Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience

Methods for Large-Scale Quantitative Analysis of Scribe Impacts on Clinical Documentation

Many medical providers employ scribes to manage electronic health record (EHR) documentation. Prior studies have shown the benefits of scribes, but no large-scale study has quantitively assessed scribe impact on documentation workflows. We propose methods that leverage EHR data for identifying scribe presence during an office visit, measuring provider documentation time, and determining how notes are edited and composed. In a case study, we found scribe use was associated with less provider documentation time overall (averaging 2.4 minutes or 39% less time, p < 0.001), fewer note edits by providers (8.4% less added and 4.2% less deleted text, p < 0.001), but significantly more documentation time after the visit for four out of seven providers (p < 0.001) and no change in the amount of copied and imported note text. Our methods could validate prior study results, identify variability for determining best practices, and determine that scribes do not improve all aspects of documentation.

Physician perceptions of documentation methods in electronic health records

This study sought to determine physician, specialty and practice factors influencing choice of method for electronic health record (EHR) documentation: direct typing (DT), electronic transcription (ET), human transcription (HT), and scribes. A survey assessing physician documentation practices was developed and distributed online. The primary outcome was the proportion of physicians using each method. Secondary outcomes were provider-rated accuracy, efficiency, and ease of navigation on a 1-5 Likert scale. Means were compared using linear mixed models with Bonferroni adjustment. The 818 respondents were mostly outpatient (46%) adult (79%) physicians, practiced for a mean 15.8 years, and used DT for EHR documentation (72%). Emergency physicians were more likely to use scribes (p < 0.0001). DT was rated less efficient than all other methods (p < 0.0001). ET was rated less accurate than DT (p < 0.001) and HT (p < 0.001). HT was rated less easy to navigate than DT (p = 0.002) and scribe (p < 0.001), and ET less than scribe (p = 0.002). Two hundred and forty-three respondents provided free-text comments that further described opinions. DT was the most commonly used EHR method but rated least efficient. Scribes were rated easy to navigate and efficient but infrequently used outside of emergency settings. Further innovation is needed to design systems responsive to all physician EHR needs.

Pediatrician Electronic Health Record Time Use for Outpatient Encounters

BACKGROUND

The time providers spend using their electronic health records (EHRs) delivering care and its potential impact on patient care are of concern for the health care system. In studies to date, researchers have focused on providers who primarily care for adults. Scant information exists for pediatricians. Given this gap, it is important to quantify EHR activity for this group.

METHODS

We studied pediatricians practicing in US-based ambulatory practices using the Cerner Millennium EHR by extracting data from software log files in the Lights On Network for the calendar year 2018 and summarizing the time spent on each of 13 clinically-focused EHR functions according to clinical specialty.

RESULTS

Our data included >20 million encounters by almost 30 thousand physicians from 417 health systems. Pediatric physicians spent an average of 16 minutes per encounter using their EHR. Chart review (31%), documentation (31%), and ordering (13%) functions accounted for most of the time. The distribution of time spent by providers using their EHR is highly variable within subspecialty but is similar across specialties. Because of data limitations, we were unable to examine geographic or health system-specific variation.

CONCLUSIONS

Pediatricians, like physicians who care for adults, spend a large portion of their day using their EHR. Additionally, although chart review and documentation accounted for 62% of the activity, as in previously published studies, in our study, we found that chart review accounted for half of that time. Wide variation suggests opportunities to optimize both the processes of entering information and searching for patient data within the EHR.

A Markov chain model for analysis of physician workflow in primary care clinics

This paper studies physician workflow management in primary care clinics using terminating Markov chain models. The physician workload is characterized by face-to-face encounters with patients and documentation of electronic health record (EHR) data. Three workflow management policies are considered: preemptive priority (stop ongoing documentation tasks if a new patient arrives); non-preemptive priority (finish ongoing documentation even if a new patient arrives); and batch documentation (start and finish documentation when the desired number of tasks is reached). Analytical formulas are derived to quantify the performance measures of three management policies, such as physician's daily working time, patient's waiting time, and documentation waiting time. A comparison of the results under three policies is carried out. Finally, a case study in a primary care clinic is carried out to illustrate model applicability. Such a work provides a quantitative tool for primary care physicians to design and manage their workflow to improve care quality.

Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices’ successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

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.

Promoting Quality Face-to-Face Communication during Ophthalmology Encounters in the Electronic Health Record Era

OBJECTIVE

To evaluate informatics-enabled quality improvement (QI) strategies for promoting time spent on face-to-face communication between ophthalmologists and patients.

METHODS

This prospective study involved deploying QI strategies during implementation of an enterprise-wide vendor electronic health record (EHR) in an outpatient academic ophthalmology department. Strategies included developing single sign-on capabilities, activating mobile- and tablet-based applications, EHR personalization training, creating novel workflows for team-based orders, and promoting problem-based charting to reduce documentation burden. Timing data were collected during 648 outpatient encounters. Outcomes included total time spent by the attending ophthalmologist on the patient, time spent on documentation, time spent on examination, and time spent talking with the patient. Metrics related to documentation efficiency, use of personalization features, use of team-based orders, and note length were also measured from the EHR efficiency portal and compared with averages for ophthalmologists nationwide using the same EHR.

