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Minkoff H, O'Brien J, Berkowitz R. Quality of Care and Quality of Life: Balancing Patient Safety and Physician Burnout. Obstet Gynecol 2024:00006250-990000000-01122. [PMID: 39053004 DOI: 10.1097/aog.0000000000005681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 05/23/2024] [Indexed: 07/27/2024]
Abstract
Since the publication of the Institute of Medicine's landmark report on medical errors in 2000, a large number of safety programs have been implemented in American hospitals. Concurrently, there has been a dramatic increase in the rate of burnout among physicians. Although there are many unrelated causes of burnout (eg, loss of autonomy), and multiple safety programs that are applauded by physicians (eg, The Safe Motherhood Initiative), other programs created in the name of safety improvements may be contributing to physician distress. In this piece, we review several of those programs, describe their limitations and costs to physician well-being, and discuss the manner in which they might be modified to retain their benefits while mitigating the burdens they place on physicians.
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Affiliation(s)
- Howard Minkoff
- Department of Obstetrics and Gynecology, Maimonides Medical Center, and the Department of Obstetrics and Gynecology and the School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, and the Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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Schwartz-Dillard J, Ng T, Villegas J, Johnson D, Murray-Weir M. Electronic documentation burden among outpatient rehabilitation therapists: a qualitative descriptive study and quality improvement initiative. J Am Med Inform Assoc 2024:ocae192. [PMID: 39042519 DOI: 10.1093/jamia/ocae192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/13/2024] [Accepted: 07/08/2024] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVES Outpatient rehabilitation (rehab) physical, occupational, and speech therapists use electronic health records (EHR), yet their documentation experiences, including any documentation burden, are not well researched. Therapists are a growing portion of the U.S. healthcare workforce, whose need is critical to the health of an aging population. We aimed to describe outpatient rehab therapists' documentation experiences and identify strategies for mitigating any documentation burden. MATERIALS AND METHODS We used qualitative descriptive methodology to conduct 4 focus groups with outpatient rehab therapists at Hospital for Special Surgery, a multi-site orthopedic institution. Transcripts were inductively coded to identify themes and actionable strategies for improving the therapists' documentation experiences. Therapists provided feedback and prioritization of proposed strategies. RESULTS A total of 13 therapists were interviewed. Five themes and 10 subthemes characterize the therapists' documentation experience by a feeling that documentation inhibits clinical care and work/life balance, a perceived lack of support and efficiencies, the desire to document to communicate clinical care, and a design vision for improving the EHR. Top prioritized strategies for improvement included use of timesaving templates, expanding dictation, decluttering the EHR interface, and support for free texting over discrete data capture. DISCUSSION Outpatient rehab therapists experience documentation burden similar to that documented of physicians and nurses. Manual data entry imposes burden on therapists' time and clinical care. CONCLUSION A multi-faceted approach is needed for improving therapists' experiences including EHR redesign, technology supporting dictation and narrative to discrete data capture, and support from leadership and regulators.
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Affiliation(s)
| | - Travis Ng
- Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States
| | - Joann Villegas
- Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States
| | - Derrick Johnson
- Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States
| | - Mary Murray-Weir
- Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States
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Galán M, Sellarès J, Monteserín R, Vicuña J, Moral I, Brotons C. [Effectiveness of the clinical assistant in the control of hypertensive and diabetic patients in primary care]. Aten Primaria 2024; 56:102853. [PMID: 38244288 PMCID: PMC10831181 DOI: 10.1016/j.aprim.2023.102853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVE To evaluate the effectiveness of the incorporation of the clinical assistant in improving the control of type 2 diabetes mellitus and hypertension in a primary care center. DESIGN Quasi-experimental study (pre-post), with a control group, with a 1-year follow-up. SETTING Primary care center. PARTICIPANTS Patients between the ages of 18 and 85 with a diagnosis of diabetes type 2 and/or hypertension were selected. INTERVENTION Incorporation of the figure of the clinical assistant, previously trained. The latter contacted the patient to explain their role and obtain informed consent, assessed compliance with the protocols, and when they were incomplete and/or detected warning signs, referred the patient directly to medicine and/or nursing. RESULTS Three thousand and sixty-four patients participated, 30.74% assigned to the intervention group. Fifty percent were women. The mean age was 68.5 years (SD 11.07). 93.59% of diabetic patients in the intervention group had at least one determination of glycosylated hemoglobin compared to 86.83% in the control group (p=0.003). Fundus and diabetic foot screening was significantly higher in the intervention group (94.31% and 85.41% vs. 83.49% and 72.38%). 88.43% of the patients in the intervention group had registered blood pressure figures compared to 62.06% of the patients in the control group (p<0.05). There were not statistically significant differences in the control of blood pressure between the patients with recorded measures (p=0.478). CONCLUSIONS Clinical assistants can facilitate the implementation and compliance with chronic diseases protocols, and in the long run improve the degree of control of these patients and the quality of care.
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Affiliation(s)
- Marisa Galán
- EAP Sardenya, Barcelona, España; Unitat Docent Multiprofessional d'Atenció Familiar i Comunitària ACEBA, Barcelona, España; Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, España.
| | - Jaume Sellarès
- EAP Sardenya, Barcelona, España; Unitat Docent Multiprofessional d'Atenció Familiar i Comunitària ACEBA, Barcelona, España; Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, España
| | - Rosa Monteserín
- EAP Sardenya, Barcelona, España; Unitat Docent Multiprofessional d'Atenció Familiar i Comunitària ACEBA, Barcelona, España; Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, España
| | - Johanna Vicuña
- Servicio de Epidemiología Clínica y Salud Pública, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Irene Moral
- EAP Sardenya, Barcelona, España; Unitat Docent Multiprofessional d'Atenció Familiar i Comunitària ACEBA, Barcelona, España; Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, España
| | - Carlos Brotons
- EAP Sardenya, Barcelona, España; Unitat Docent Multiprofessional d'Atenció Familiar i Comunitària ACEBA, Barcelona, España; Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, España
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Sloss EA, Abdul S, Aboagyewah MA, Beebe A, Kendle K, Marshall K, Rosenbloom ST, Rossetti S, Grigg A, Smith KD, Mishuris RG. Toward Alleviating Clinician Documentation Burden: A Scoping Review of Burden Reduction Efforts. Appl Clin Inform 2024; 15:446-455. [PMID: 38839063 PMCID: PMC11152769 DOI: 10.1055/s-0044-1787007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/17/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Studies have shown that documentation burden experienced by clinicians may lead to less direct patient care, increased errors, and job dissatisfaction. Implementing effective strategies within health care systems to mitigate documentation burden can result in improved clinician satisfaction and more time spent with patients. However, there is a gap in the literature regarding evidence-based interventions to reduce documentation burden. OBJECTIVES The objective of this review was to identify and comprehensively summarize the state of the science related to documentation burden reduction efforts. METHODS Following Joanna Briggs Institute Manual for Evidence Synthesis and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, we conducted a comprehensive search of multiple databases, including PubMed, Medline, Embase, CINAHL Complete, Scopus, and Web of Science. Additionally, we searched gray literature and used Google Scholar to ensure a thorough review. Two reviewers independently screened titles and abstracts, followed by full-text review, with a third reviewer resolving any discrepancies. Data extraction was performed and a table of evidence was created. RESULTS A total of 34 articles were included in the review, published between 2016 and 2022, with a majority focusing on the United States. The efforts described can be categorized into medical scribes, workflow improvements, educational interventions, user-driven approaches, technology-based solutions, combination approaches, and other strategies. The outcomes of these efforts often resulted in improvements in documentation time, workflow efficiency, provider satisfaction, and patient interactions. CONCLUSION This scoping review provides a comprehensive summary of health system documentation burden reduction efforts. The positive outcomes reported in the literature emphasize the potential effectiveness of these efforts. However, more research is needed to identify universally applicable best practices, and considerations should be given to the transfer of burden among members of the health care team, quality of education, clinician involvement, and evaluation methods.
