Medical scribes improve documentation consistency and efficiency in an otolaryngology clinic.

ABSTRACT

OBJECTIVE: Scribes in medical practice enable more efficient documentation requirements but insufficient analyses have occurred to fully evaluate their efficacy in otolaryngology. We analyzed pre/post metrics of scribe implementation that may aid practitioners in determining feasibility for use in their practices. METHODS: 1808 patient charts were analyzed in The Epic Electronic Medical Record system (EMR) (903 pre and 905 post scribe implementation). We measured clinic volumes, time saved in documentation, chart billing level, and lag days of chart closure. RESULTS: Patient volumes increased by 3.02% with an 11-17% decrease in time spent in clinic/day and lag days for billing. The distribution of visits for new patients was 17.75% level 2, 51.45% level 3, 29.71% level 4 before the scribe and was 6.83% level 2, 89.21% level 3, 3.96% level 4 after the scribe. For established patients it was 3.97% level 2, 84.92% level 3, 8.93% level 4 before and 0.34% level 2, 91.76% level 3, 7.73% level 4 after. The change in level of documentation for established and new patients pre and post scribe implementation was not statistically significant (p = 0.821, 0.063, respectively). Charts were closed within 0 to 7 days with the implementation of a scribe instead of 7-21 days when awaiting dictations for transcription. CONCLUSIONS: The implementation of a scribe in an academic otolaryngology clinic facilitated more rapid completion of documentation while decreasing provider hours/day in clinic. We feel the analysis can be generalized to otolaryngology practitioners in general and the data structures we implemented are usable for others.