RESULTS

Time spent on exclusive face-to-face communication with patients initially decreased with EHR implementation (2.9 to 2.3 minutes, p = 0.005) but returned to the paper baseline by 6 months (2.8 minutes, p = 0.99). Observed participants outperformed national averages of ophthalmologists using the same vendor system on documentation time per appointment, number of customized note templates, number of customized order lists, utilization of team-based orders, note length, and time spent after-hours on EHR use.

CONCLUSION

Informatics-enabled QI interventions can promote patient-centeredness and face-to-face communication in high-volume outpatient ophthalmology encounters. By employing an array of interventions, time spent exclusively talking with the patient returned to levels equivalent to paper charts by 6 months after EHR implementation. This was achieved without requiring EHR redesign, use of scribes, or excessive after-hours work. Documentation efficiency can be achieved using interventions promoting personalization and team-based workflows. Given their efficacy in preserving face-to-face physician-patient interactions, these strategies may help alleviate risk of physician burnout.

The Struggling Infectious Diseases Fellow: Remediation Challenges and Opportunities

Remediation of struggling learners is a challenge faced by all educators. In recognition of this reality, and in light of contemporary challenges facing infectious diseases (ID) fellowship program directors, the Infectious Diseases Society of America Training Program Directors' Committee focused the 2018 National Fellowship Program Directors' Meeting at IDWeek on "Remediation of the Struggling Fellow." Small group discussions addressed 7 core topics, including feedback and evaluations, performance management and remediation, knowledge deficits, fellow well-being, efficiency and time management, teaching skills, and career development. This manuscript synthesizes those discussions around a competency-based framework to provide program directors and other educators with a roadmap for addressing common contemporary remediation challenges.

Physician Time Spent Using the Electronic Health Record During Outpatient Encounters: A Descriptive Study

BACKGROUND

The amount of time that providers spend using electronic health records (EHRs) to support the care delivery process is a concern for the U.S. health care system. Given the potential effect on patient care and the high costs related to this time, particularly for medical specialists whose work is largely cognitive, these findings warrant more precise documentation of the time physicians invest in these clinically focused EHR functions.

OBJECTIVE

To describe how much time ambulatory medical subspecialists and primary care physicians across several U.S. care delivery systems spend on various EHR functions.

DESIGN

Descriptive study.

SETTING

U.S.-based, adult, nonsurgical, ambulatory practices using the Cerner Millennium EHR.

PARTICIPANTS

155 000 U.S. physicians.

MEASUREMENTS

Data were extracted from software log files in the Lights On Network (Cerner) during 2018 that totaled the time spent on each of the 13 clinically focused EHR functions. Averages per encounter by specialty were computed.

RESULTS

This study included data from approximately 100 million patient encounters with about 155 000 physicians from 417 health systems. Physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. The distribution of time spent by providers using EHRs varies greatly within specialty. The proportion of time spent on various clinically focused functions was similar across specialties.

LIMITATION

Variation by health system could not be examined, and all providers used the same software.

CONCLUSION

The time spent using EHRs to support care delivery constitutes a large portion of the physicians' day, and wide variation suggests opportunities to optimize systems and processes.

PRIMARY FUNDING SOURCE

None.

Physician Stress and Burnout

Tens (or hundreds) of thousands of Americans die each year as a result of preventable medical errors. Changes in the practice and business of medicine have caused some to question whether burnout among physicians and other healthcare providers may adversely affect patient outcomes. A clear consensus supports the contention that burnout affects patients, albeit with low-quality objective data. The psychological and physical impact on physicians and other providers is quite clear, however, and the impact on the physician workforce (where large shortages are projected) is yet another cause for concern. We have all heard the airplane safety announcement remind us to "Please put on your own oxygen mask first before assisting others." Unfortunately, like many airline passengers (very few of whom use oxygen masks correctly when they are needed), physicians often do not recognize symptoms of burnout or depression, and even less often do they seek help. We detail the causes and consequences of physician burnout and propose solutions to increase physician work satisfaction.

Associations Between Burnout and Practice Organization in Family Physicians

PURPOSE

Burnout has been reported to be as high as 63% among family physicians and has negative effects on physicians, patients, and the medical system. There are likely structural causes of burnout, but little is known about the relationship between practice organization and burnout. Our objective was to study this association in family physicians.

METHODS

This cross-sectional study uses secondary data supplied by practicing physicians from the 2017 American Board of Family Medicine (ABFM) Family Medicine Certification examination registration questionnaire, a mandatory component of registration, yielding a 100% response rate. Burnout was measured as a positive response to either of 2 validated questions measuring emotional exhaustion and depersonalization. Practice environment was measured with questions on work stressors and teamwork. Logistic regression determined independent associations between burnout and individual and practice characteristics.