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Affiliation(s)
- Elizabeth A. Sloss
- Division of Health Systems and Community Based Care, College of Nursing, University of Utah, Utah, United States
| | - Shawna Abdul
- John D. Dingell VA Medical Center, Detroit, Michigan, United States
| | - Mayfair A. Aboagyewah
- Case Management, Mount Sinai Health System, MSH Main Campus, New York, New York, United States
| | - Alicia Beebe
- Saint Luke's Health System (MO), Kansas City, Missouri, United States
| | - Kathleen Kendle
- Section of Health Informatics, El Paso VA Health Care System, El Paso, Texas, United States
| | - Kyle Marshall
- Department of Emergency Medicine, Geisinger, Danville, Pennsylvania, United States
| | - S. Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Sarah Rossetti
- Biomedical Informatics and Nursing, Columbia University Irving Medical Center, New York, New York, United States
| | - Aaron Grigg
- Department of Informatics, Grande Ronde Hospital, La Grande, Oregon, United States
| | - Kevin D. Smith
- Department of Pediatrics, University of Chicago Medicine, Chicago, Illinois, United States
| | - Rebecca G. Mishuris
- Digital, Mass General Brigham, Somerville, Massachusetts, United States
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
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Rotenstein L, Melnick ER, Iannaccone C, Zhang J, Mugal A, Lipsitz SR, Healey MJ, Holland C, Snyder R, Sinsky CA, Ting D, Bates DW. Virtual Scribes and Physician Time Spent on Electronic Health Records. JAMA Netw Open 2024; 7:e2413140. [PMID: 38787556 PMCID: PMC11127114 DOI: 10.1001/jamanetworkopen.2024.13140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/18/2024] [Indexed: 05/25/2024] Open
Abstract
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.
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Affiliation(s)
- Lisa Rotenstein
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
- University of California at San Francisco
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Biostatistics (Health Informatics), Yale School of Public Health, New Haven, Connecticut
| | | | - Jianyi Zhang
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Aqsa Mugal
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stuart R. Lipsitz
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael J. Healey
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | | | - David Ting
- Harvard Medical School, Boston, Massachusetts
- Mass General Brigham, Boston, Massachusetts
- Massachusetts General Hospital, Boston
| | - David W. Bates
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard School of Public Health, Boston, Massachusetts
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Williams CY, Bains J, Tang T, Patel K, Lucas AN, Chen F, Miao BY, Butte AJ, Kornblith AE. Evaluating Large Language Models for Drafting Emergency Department Discharge Summaries. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.03.24305088. [PMID: 38633805 PMCID: PMC11023681 DOI: 10.1101/2024.04.03.24305088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Importance Large language models (LLMs) possess a range of capabilities which may be applied to the clinical domain, including text summarization. As ambient artificial intelligence scribes and other LLM-based tools begin to be deployed within healthcare settings, rigorous evaluations of the accuracy of these technologies are urgently needed. Objective To investigate the performance of GPT-4 and GPT-3.5-turbo in generating Emergency Department (ED) discharge summaries and evaluate the prevalence and type of errors across each section of the discharge summary. Design Cross-sectional study. Setting University of California, San Francisco ED. Participants We identified all adult ED visits from 2012 to 2023 with an ED clinician note. We randomly selected a sample of 100 ED visits for GPT-summarization. Exposure We investigate the potential of two state-of-the-art LLMs, GPT-4 and GPT-3.5-turbo, to summarize the full ED clinician note into a discharge summary. Main Outcomes and Measures GPT-3.5-turbo and GPT-4-generated discharge summaries were evaluated by two independent Emergency Medicine physician reviewers across three evaluation criteria: 1) Inaccuracy of GPT-summarized information; 2) Hallucination of information; 3) Omission of relevant clinical information. On identifying each error, reviewers were additionally asked to provide a brief explanation for their reasoning, which was manually classified into subgroups of errors. Results From 202,059 eligible ED visits, we randomly sampled 100 for GPT-generated summarization and then expert-driven evaluation. In total, 33% of summaries generated by GPT-4 and 10% of those generated by GPT-3.5-turbo were entirely error-free across all evaluated domains. Summaries generated by GPT-4 were mostly accurate, with inaccuracies found in only 10% of cases, however, 42% of the summaries exhibited hallucinations and 47% omitted clinically relevant information. Inaccuracies and hallucinations were most commonly found in the Plan sections of GPT-generated summaries, while clinical omissions were concentrated in text describing patients' Physical Examination findings or History of Presenting Complaint. Conclusions and Relevance In this cross-sectional study of 100 ED encounters, we found that LLMs could generate accurate discharge summaries, but were liable to hallucination and omission of clinically relevant information. A comprehensive understanding of the location and type of errors found in GPT-generated clinical text is important to facilitate clinician review of such content and prevent patient harm.
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Affiliation(s)
| | - Jaskaran Bains
- Department of Emergency Medicine; University of California, San Francisco
| | - Tianyu Tang
- Department of Emergency Medicine; University of California, San Francisco
| | - Kishan Patel
- Department of Emergency Medicine; University of California, San Francisco
| | - Alexa N. Lucas
- Department of Emergency Medicine; University of California, San Francisco
| | - Fiona Chen
- Department of Emergency Medicine; University of California, San Francisco
| | - Brenda Y. Miao
- Bakar Computational Health Sciences Institute; University of California, San Francisco
| | - Atul J. Butte
- Bakar Computational Health Sciences Institute; University of California, San Francisco
| | - Aaron E. Kornblith
- Bakar Computational Health Sciences Institute; University of California, San Francisco
- Department of Emergency Medicine; University of California, San Francisco
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Bradley CJ, Kitchen S, Owsley KM. Much work to do about measuring work. J Natl Cancer Inst 2024; 116:194-199. [PMID: 38070483 PMCID: PMC10852620 DOI: 10.1093/jnci/djad258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/09/2023] [Accepted: 12/05/2023] [Indexed: 02/10/2024] Open
Abstract
Work ability is a critical economic and well-being indicator in cancer care. Yet, work ability is understudied in clinical trials and observational research and is often undocumented in medical records. Despite agreement on the importance of work from well-being, health insurance, and financial perspectives, standardized approaches for collecting, measuring, and analyzing work outcomes are lacking in the health-care setting. The necessary components for closing the gap in patient and caregiver employment research in health-care settings involve a common set of measures, including those that replace or translate generic measures of mental and physical functioning into work outcomes in observational and clinical trial research, standardized approaches to data collection and documentation, and the use of longitudinal data to understand the consequences of reduced work ability over time. We present a conceptual framework for the inclusion of work ability in outcomes research. We cover constructs for employment and work ability measurement that can be adopted in research, recorded as patient-level data, and used to guide treatment decisions. The inclusion of return to work and hours worked, productivity, and ability to perform in a similar job can support conversations that guide treatment decisions and minimize economic consequences. Our hope is that by considering impact on work ability, improved treatments will be developed, health inequities reduced, and resources directed toward aiding patients and their caregivers in balancing work and health demands.
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Affiliation(s)
- Cathy J Bradley
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, Aurora, CO, USA
- University of Colorado Comprehensive Cancer Center, Aurora, CO, USA
| | - Sara Kitchen
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, Aurora, CO, USA
| | - Kelsey M Owsley
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, Little Rock, AR, USA
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Khalil S, Olds A, Chin K, Erkmen CP. Implementation of Well-Being for Cardiothoracic Surgeons. Thorac Surg Clin 2024; 34:63-76. [PMID: 37953054 DOI: 10.1016/j.thorsurg.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Well-being is a quality of positive physical, mental, social, and environmental experiences. Well-being enables thoracic surgeons to achieve their full potential across personal and work domains. Evidence-based guidelines to promote individual well-being include (1) progress toward a goal; (2) actions commensurate with experience, interest, mission; (3) interconnectivity with others; (4) social relatedness of the work one does; (5) safety; and (6) autonomy. Successful pursuit of well-being includes the development of individual skills of mindfulness, resilience, and connection with others. However, well-being among individuals cannot be achieved without support of workplace leaders and durable institutional infrastructure.
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Affiliation(s)
- Sarah Khalil
- Department of General Surgery, Western Michigan University, Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008, USA
| | - Anna Olds
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, Suite 4300, Los Angeles, CA 90033, USA
| | - Kristine Chin
- Lewis Katz School of Medicine at Temple University, 3500 North Broad Street, Philadelphia, PA 19140, USA
| | - Cherie P Erkmen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Suite 501, Parkinson Pavilion, Philadelphia, PA 19140, USA.
