes.

BACKGROUND: The patient-centered medical home (PCMH) concept requires collaboration among clinicians both within the medical home clinic, and outside the clinic. As we redesign health information technology (HIT) to support transformation to the PCMH, we need to better understand these collaboration patterns. This study provides quantitative data describing these collaborations in order to facilitate the design of systems to allow for more efficient collaboration. APPROACH: Eighty-four clinicians in eight clinics identified their two most recent significant collaborators - one each within the clinic and in the medical neighborhood. They also identified the communication channels used in these collaborations. We used k-means clustering to identify communication patterns. RESULTS: Within the clinic, half of the primary care providers (PCPs) identified a care manager as their most recent collaborator. Outside specialists were their most common external collaborators. Ninety-two percent of the non-PCP participants identified PCP's as their most recent internal collaborators. The best model for communication channel usage (p < .0001) had six clusters. In general, inside communications were more informal but outside collaborations were more often formal written communications (faxes, letters) or the exchange of electronic health record progress notes. But there were exceptions to these patterns and in many cases multiple channels were used for the same collaboration. CONCLUSION: Systems design (and redesign) needs to focus on reducing communications load and increasing communication effectiveness while maintaining flexibility.

The Evolving Role of Medical Scribe: Variation and Implications for Organizational Effectiveness and Safety.

Increasing use of medical scribes is an unintended consequence of electronic health record adoption in the U.S. The role of scribe is not universally defined, leading to variations in scribe training and operations, as well as questions about scribe efficiency, effectiveness, and safety. Studies published since 2009 have primarily focused on the financial aspects of scribe use, but no published studies have taken an organizational view of this phenomenon. This paper describes stakeholder perspectives on scribes working in outpatient settings within an urban tertiary academic medical center. It places factors associated with of scribe systems within an eight-dimension sociotechnical framework for evaluating health information technology, and discusses key aspects of those perspectives.

A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.

OBJECTIVE: To understand the different types and causes of prescribing errors associated with computerized provider order entry (CPOE) systems, and recommend improvements in these systems. MATERIALS AND METHODS: We conducted a systematic review of the literature published between January 2004 and June 2015 using three large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Studies that reported qualitative data about the types and causes of these errors were included. A narrative synthesis of all eligible studies was undertaken. RESULTS: A total of 1185 publications were identified, of which 34 were included in the review. We identified 8 key themes associated with CPOE-related prescribing errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users' work processes, and clinical decision support systems. Displaying an incomplete list of a patient's medications on the computer screen often contributed to prescribing errors. Lack of system flexibility resulted in users employing error-prone workarounds, such as the addition of contradictory free-text comments. Users' misinterpretations of how text was presented in CPOE systems were also linked with the occurrence of prescribing errors. DISCUSSION AND CONCLUSIONS: Human factors design is important to reduce error rates. Drop-down menus should be designed with safeguards to decrease the likelihood of selection errors. Development of more sophisticated clinical decision support, which can perform checks on free-text, may also prevent errors. Further research is needed to ensure that systems minimize error likelihood and meet users' workflow expectations.