RESULTS

Of the 1,437 physicians included, the burnout rate was 43.7%; 33.7% worked in hospital-owned practices and 65.5% reported no ownership stake in their practice. Controlling for personal characteristics and practice organization, being in a hospital-owned practice (odds ratio (OR) = 1.68; 95% CI, 1.14-2.46) and being a partial owner (OR =1.67; 95% CI, 1.13-2.46) were positively associated with burnout. When also controlling for practice environment, no practice organization variable remained associated with burnout.

CONCLUSION

Burnout in family physicians should not be attributed solely to practice organization. No single practice type or ownership status was independently associated with burnout, which indicates that any practice can attempt to mitigate burnout.

The Impact of Medical Scribes on Patient Satisfaction in an Academic Otolaryngology Clinic

Objectives:

Evidence shows that scribes can improve provider efficiency and satisfaction in several settings, but is mixed on whether scribes improve patient satisfaction. We studied whether scribes improved patient satisfaction in an academic otolaryngology clinic.

Methods:

The authors performed a retrospective review of patient responses to the Press Ganey survey between 12/2016 and 12/2017. Their responses about satisfaction with the provider and wait times were examined. Three providers worked with scribes during this year; each spent six months with a scribe and six without. The authors compared survey responses from periods with and without scribes using the Fischer exact test. Average overall provider ratings were compared using the Student’s t-test.

Results:

A total of 87 patients filled out Press Ganey surveys for the 3 providers over the year: 54 for visits without scribes, and 33 for visits with scribes. Fischer exact analysis demonstrated no significant difference in satisfaction with providers and wait times for both individual providers and all providers combined (all P > .05). There was also no difference in patients’ likelihood of recommending the provider’s office ( P = .91). Overall provider rating (0-10 scale) was high without scribes (9.48 ± 1.06) and was unchanged by the presence of scribes (9.53 ± 0.8) ( P = .97).

Conclusion:

Patient satisfaction with wait times and providers was high overall and was not affected by the presence of a medical scribe.

Human Factors and Sociotechnical Issues

OBJECTIVE

To summarize significant research contributions on human factors (HF) and organizational issues in medical informatics published in 2018.

METHODS

An extensive search using PubMed/Medline and Web of Science^® was conducted to identify the scientific contributions published in 2018 that address human factors and organizational issues in medical informatics. The selection process comprised three steps: (i) 15 candidate best papers were first selected by the two section editors, (ii) external reviewers from internationally renowned research teams reviewed each candidate best paper, and (iii) the final selection of four best papers was conducted by the editorial board of the Yearbook.

RESULTS

The four selected best papers are excellent contributions to the HF literature: they show the added value of HF studies by providing nice illustrated and rigorous interventions.

CONCLUSION

HF interventions are known to have great potential to contribute to efficient HIT design, but the interventions still face challenges in successfully demonstrating their value to the main stakeholders of the healthcare domain. There is a need to strengthen the demand for high-quality HF studies by increasing awareness among powerful stakeholders of the value of high-quality HF studies.

Taking note: A qualitative study of implementing a scribing practice in team-based primary care clinics

BACKGROUND

Though much is known about the benefits attributed to medical scribes documenting patient visits (e.g., reducing documentation time for the provider, increasing patient-care time, expanding the roles of licensed and non-licensed personnel), little attention has been paid to how care workers enact scribing as a part of their existing practice. The purpose of this study was to perform an ethnographic process evaluation of an innovative medical scribing practice with primary care teams in Veterans Health Administration (VHA) clinics across the United States. The aim of our study was to understand barriers and facilitators to implementing a scribing practice in primary care.

METHODS

At three to six months after medical scribing was introduced, we used semi-structured interviews and direct observations during site visits to five sites to describe the intervention, understand if the intervention was implemented as planned, and to record the experience of the teams who implemented the intervention. This manuscript only reports on semi-structured interview data collected from providers and scribes. Initial matrix analysis based on categories outlined in the evaluation plan informed subsequent deductive coding using the social-shaping theory Normalization Process Theory.

RESULTS

Through illustrating the slow accumulation of interactions and knowledge that fostered cautious momentum of teams working to normalize scribing practice in VHA primary care clinics, we show how the practice had 1) an organizing effect, as it centered a shared goal (the creation of the note) between the provider, scribe, and patient, and 2) a generative effect, as it facilitated care workers developing relationships that were both interpersonally and inter-professionally valuable. Based on our findings, we suggest that a scribing practice emphasizes the complementarity of existing professional roles, which thus leverage the interactional possibilities already present in the primary care team. Scribing, as a skill, forged moments of interprofessional fit. Scribing, in practice, created opportunities for interpersonal connection.

CONCLUSIONS

Our research suggests that individuals will notice different benefits to scribing based on their professional expectations and organizational roles related to documenting patient visits.