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Langley J, Urquhart R, Tschupruk C, Christian E, Warner G. Barriers to and facilitators of successful implementation of a palliative approach to care in primary care practices: a mixed methods study. BMJ Open 2024; 14:e079234. [PMID: 38296276 PMCID: PMC10831432 DOI: 10.1136/bmjopen-2023-079234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE Integrating a palliative approach to care into primary care is an emerging evidence-based practice. Despite the evidence, this type of care has not been widely adopted into primary care settings. The objective of this study was to examine the barriers to and facilitators of successful implementation of a palliative approach to care in primary care practices by applying an implementation science framework. DESIGN This convergent mixed methods study analysed semistructured interviews and expression of interest forms to evaluate the implementation of a protocol, linked to implementation strategies, for a palliative approach to care called Early Palliation through Integrated Care (EPIC) in three primary care practices. This study assessed barriers to and facilitators of implementation of EPIC and was guided by the Consolidated Framework for Implementation Research (CFIR). A framework analysis approach was used during the study to determine the applicability of CFIR constructs and domains. SETTING Primary care practices in Canada. Interviews were conducted between September 2020 and November 2021. PARTICIPANTS 10 individuals were interviewed, who were involved in implementing EPIC. Three individuals from each practice were reinterviewed to clarify emerging themes. RESULTS Overall, there were implementation barriers at multiple levels that caused some practices to struggle. However, barriers were mitigated when practices had the following facilitators: (1) a high level of intra-practice collaboration, (2) established practices with organisational structures that enhanced communications, (3) effective leveraging of EPIC project supports to transition care, (4) perceptions that EPIC was an opportunity to make a long-term change in their approach to care as opposed to a limited term project and (5) strong practice champions. CONCLUSIONS Future implementation work should consider assessing facilitators identified in our results to better gauge primary care pre-implementation readiness. In addition, providing primary care practices with support to help offset the additional work of implementing innovations and networking opportunities where they can share strategies may improve implementation success.
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Affiliation(s)
- Jodi Langley
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Cheryl Tschupruk
- Palliative Health Network, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Erin Christian
- Primary Health Care and Chronic Disease Management Network, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Grace Warner
- Department of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
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Kang C, Sarkar IN. Interventions to Reduce Electronic Health Record-Related Burnout: A Systematic Review. Appl Clin Inform 2024; 15:10-25. [PMID: 37923381 PMCID: PMC10764123 DOI: 10.1055/a-2203-3787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/02/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Electronic health records are a significant contributing factor in clinician burnout, which negatively impacts patient care. OBJECTIVES To identify and appraise published solutions that aim to reduce EHR-related burnout in clinicians. METHODS A literature search strategy was developed following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Six databases were searched for articles published between January 1950 and March 2023. The inclusion criteria were peer-reviewed, full-text, English language articles that described interventions targeting EHR-related burnout in any type of clinician, with reported outcomes related to burnout, wellness, EHR satisfaction, or documentation workload. Studies describing interventions without an explicit focus on reducing burnout or enhancing EHR-related satisfaction were excluded. RESULTS We identified 44 articles describing interventions to reduce EHR-related burnout. These interventions included the use of scribes, EHR training, and EHR modifications. These interventions were generally well received by the clinicians and patients, with subjective improvements in documentation time and EHR satisfaction, although objective data were limited. CONCLUSION The findings of this review underscore the potential benefits of interventions to reduce EHR-related burnout as well as the need for further research with more robust study designs involving randomized trials, control groups, longer study durations, and validated, objective outcome measurements.
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Affiliation(s)
- Chaerim Kang
- Center for Biomedical Informatics, Brown University, Providence, Rhode Island, United States
| | - Indra Neil Sarkar
- Center for Biomedical Informatics, Brown University, Providence, Rhode Island, United States
- Rhode Island Quality Institute, Providence, Rhode Island, United States
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Rotenstein LS, Holmgren AJ, Horn DM, Lipsitz S, Phillips R, Gitomer R, Bates DW. System-Level Factors and Time Spent on Electronic Health Records by Primary Care Physicians. JAMA Netw Open 2023; 6:e2344713. [PMID: 37991757 PMCID: PMC10665969 DOI: 10.1001/jamanetworkopen.2023.44713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/13/2023] [Indexed: 11/23/2023] Open
Abstract
Importance Primary care physicians (PCPs) spend the most time on the electronic health record (EHR) of any specialty. Thus, it is critical to understand what factors contribute to varying levels of PCP time spent on EHRs. Objective To characterize variation in EHR time across PCPs and primary care clinics, and to describe how specific PCP, patient panel, clinic, and team collaboration factors are associated with PCPs' time spent on EHRs. Design, Setting, and Participants This cross-sectional study included 307 PCPs practicing across 31 primary care clinics at Massachusetts General Hospital and Brigham and Women's Hospital during 2021. Data were analyzed from October 2022 to October 2023. Main Outcomes and Measures Total per-visit EHR time, total per-visit pajama time (ie, time spent on the EHR between 5:30 pm to 7:00 am and on weekends), and total per-visit time on the electronic inbox as measured by activity log data derived from an EHR database. Results The sample included 307 PCPs (183 [59.6%] female). On a per-visit basis, PCPs spent a median (IQR) of 36.2 (28.9-45.7) total minutes on the EHR, 6.2 (3.1-11.5) minutes of pajama time, and 7.8 (5.5-10.7) minutes on the electronic inbox. When comparing PCP time expenditure by clinic, median (IQR) total EHR time, median (IQR) pajama time, and median (IQR) electronic inbox time ranged from 23.5 (20.7-53.1) to 47.9 (30.6-70.7) minutes per visit, 1.7 (0.7-10.5) to 13.1 (7.7-28.2) minutes per visit, and 4.7 (4.1-5.2) to 10.8 (8.9-15.2) minutes per visit, respectively. In a multivariable model with an outcome of total per-visit EHR time per visit, an above median percentage of teamwork on orders was associated with 3.81 (95% CI, 0.49-7.13) minutes per visit fewer and having a clinic pharmacy technician was associated with 7.87 (95% CI, 2.03-13.72) minutes per visit fewer. Practicing in a community health center was associated with fewer minutes of total EHR time per visit (5.40 [95% CI, 0.06-10.74] minutes). Conclusions and Relevance There is substantial variation in EHR time among individual PCPs and PCPs within clinics. Organization-level factors, such as team collaboration on orders, support for medication refill functions, and practicing in a community health center, are associated with lower EHR time for PCPs. These findings highlight the importance of addressing EHR burden at a systems level.
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Affiliation(s)
- Lisa S. Rotenstein
- Brigham and Women’s Hospital, Boston, Massachusetts
- University of California at San Francisco
| | | | - Daniel M. Horn
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Boston
| | - Stuart Lipsitz
- Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Russell Phillips
- Harvard Medical School, Boston, Massachusetts
- Harvard Center for Primary Care, Boston, Massachusetts
| | - Richard Gitomer
- Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - David W. Bates
- Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Sittig DF, Wright A. A guide to mitigating audit log-related risk in medical professional liability cases. J Healthc Risk Manag 2023; 43:37-47. [PMID: 37486791 DOI: 10.1002/jhrm.21553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/13/2023] [Indexed: 07/26/2023]
Abstract
Following the American Recovery and Reinvestment Act in 2009, use of electronic health records (EHRs) has become ubiquitous. Accordingly, one should expect most medical professional liability cases to involve review of patient records produced from EHRs. When questions arise regarding who was involved in care of a patient, what they knew and when, or the meaning, completeness, integrity, validity, timeliness, confidentiality, accuracy, or legitimacy of data, or ways that the EHR's user interface or automated clinical decision support tools may have contributed to the alleged events, one often turns to the EHR and its audit log. This manuscript discusses lines of defense incorporated into the design, development, implementation, and use of EHRs to ensure their integrity and the types of EHR transaction logs (e.g., audit log) that exist. Using these logs can help one answer questions that often arise in medical malpractice cases. Finally, there are "best practices" surrounding EHR audit logs that health care organizations should implement. When used appropriately, EHRs and their audit logs provide another source of information to help hospital risk managers, legal counsel, and EHR expert witnesses to investigate adverse incidents and, if needed, prosecute or defend clinicians and/or health care organizations involved in the patient's care.
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Affiliation(s)
- Dean F Sittig
- Center for Healthcare Quality & Safety, McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Informatics-Review LLC, Lake Oswego, Oregon, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Cullati S, Semmer NK, Tschan F, Choupay G, Chopard P, Courvoisier DS. When Illegitimate Tasks Threaten Patient Safety Culture: A Cross-Sectional Survey in a Tertiary Hospital. Int J Public Health 2023; 68:1606078. [PMID: 37744414 PMCID: PMC10511767 DOI: 10.3389/ijph.2023.1606078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
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.
