Variable Impact of Medical Scribes on Physician Electronic Health Record Documentation Practices: A Quantitative Analysis Across a Large, Integrated Health-System.

BACKGROUND: Medical scribes have been utilized to reduce electronic health record (EHR) associated documentation burden. Although evidence suggests benefits to scribes, no large-scale studies have quantitatively evaluated scribe impact on physician documentation across clinical settings. This study aimed to evaluate the effect of scribes on physician EHR documentation behaviors and performance. METHODS: This retrospective cohort study used EHR audit log data from a large academic health system to evaluate clinical documentation for all ambulatory encounters between January 2014 and December 2019 to evaluate the effect of scribes on physician documentation behaviors. Scribe services were provided on a first-come, first-served basis on physician request. Based on a physician's scribe use, encounters were grouped into 3 categories: never using a scribe, prescribe (before scribe use), or using a scribe. Outcomes included chart closure time, the proportion of delinquent charts, and charts closed after-hours. RESULTS: Three hundred ninety-five physicians (23% scribe users) across 29 medical subspecialties, encompassing 1,132,487 encounters, were included in the analysis. At baseline, scribe users had higher chart closure time, delinquent charts, and after-hours documentation than physicians who never used scribes. Among scribe users, the difference in outcome measures postscribe compared with baseline varied, and using a scribe rarely resulted in outcome measures approaching a range similar to the performance levels of nonusing physicians. In addition, there was variability in outcome measures across medical specialties and within similar subspecialties. CONCLUSION: Although scribes may improve documentation efficiency among some physicians, not all will improve EHR-related documentation practices. Different strategies may help to optimize documentation behaviors of physician-scribe dyads and maximize outcomes of scribe implementation.

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.

Medical Record Closure Practices of Physicians Before and After the Use of Medical Scribes.

This study uses electronic health record data to evaluate medical record closure outcomes before and after the use of medical scribes at a large academic medical center.

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.

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.

The Impact of Electronic Health Record-Based Simulation During Intern Boot Camp: Interventional Study.

BACKGROUND: Accurate data retrieval is an essential part of patient care in the intensive care unit (ICU). The electronic health record (EHR) is the primary method for data storage and data review. We previously reported that residents participating in EHR-based simulations have varied and nonstandard approaches to finding data in the ICU, with subsequent errors in recognizing patient safety issues. We hypothesized that a novel EHR simulation-based training exercise would decrease EHR use variability among intervention interns, irrespective of prior EHR experience. OBJECTIVE: This study aims to understand the impact of a novel, short, high-fidelity, simulation-based EHR learning activity on the intern data gathering workflow and satisfaction. METHODS: A total of 72 internal medicine interns across the 2018 and 2019 academic years underwent a dedicated EHR training session as part of a week-long boot camp early in their training. We collected data on previous EHR and ICU experience for all subjects. Training consisted of 1 hour of guided review of a high-fidelity, simulated ICU patient chart focusing on best navigation practices for data retrieval. Specifically, the activity focused on using high- and low-yield data visualization screens determined by expert consensus. The intervention group interns then had 20 minutes to review a new simulated patient chart before the group review. EHR screen navigation was captured using screen recording software and compared with data from existing ICU residents performing the same task on the same medical charts (N=62). Learners were surveyed immediately and 6 months after the activity to assess satisfaction and preferred EHR screen use. RESULTS: Participants found the activity useful and enjoyable immediately and after 6 months. Intervention interns used more individual screens than reference residents (18 vs 20; P=.008), but the total number of screens used was the same (35 vs 38; P=.30). Significantly more intervention interns used the 10 most common screens (73% vs 45%; P=.001). Intervention interns used high-yield screens more often and low-yield screens less often than the reference residents, which are persistent on self-report 6 months later. CONCLUSIONS: A short, high-fidelity, simulation-based learning activity focused on provider-specific data gathering was found to be enjoyable and to modify navigation patterns persistently. This suggests that workflow-specific simulation-based EHR training throughout training is of educational benefit to residents.

Chart Completion Time of Attending Physicians While Using Medical Scribes.

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.

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.

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.