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Affiliation(s)
- Stéphane Cullati
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Norbert K. Semmer
- Department of Psychology, University of Bern, Bern, Switzerland
- National Center for Competence in Research on Affective Sciences, Geneva, Switzerland
- Biological Work and Health Psychology, University of Konstanz, Konstanz, Germany
| | - Franziska Tschan
- National Center for Competence in Research on Affective Sciences, Geneva, Switzerland
- Institute for Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, Switzerland
| | - Gaëlle Choupay
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Pierre Chopard
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Delphine S. Courvoisier
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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14
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Palani S, Saeed I, Legler A, Sadej I, MacDonald C, Kirsh SR, Pizer SD, Shafer PR. Effect of a National VHA Medical Scribe Pilot on Provider Productivity, Wait Times, and Patient Satisfaction in Cardiology and Orthopedics. J Gen Intern Med 2023:10.1007/s11606-023-08114-6. [PMID: 37340268 DOI: 10.1007/s11606-023-08114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 02/23/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Section 507 of the VA MISSION Act of 2018 mandated a 2-year pilot study of medical scribes in the Veterans Health Administration (VHA), with 12 VA Medical Centers randomly selected to receive scribes in their emergency departments or high wait time specialty clinics (cardiology and orthopedics). The pilot began on June 30, 2020, and ended on July 1, 2022. OBJECTIVE Our objective was to evaluate the impact of medical scribes on provider productivity, wait times, and patient satisfaction in cardiology and orthopedics, as mandated by the MISSION Act. DESIGN Cluster randomized trial, with intent-to-treat analysis using difference-in-differences regression. PATIENTS Veterans using 18 included VA Medical Centers (12 intervention and 6 comparison sites). INTERVENTION Randomization into MISSION 507 medical scribe pilot. MAIN MEASURES Provider productivity, wait times, and patient satisfaction per clinic-pay period. KEY RESULTS Randomization into the scribe pilot was associated with increases of 25.2 relative value units (RVUs) per full-time equivalent (FTE) (p < 0.001) and 8.5 visits per FTE (p = 0.002) in cardiology and increases of 17.3 RVUs per FTE (p = 0.001) and 12.5 visits per FTE (p = 0.001) in orthopedics. We found that the scribe pilot was associated with a decrease of 8.5 days in request to appointment day wait times (p < 0.001) in orthopedics, driven by a 5.7-day decrease in appointment made to appointment day wait times (p < 0.001), and observed no change in wait times in cardiology. We also observed no declines in patient satisfaction with randomization into the scribe pilot. CONCLUSIONS Given the potential improvements in productivity and wait times with no change in patient satisfaction, our results suggest that scribes may be a useful tool to improve access to VHA care. However, participation in the pilot by sites and providers was voluntary, which could have implications for scalability and what effects could be expected if scribes were introduced to the care process without buy-in. Cost was not considered in this analysis but is an important factor for future implementation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04154462.
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Affiliation(s)
- Sivagaminathan Palani
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Health Law, Policy, and Management, Boston University, Boston, MA, USA
| | - Iman Saeed
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Health Law, Policy, and Management, Boston University, Boston, MA, USA
| | - Aaron Legler
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Izabela Sadej
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Carol MacDonald
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Susan R Kirsh
- Veterans Health Administration, Department of Veterans Affairs, DC, Washington, USA
| | - Steven D Pizer
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Health Law, Policy, and Management, Boston University, Boston, MA, USA
| | - Paul R Shafer
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA.
- Department of Health Law, Policy, and Management, Boston University, Boston, MA, USA.
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Lam M, Sabharwal S. The Role of Scribes in Orthopaedics. JBJS Rev 2023; 11:01874474-202303000-00005. [PMID: 36947638 DOI: 10.2106/jbjs.rvw.22.00247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
» The rapid increase in the use of electronic medical records (EMRs) has led to some unintended consequences that negatively affect physicians and their patients. » The use of medical scribes may serve as a possible solution to some of the EMR-related concerns. » Research has demonstrated an overall positive impact of having scribes on both physician and patient well-being, safety, and satisfaction. » Adaptation of advances in technology, including remote and asynchronous scribing, use of face-mounted devices, voice recognition software, and applications of artificial intelligence may address some of the barriers to more traditional in-person scribes.
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Affiliation(s)
- Michelle Lam
- Department of Orthopaedic Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, California
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McBride S, Alexander GL, Baernholdt M, Vugrin M, Epstein B. Scoping review: Positive and negative impact of technology on clinicians. Nurs Outlook 2023; 71:101918. [PMID: 36801609 DOI: 10.1016/j.outlook.2023.101918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/20/2022] [Accepted: 01/21/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Unnecessary electronic health record (EHRs) documentation burden and usability issues have negatively impacted clinician well-being (e.g., burnout and moral distress). PURPOSE This scoping review was conducted by members from three expert panels of the American Academy of Nurses to generate consensus on the evidence of both positive and negative impact of EHRs on clinicians. METHODS The scoping review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. RESULTS The scoping review captured 1,886 publications screened against title and abstract 1,431 excluded, examined 448 in a full-text review, excluded 347 with 101 studies informing the final review. DISCUSSION Findings suggest few studies that have explored the positive impact of EHRs and more studies that have explored the clinician's satisfaction and work burden. Significant gaps were identified in associating distress to use of EHRs and minimal studies on EHRs' impact on nurses. CONCLUSION Examined the evidence of HIT's positive and negative impacts on clinician's practice, clinicians work environment, and if psychological impact differed among clinicians.
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Affiliation(s)
- Susan McBride
- School of Nursing, The University of Texas at Tyler, Tyler, TX.
| | | | | | | | - Beth Epstein
- University of Virginia School of Nursing, Charlottesville, VA
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Gellert GA. Medical Scribes: Symptom or Cause of Impeded Evolution of a Transformative Artificial Intelligence in the Electronic Health Record? PERSPECTIVES IN HEALTH INFORMATION MANAGEMENT 2023; 20:1d. [PMID: 37215336 PMCID: PMC9860472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Studies have quantified various specific benefits related to the use of medical scribes, finding physician workflow and productivity improvements, with some demonstrating marginal value or detrimental impact. However, this evidence base misses a critical underlying issue with the expanding number of physicians using medical scribes routinely. There are an estimated 28,000-33,000 peer reviewed biomedical journals worldwide, currently publishing an estimated 1.8-2 million scientific articles every year. Over a typical physician's career from the 11-13 years of undergraduate through medical school and specialty/residency training as well as 34-36 practice/care delivery years beyond (to age 65), this yields 84-94+ million peer reviewed journal articles that are published in the global medical literature and to be potentially consumed/ considered over a roughly 47-year career. Clinical trial results in various stages of peer review, with 409,000 clinical trials registered in 2022, augment this massive volume of new clinical and bioscience information that clinicians might utilize to advance their care delivery by over 19 million bioscientific reports over a lifetime of training and care delivery. Inclusive of clinical trial reports and peer reviewed journal articles, a physician might derive clinical care value from an expanding career-long evidence base of 103-113+ million scientific communications. Even if only 0.1 percent of the global output of biomedical science has clinical relevance to a highly specialized physician, the narrowed career-long total remains a staggering 103,000 journal publications and clinical trial reports. For physicians with a more general and diverse clinical focus such as family medicine, emergency medicine physicians, and hospitalists, if 1 percent of newly published evidence-based literature is pertinent, the total career-long estimate is over 1 million journal articles and clinical trials to be reviewed and clinically integrated. As a result, a challenging issue created by the increasing role of medical scribes is not just evaluating their value (or lack thereof) for practicing physicians in their workflows and productivity. Rather it concerns the impact that medical scribes may be having by decoupling physicians from the iterative technological and cognitive progression of the electronic health record (EHR) and its evolving artificial intelligence (AI), which can facilitate the integration of the year-over-year proliferation of clinically pertinent new scientific evidence into a physician's practice of medicine. This commentary addresses the challenge to the evolution of the AI of the EHR posed by physicians' increasing use of and reliance upon medical scribes, and highlights how medical scribes may also, inadvertently, isolate and insulate physicians from their essential role in continuous refinement and advancement of EHR AI. Consideration is given to the broader challenge of inadequate focus and resources needed across sectors to drive the evolution of AI in the EHR, and associated health informatics research, as a US national priority.
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McCarthy EM, Feinn R, Thomas LA. Self-efficacy and confidence of medical students with prior scribing experience: A mixed methods study. MEDICAL EDUCATION ONLINE 2022; 27:2033421. [PMID: 35174763 PMCID: PMC8856037 DOI: 10.1080/10872981.2022.2033421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 12/30/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE Medical scribing is an increasingly common way for pre-medical students to gain clinical experience. Scribes are a valuable part of the healthcare team and have high rates of matriculation into health professional programs. Little is known about the effects of scribing on the success of the student. This manuscript aims to determine the effect of scribing experience on clinical self-efficacy during medical school. PARTICIPANTS AND METHODS Perceived clinical self-efficacy was evaluated with validated survey questions using a 5-point Likert-type scale as well as free text responses. The survey was completed by 175 medical students at the Frank H. Netter, MD School of Medicine. Statistical analysis was conducted using SPSS. As part of the mixed methods study, free text responses were analyzed using thematic analysis. RESULTS Quantitative results showed no statistical difference in perceived clinical self-efficacy between medical students with scribing experience and those without. Analysis of free text responses showed that medical students believed their scribing experience improved comfort in the clinical setting and increased familiarity with medical terminology. DISCUSSION AND CONCLUSIONS Medical students with scribing experience did not demonstrate greater clinical self-efficacy than their peers without scribing experience. However, medical students with scribing experience have a perceived value of their pre-medical scribing experience on their success in medical school.
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How Providers Can Optimize Effective and Safe Scribe Use: a Qualitative Study. J Gen Intern Med 2022:10.1007/s11606-022-07942-2. [PMID: 36385408 PMCID: PMC9668220 DOI: 10.1007/s11606-022-07942-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022]
Abstract
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.
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Florig ST, Corby S, Devara T, Weiskopf NG, Mohan V, Gold JA. Medical Record Closure Practices of Physicians Before and After the Use of Medical Scribes. JAMA 2022; 328:1350-1352. [PMID: 36048452 PMCID: PMC9437823 DOI: 10.1001/jama.2022.13558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Sarah T. Florig
- Division of Pulmonology and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Sky Corby
- Division of Pulmonology and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Tanuj Devara
- Division of Pulmonology and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Nicole G. Weiskopf
- Department of Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Vishnu Mohan
- Department of Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Jeffrey A. Gold
- Division of Pulmonology and Critical Care Medicine, Oregon Health & Science University, Portland
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Lo B, Sequeira L, Strudwick G, Jankowicz D, Almilaji K, Karunaithas A, Hang D, Tajirian T. Accuracy of Physician Electronic Health Record Usage Analytics using Clinical Test Cases. Appl Clin Inform 2022; 13:928-934. [PMID: 36198309 PMCID: PMC9534596 DOI: 10.1055/s-0042-1756424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/25/2022] [Indexed: 11/02/2022] Open
Abstract
Usage log data are an important data source for characterizing the potential burden related to use of the electronic health record (EHR) system. However, the utility of this data source has been hindered by concerns related to the real-world validity and accuracy of the data. While time-motion studies have historically been used to address this concern, the restrictions caused by the pandemic have made it difficult to carry out these studies in-person. In this regard, we introduce a practical approach for conducting validation studies for usage log data in a controlled environment. By developing test runs based on clinical workflows and conducting them within a test EHR environment, it allows for both comparison of the recorded timings and retrospective investigation of any discrepancies. In this case report, we describe the utility of this approach for validating our physician EHR usage logs at a large academic teaching mental health hospital in Canada. A total of 10 test runs were conducted across 3 days to validate 8 EHR usage log metrics, finding differences between recorded measurements and the usage analytics platform ranging from 9 to 60%.
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Affiliation(s)
- Brian Lo
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Canada
- Centre for Complex Interventions (Digital Interventions Unit), Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Lydia Sequeira
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Canada
- Centre for Complex Interventions (Digital Interventions Unit), Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Gillian Strudwick
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Canada
- Centre for Complex Interventions (Digital Interventions Unit), Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Damian Jankowicz
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Canada
| | - Khaled Almilaji
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Canada
| | - Anjchuca Karunaithas
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Health and Society, University of Toronto Scarborough, Scarborough, Canada
| | - Dennis Hang
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Canada
- Health Information Science, University of Victoria, Victoria, British Columbia, Canada
| | - Tania Tajirian
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
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22
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Bodenheimer T. Revitalizing Primary Care, Part 2: Hopes for the Future. Ann Fam Med 2022; 20:469-478. [PMID: 36228059 PMCID: PMC9512544 DOI: 10.1370/afm.2859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
Part 1 of this essay argued that the root causes of primary care's problems lie in (1) the low percent of national health expenditures dedicated to primary care and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access. Part 2 explores policies and practice changes that could solve or mitigate these primary care problems.Initiatives attempting to improve primary care are discussed. Diffuse multi-component initiatives-patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and Comprehensive Primary Care Plus (CPC+)-have had limited success in addressing primary care's core problems. More focused initiatives-care management, open access, and telehealth-offer more promise.To truly revitalize primary care, 2 fundamental changes are needed: (1) a substantially greater percent of health expenditures dedicated to primary care, and (2) the building of powerful teams that add capacity to care for large panels while reducing burnout.Part 2 of the essay reviews 3 approaches to increasing primary care spending: state-level legislation, eliminating Medicare's disparity between primary care and procedural specialty reimbursement, and efforts by health systems. The final section of Part 2 addresses the building of powerful core and interprofessional teams.
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Affiliation(s)
- Thomas Bodenheimer
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California
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Medical scribes improve documentation consistency and efficiency in an otolaryngology clinic. Am J Otolaryngol 2022; 43:103510. [PMID: 35636088 DOI: 10.1016/j.amjoto.2022.103510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 11/24/2022]
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.
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Corby S, Ash JS, Whittaker K, Mohan V, Solberg N, Becton J, Bergstrom R, Orwoll B, Hoekstra C, Gold JA. Translating ethnographic data into knowledge, skills, and attitude statements for medical scribes: a modified Delphi approach. J Am Med Inform Assoc 2022; 29:1679-1687. [PMID: 35689649 DOI: 10.1093/jamia/ocac091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/13/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Sky Corby
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Joan S Ash
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Keaton Whittaker
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Vishnu Mohan
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nicholas Solberg
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - James Becton
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robby Bergstrom
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Benjamin Orwoll
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Department of Pediatric Critical Care, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Christopher Hoekstra
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeffrey A Gold
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Pollock JR, Moore ML, Llanes AC, Brinkman JC, Makovicka JL, Dulle DL, Hinckley NB, Barcia A, Anastasi M, Chhabra A. Medical Scribes in an Orthopedic Sports Medicine Clinic Improve Productivity and Physician Well-Being. Arthrosc Sports Med Rehabil 2022; 4:e997-e1005. [PMID: 35747641 PMCID: PMC9210372 DOI: 10.1016/j.asmr.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose The purpose of this study is to examine the effects of scribe use on physicians, nurses, and patients in an orthopaedic sports medicine clinic. Methods Surveys containing validated outcome measures relating to physician well-being and workplace satisfaction, among other variables, were used to assess the influence of medical scribes on clinic function. These surveys were collected for 8 months from all patients, nurses, and orthopaedic surgeons working in one orthopaedic sports medicine clinic. Time during a half-day clinic (i.e., 20 or more patients) was documented by surgeons after the last patient was seen. Results The average time spent per half day of clinic was 104 minutes on nonscribe days and 25 minutes on scribe days. Additionally, the time spent documenting encounters per half day of clinic was 87 minutes on average without scribes and 26 minutes on average with scribes. The average surgeon single assessment numeric evaluation (SANE) score was 48.1 without scribes, and 89.3 with scribes. The overall assessment of the clinic by nurses was 73.4 out of 100 on average without scribes and 87.7 out of 100 on average with scribes. Patients did not report a significant change in rating of overall experience (4.7/5.0 with scribes and 4.8/5.0 without scribes, (P = .27) or wait time between scheduled appointment time and surgeon arrival (15.1 minutes with scribes and 18.1 minutes without scribes; P = .12). Conclusions We found the use of scribes in a high-volume orthopaedic sports medicine clinic to have a favorable impact on physicians, nurses, and trainees. The use of a scribe also significantly reduced the time required by surgeons for documentation during clinic and at the end of each clinic day. Patients also reported no significant difference in patient clinic experience scores. Clinical Relevance Orthopaedic surgeons spend a substantial amount of time on paperwork. The results of this study could provide information on whether the use of a scribe helps to reduce administrative burden on orthopedic surgeons.
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Affiliation(s)
| | - M. Lane Moore
- Mayo Clinic Alix School of Medicine, Scottsdale Arizona, U.S.A
| | - Aaron C. Llanes
- University of Arizona School of Medicine, Phoenix, Arizona, U.S.A
| | - Joseph C. Brinkman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Donald L. Dulle
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Anthony Barcia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Matthew Anastasi
- Department of Family Medicine, Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
- Address correspondence to Anikar Chhabra, M.D., Department of Orthopedics, Mayo Clinic, 5777 E Mayo Blvd., Phoenix, AZ, 85054, U.S.A.
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26
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Pfoh ER, Hong S, Baranek L, Rothberg MB, Beinkampen S, Misra-Hebert AD, Rehm SJ, Sikon AL. Reduced Cognitive Burden and Increased Focus: A Mixed-methods Study Exploring How Implementing Scribes Impacted Physicians. Med Care 2022; 60:316-320. [PMID: 34999634 PMCID: PMC8966589 DOI: 10.1097/mlr.0000000000001688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Understanding how medical scribes impact care delivery can inform decision-makers who must balance the cost of hiring scribes with their contribution to alleviating clinician burden. OBJECTIVE The objective of this study was to understand how scribes impacted provider efficiency and satisfaction. DESIGN This was mixed-methods study. PARTICIPANTS Internal and family medicine clinicians were included. MEASURES We administered structured surveys and conducted unstructured interviews with clinicians who adopted scribes. We collected average days to close charts and quantity of after-hours clinical work in the 6 months before and after implementation using electronic health record data. We conducted a difference in difference (DID) analysis using a multilevel Poisson regression. RESULTS Three themes emerged from the interviews: (1) charting time is less after training; (2) clinicians wanted to continue working with scribes; and (3) scribes did not reduce the overall inbox burden. In the 6-month survey, 76% of clinicians endorsed that working with a scribe improved work satisfaction versus 50% at 1 month. After implementation, days to chart closure decreased [DID=0.38 fewer days; 95% confidence interval (CI): -0.61, -0.15] the average minutes worked after hours on clinic days decreased (DID=-11.5 min/d; 95% CI: -13.1, -9.9) as did minutes worked on nonclinical days (DID=-24.9 min/d; 95% CI: -28.1, -21.7). CONCLUSIONS Working with scribes was associated with reduced time to close charts and reduced time using the electronic health record, markers of efficiency. Increased satisfaction accrued once scribes had experience.
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Affiliation(s)
- Elizabeth R. Pfoh
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
| | - Sandra Hong
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Laura Baranek
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
| | - Michael B. Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
| | | | - Anita D. Misra-Hebert
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, Ohio
| | - Susan J. Rehm
- Office of Professional Staff Affairs, Cleveland Clinic, Cleveland, Ohio
| | - Andrea L. Sikon
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, Ohio
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Impact of Scribe Intervention on Documentation in an Outpatient Pediatric Primary Care Practice. Acad Pediatr 2022; 22:289-295. [PMID: 34020102 DOI: 10.1016/j.acap.2021.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/08/2021] [Accepted: 05/12/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE The use of the electronic health record (EHR) has led to physician dissatisfaction, physician burnout, and delays in documentation and billing. Medical scribes can mitigate these unintended consequences by reducing documentation workload and increasing efficiency. OBJECTIVE To study the effects of medical scribes on time to completion of notes and clinician experience, with a focus on time spent charting during clinic and after-hours. We hypothesized that medical scribes in an outpatient pediatric setting would decrease clinician time spent charting, time to finalize encounter notes, and clinician's perceived documentation time. METHODS This 15-month single-center observational study was carried out with 3 study periods: pre-scribe, with-scribe, and scribe-withheld. Time spent in EHR was extracted by our EHR vendor. Participants completed surveys regarding time spent documenting. Six clinicians (5 physicians, 1 nurse practitioner) participated in this study to trial the implementation of medical scribes. RESULTS EHR time data were collected for 4329 patient visits (2232 pre-scribe, 1888 with-scribe, 209 scribe-withheld periods). Comparing pre-scribe versus with-scribe periods, documentation time per patient decreased by 3-minutes 28-seconds per patient (pre-scribe IQR: 6, with-scribe IQR: 3, P = .028); note timeliness decreased from 0.96 days to 0.26 days (pre-scribe IQR: 0.22, with-scribe IQR: 0.11, P = .028); and clinicians' estimates of time spent in the EHR decreased by 1.2 hours per clinic session (pre-scribe IQR: 0.5, with-scribe IQR: 0.5, P = .031). CONCLUSIONS Medical scribes in an outpatient pediatric setting result in: 1) decreased time spent charting, 2) reduced time to final sign clinic notes, and 3) decrease in clinician's perceived time spent documenting.
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Florig ST, Corby S, Rosson NT, Devara T, Weiskopf NG, Gold JA, Mohan V. Chart Completion Time of Attending Physicians While Using Medical Scribes. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2021:457-465. [PMID: 35308986 PMCID: PMC8861674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
| | - Sky Corby
- Oregon Health & Science University, Portland, OR, USA
| | | | - Tanuj Devara
- Oregon Health & Science University, Portland, OR, USA
| | | | | | - Vishnu Mohan
- Oregon Health & Science University, Portland, OR, USA
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29
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An Ethical Case for Medical Scribes. Camb Q Healthc Ethics 2022; 31:95-104. [PMID: 35049454 DOI: 10.1017/s0963180121000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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30
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Time and Clerical Burden Posed by the Current Electronic Health Record for Orthopaedic Surgeons. J Am Acad Orthop Surg 2022; 30:e34-e43. [PMID: 34613950 DOI: 10.5435/jaaos-d-21-00094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/02/2021] [Indexed: 02/01/2023] Open
Abstract
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.
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31
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Daly JM, Schmidt ME, Thoma KD, Levy BT. Trained Clinician's Documentation of Serious Illness Conversations and Use of Billing CPT 99497. J Palliat Care 2021; 37:323-331. [PMID: 34918568 DOI: 10.1177/08258597211049136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advance care planning (ACP) involves patients and family members in discussions with clinicians about their values, goals, and preferences regarding future medical care. Objectives: To (1) assess whether an ACP conversation using the Serious Illness Conversation (SIC) was initiated and documented; (2) assess which components of SIC were documented; (3) determine how frequently clinicians trained to use the SIC guide used ACP billing codes during the study time period, (4) determine whether there was a significant difference in mortality risk score according to documentation of each component of the SIC. Methods; Thirteen clinicians at three family medicine offices were trained in the Serious Illness Care Program and asked to document SICs in the electronic medical record (EMR). A retrospective chart review of SIC components was conducted in the EMRs of patients who presumably had ACP conversations initiated by the trained clinicians. Patients were identified using the billing codes for ACP conversations and through referrals from another study that requires clinicians to have ACP conversations with their patients. Pearson chi-square test for categorical variables and t-tests for continuous variables were conducted. Results: A total of 157 patients were included in this study; 131 patients referred from another ACP study and an additional 26 patients using the billing codes of ACP conversations. Through retrospective chart review, the mean age of patients was 72 years and 54 were male. Sixty-two (40%) charts had one or more SIC components documented. "Explore key topics" was documented most frequently for 58 (38%) patients by the 13 participating clinicians. Mean mortality risk score was 10.7 and higher scores were significantly correlated with more SIC components documented (rp = 0.217, P = 0.007). Conclusion: Little use of the SIC guide among trained physicians was found in the EMR. It was expected that provision of an EMR template for documenting the SIC would have facilitated documentation of SICs.
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Affiliation(s)
- Jeanette M Daly
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Megan E Schmidt
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | | | - Barcey T Levy
- University of Iowa Carver College of Medicine, Iowa City, IA, USA.,University of Iowa, College of Public Health, Iowa City, IA, USA.,University of Iowa, Iowa City, IA, USA
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32
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Dusek HL, Goldstein IH, Rule A, Chiang MF, Hribar MR. Clinical Documentation During Scribed and Non-scribed Ophthalmology Office Visits. OPHTHALMOLOGY SCIENCE 2021; 1:100088. [PMID: 35059685 PMCID: PMC8765735 DOI: 10.1016/j.xops.2021.100088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 11/08/2022]
Abstract
PURPOSE Observe the impact of employing scribes on documentation efficiency in ophthalmology clinics. DESIGN Single-center retrospective cohort study. PARTICIPANTS A total of 29,997 outpatient visits conducted by seven attending ophthalmologists between 1/1/2018 and 12/31/2019 were included in the study; 18,483 with a scribe present during the encounter and 11,514 without a scribe present. INTERVENTION Use of a scribe. MAIN OUTCOME MEASURES Total physician documentation time, physician documentation time during and after the visit, visit length, time to chart closure, note length, and percent of note text edited by physician. RESULTS Total physician documentation time was significantly less when working with a scribe (mean ± SD, 4.7 ± 2.9 vs. 7.6 ± 3.8 minutes/note, P<.001), as was documentation time during the visit (2.8 ± 2.2 vs. 5.9 ± 3.1 minutes/note, P<.001). Physicians also edited scribed notes less, deleting 1.9 ± 4.4% of scribes' draft note text and adding 14.8 ± 11.4% of the final note text, compared to deleting 6.0 ± 9.1%(P<.001) of draft note text and adding 21.2 ± 15.3%(P<.001) of final note text when not working with a scribe. However, physician after-visit documentation time was significantly higher with a scribe for 3 of 7 physicians (P<.001). Scribe use was also associated with an office visit length increase of 2.9 minutes (P<.001) per patient and time to chart closure of 3.0 hours (P<.001), according to mixed-effects linear models. CONCLUSIONS Scribe use was associated with increased documentation efficiency through lower total documentation time and less note editing by physicians. However, the use of a scribe was also associated with longer office visit lengths and time to chart closure. The variability in the impact of scribe use on different measures of documentation efficiency leaves unanswered questions about best practices for the implementation of scribes, and warrants further study of effective scribe use.
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Affiliation(s)
- Haley L. Dusek
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon
| | - Isaac H. Goldstein
- Department of Statistics, University of California, Irvine, Irvine, California
| | - Adam Rule
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon
| | - Michael F. Chiang
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Michelle R. Hribar
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
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Abstract
Burnout is a response to sustained job stressors manifesting as a classic triad of emotional exhaustion, depersonalization, and a sense of reduced accomplishment. With 42% of physicians demonstrating some symptoms of burnout, this has already reached epidemic proportions. The COVID-19 pandemic has only worsened this phenomenon.
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Affiliation(s)
- Aarti Chandawarkar
- Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, OH, United States; Section of Primary Care Pediatrics Nationwide Children's Hospital, Columbus, OH, United States; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States; Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, United States.
| | - Juan D Chaparro
- Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, OH, United States; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States; Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, United States
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Abstract
BACKGROUND Clerical burdens have strained primary care providers already facing a shifting health care landscape and workforce shortages. These pressures may cause burnout and job dissatisfaction, with negative implications for patient care. Medical scribes, who perform real-time electronic health record documentation, have been posited as a solution to relieve clerical burdens, thus improving provider satisfaction and other outcomes. OBJECTIVE The purpose of this study is to identify and synthesize the published research on medical scribe utilization in primary care and safety net settings. RESEARCH DESIGN We conducted a review of the literature to identify outcomes studies published between 2010 and 2020 assessing medical scribe utilization in primary care settings. Searches were conducted in PubMed and supplemented by a review of the gray literature. Articles for inclusion were reviewed by the study authors and synthesized based on study characteristics, medical scribe tasks, and reported outcomes. RESULTS We identified 21 publications for inclusion, including 5 that examined scribes in health care safety net settings. Scribe utilization was consistently reported as being associated with improved productivity and efficiency, provider experience, and documentation quality. Findings for patient experience were mixed. CONCLUSIONS Published studies indicate scribe utilization in primary care may improve productivity, clinic and provider efficiencies, and provider experience without diminishing the patient experience. Further large-scale research is needed to validate the reliability of study findings and assess additional outcomes, including how scribes enhance providers' ability to advance health equity.
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35
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Thomas Craig KJ, Willis VC, Gruen D, Rhee K, Jackson GP. The burden of the digital environment: a systematic review on organization-directed workplace interventions to mitigate physician burnout. J Am Med Inform Assoc 2021; 28:985-997. [PMID: 33463680 PMCID: PMC8068437 DOI: 10.1093/jamia/ocaa301] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/21/2020] [Accepted: 11/16/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To conduct a systematic review identifying workplace interventions that mitigate physician burnout related to the digital environment including health information technologies (eg, electronic health records) and decision support systems) with or without the application of advanced analytics for clinical care. MATERIALS AND METHODS Literature published from January 1, 2007 to June 3, 2020 was systematically reviewed from multiple databases and hand searches. Subgroup analysis identified relevant physician burnout studies with interventions examining digital tool burden, related workflow inefficiencies, and measures of burnout, stress, or job satisfaction in all practice settings. RESULTS The search strategy identified 4806 citations of which 81 met inclusion criteria. Thirty-eight studies reported interventions to decrease digital tool burden. Sixty-eight percent of these studies reported improvement in burnout and/or its proxy measures. Burnout was decreased by interventions that optimized technologies (primarily electronic health records), provided training, reduced documentation and task time, expanded the care team, and leveraged quality improvement processes in workflows. DISCUSSION The contribution of digital tools to physician burnout can be mitigated by careful examination of usability, introducing technologies to save or optimize time, and applying quality improvement to workflows. CONCLUSION Physician burnout is not reduced by technology implementation but can be mitigated by technology and workflow optimization, training, team expansion, and careful consideration of factors affecting burnout, including specialty, practice setting, regulatory pressures, and how physicians spend their time.
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Affiliation(s)
- Kelly J Thomas Craig
- Center for AI, Research, and Evaluation, IBM Watson Health, Cambridge, Massachusetts, USA
| | - Van C Willis
- Center for AI, Research, and Evaluation, IBM Watson Health, Cambridge, Massachusetts, USA
| | - David Gruen
- Center for AI, Research, and Evaluation, IBM Watson Health, Cambridge, Massachusetts, USA
| | - Kyu Rhee
- Center for AI, Research, and Evaluation, IBM Watson Health, Cambridge, Massachusetts, USA
| | - Gretchen P Jackson
- Center for AI, Research, and Evaluation, IBM Watson Health, Cambridge, Massachusetts, USA.,Vanderbilt University Medical Center, Nashville, Tennessee, USA
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36
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Corby S, Ash JS, Mohan V, Becton J, Solberg N, Bergstrom R, Orwoll B, Hoekstra C, Gold JA. A qualitative study of provider burnout: do medical scribes hinder or help? JAMIA Open 2021; 4:ooab047. [PMID: 34396055 PMCID: PMC8358329 DOI: 10.1093/jamiaopen/ooab047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/07/2021] [Accepted: 06/07/2021] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Sky Corby
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Joan S Ash
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Vishnu Mohan
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - James Becton
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nicholas Solberg
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robby Bergstrom
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Benjamin Orwoll
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Christopher Hoekstra
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeffrey A Gold
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Ash JS, Corby S, Mohan V, Solberg N, Becton J, Bergstrom R, Orwoll B, Hoekstra C, Gold JA. Safe use of the EHR by medical scribes: a qualitative study. J Am Med Inform Assoc 2021; 28:294-302. [PMID: 33120424 PMCID: PMC7883983 DOI: 10.1093/jamia/ocaa199] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/26/2020] [Accepted: 08/04/2020] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Joan S Ash
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Sky Corby
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Vishnu Mohan
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nicholas Solberg
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - James Becton
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robby Bergstrom
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Benjamin Orwoll
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Division of Pediatric Critical Care, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Christopher Hoekstra
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeffrey A Gold
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Piersa AP, Laiteerapong N, Ham SA, Del Castillo FF, Shah S, Burnet DL, Lee WW. Impact of a medical scribe on clinical efficiency and quality in an academic general internal medicine practice. BMC Health Serv Res 2021; 21:686. [PMID: 34247600 PMCID: PMC8272908 DOI: 10.1186/s12913-021-06710-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background Scribes have been proposed as an intervention to decrease physician electronic health record (EHR) workload and improve clinical quality. We aimed to assess the impact of a scribe on clinical efficiency and quality in an academic internal medicine practice. Methods Six faculty physicians worked with one scribe at an urban academic general internal medicine clinic April through June 2017. Patient visits during the 3 months prior to intervention (baseline, n = 789), unscribed visits during the intervention (concurrent control, n = 605), and scribed visits (n = 579) were included in the study. Clinical efficiency outcomes included time to close encounter, patient time in clinic, and number of visits per clinic session. Quality outcomes included EHR note quality, rates of medication and immunization review, population of patient instructions, reconciliation of outside information, and completion of preventative health recommendations. Results Median time to close encounter (IQR) was lower for scribed visits [0.4 (4.8) days] compared to baseline and unscribed visits [1.2 (5.9) and 2.9 (5.4) days, both p < 0.001]. Scribed notes were more likely to have a clear history of present illness (HPI) [OR = 7.30 (2.35–22.7), p = 0.001] and sufficient HPI information [OR = 2.21 (1.13–4.35), p = 0.02] compared to unscribed notes. Physicians were more likely to review the medication list during scribed vs. baseline visits [OR = 1.70 (1.22–2.35), p = 0.002]. No differences were found in the number of visits per clinic session, patient time in clinic, completion of preventative health recommendations, or other outcomes. Conclusions Working with a scribe in an academic internal medicine practice was associated with more timely documentation. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06710-y.
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Affiliation(s)
| | | | - Sandra A Ham
- University of Chicago Center for Health and the Social Sciences, Chicago, USA
| | | | - Sachin Shah
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Wei Wei Lee
- Department of Medicine, University of Chicago, Chicago, IL, USA.
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Corby S, Whittaker K, Ash JS, Mohan V, Becton J, Solberg N, Bergstrom R, Orwoll B, Hoekstra C, Gold JA. The future of medical scribes documenting in the electronic health record: results of an expert consensus conference. BMC Med Inform Decis Mak 2021; 21:204. [PMID: 34187457 PMCID: PMC8240616 DOI: 10.1186/s12911-021-01560-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Sky Corby
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239-3098, USA.
| | - Keaton Whittaker
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Joan S Ash
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Vishnu Mohan
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - James Becton
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Nicholas Solberg
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239-3098, USA
| | | | - Benjamin Orwoll
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
- Division of Pediatric Critical Care, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Christopher Hoekstra
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jeffrey A Gold
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239-3098, USA
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Elliott M, Padua M, Schwenk TL. Electronic Health Records, Medical Practice Problems, and Physician Distress. Int J Behav Med 2021; 29:387-392. [PMID: 34184212 DOI: 10.1007/s12529-021-10010-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/25/2022]
Abstract
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. RESULTS Frequency 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.
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Affiliation(s)
- Marta Elliott
- Department of Sociology, University of Nevada, Reno, Reno, NV, USA.
| | - Michael Padua
- Stritch School of Medicine, Loyola University, Maywood, IL, USA
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Ullman K, McKenzie L, Bart B, Park G, MacDonald R, Linskens E, Wilt TJ. The Effect of Medical Scribes in Emergency Departments: A Systematic Review. J Emerg Med 2021; 61:19-28. [PMID: 34006414 DOI: 10.1016/j.jemermed.2021.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/23/2020] [Accepted: 02/19/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Integrating medical scribes with clinicians has been suggested to improve access, quality of care, enhance patient/clinician satisfaction, and increase productivity revenue. OBJECTIVE Conduct a systematic review to evaluate the effects of medical scribes in emergency departments. METHODS Electronic databases from 2010 through December 2019. Two individuals independently reviewed study eligibility, rated risk of bias, and determined overall certainty of evidence. Data abstracted included study and population characteristics, outcomes (efficiency, patient or clinician satisfaction, financial productivity, documentation quality, cost, and training time), and the effect of compensation structure, qualifications, duties, and setting on outcomes. RESULTS Twenty studies (18 observational) were included; 12 from two institutions. All utilized in-person rather than virtual scribes. Fifteen were rated as serious or critical risk of bias; five were rated moderate. Findings indicate that scribes may increase patients seen per day and decrease length of stay; however, effects were small and may vary by setting and outcome measured (low certainty). Scribes may increase financial productivity; however, costs associated with developing, implementing, and maintaining scribe programs were not adequately reported. Results were mixed for door-to-room or door-to-provider time, patients left without being seen, and patient/clinician satisfaction. No studies examined the effects of scribes based on compensation structure, qualifications or duties. CONCLUSIONS Although information quality, quantity, and applicability are limited, in-person medical scribes may improve emergency department efficiency and financial productivity. There was no information on virtual scribes. There was little information on patient or clinician satisfaction, scribe documentation quality, or whether results vary by in-house vs. contracted hiring and training.
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Affiliation(s)
- Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Lauren McKenzie
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Bradley Bart
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota; University of Minnesota Medical School, Minneapolis, Minnesota
| | - Glennon Park
- Emergency Department, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Roderick MacDonald
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Eric Linskens
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota; University of Minnesota Medical School, Minneapolis, Minnesota
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Benjamin IJ, Valentine CM, Oetgen WJ, Sheehan KA, Brindis RG, Roach WH, Harrington RA, Levine GN, Redberg RF, Broccolo BM, Hernandez AF, Douglas PS, Piña IL, Benjamin EJ, Coylewright MJ, Saucedo JF, Ferdinand KC, Hayes SN, Poppas A, Furie KL, Mehta LS, Erwin JP, Mieres JH, Murphy DJ, Weissman G, West CP, Lawrence WE, Masoudi FA, Jones CP, Matlock DD, Miller JE, Spertus JA, Todman L, Biga C, Chazal RA, Creager MA, Fry ET, Mack MJ, Yancy CW, Anderson RE. 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report. Circulation 2021; 143:e1035-e1087. [PMID: 33974449 DOI: 10.1161/cir.0000000000000963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Benjamin IJ, Valentine CM, Oetgen WJ, Sheehan KA, Brindis RG, Roach WH, Harrington RA, Levine GN, Redberg RF, Broccolo BM, Hernandez AF, Douglas PS, Piña IL, Benjamin EJ, Coylewright MJ, Saucedo JF, Ferdinand KC, Hayes SN, Poppas A, Furie KL, Mehta LS, Erwin JP, Mieres JH, Murphy DJ, Weissman G, West CP, Lawrence WE, Masoudi FA, Jones CP, Matlock DD, Miller JE, Spertus JA, Todman L, Biga C, Chazal RA, Creager MA, Fry ET, Mack MJ, Yancy CW, Anderson RE. 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report. J Am Coll Cardiol 2021; 77:3079-3133. [PMID: 33994057 DOI: 10.1016/j.jacc.2021.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Cross DA, Levin Z, Raj M. Patient Portal Use, Perceptions of Electronic Health Record Value, and Self-Rated Primary Care Quality Among Older Adults: Cross-sectional Survey. J Med Internet Res 2021; 23:e22549. [PMID: 33970111 PMCID: PMC8145092 DOI: 10.2196/22549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/09/2020] [Accepted: 03/24/2021] [Indexed: 01/29/2023] Open
Abstract
Background Older adults are increasingly accessing information and communicating using patient-facing portals available through their providers’ electronic health record (EHR). Most theories of technology acceptance and use suggest that patients’ overall satisfaction with care should be independent of their chosen level of portal engagement. However, achieving expected benefits of portal use depends on demonstrated support from providers to meet these expectations. This is especially true among older adults, who may require more guidance. However, little is known about whether misalignment of expectations around technology-facilitated care is associated with lower perceptions of care quality. Objective The aims of this study were to analyze whether older adults’ assessment of primary care quality differs across levels of patient portal engagement and whether perceptions of how well their provider uses the EHR to support care moderates this relationship. Methods We conducted a cross-sectional survey analysis of 158 older adults over the age of 65 (average age 71.4 years) across Michigan using a 13-measure composite of self-assessed health care quality. Portal use was categorized as none, moderate (use of 1-3 functionalities), or extensive (use of 4-7 functionalities). EHR value perception was measured by asking respondents how they felt their doctor’s EHR use improved the patient–provider relationship. Results Moderate portal users, compared to those who were extensive users, had lower estimated care quality (–0.214 on 4-point scale; P=.03). Differences between extensive portal users and nonportal users were not significant. Quality perception was only particularly low among moderate portal users with low EHR value perception; those with high EHR value perception rated quality similarly to other portal user groups. Conclusions Older adults who are moderate portal users are the least satisfied with their care, and the most sensitive to perceptions of how well their provider uses the EHR to support the relationship. Encouraging portal use without compromising perceptions of quality requires thinking beyond patient-focused education. Achieving value from use of patient-facing technologies with older adults is contingent upon matched organizational investments that support technology-enabled care delivery. Providers and staff need policies and practices that demonstrate technology adeptness. Older adults may need more tailored signaling and accommodation for technology to be maximally impactful.
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Affiliation(s)
- Dori A Cross
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, United States
| | - Zachary Levin
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, United States
| | - Minakshi Raj
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana-Champaign, IL, United States
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Lin S, Duong A, Nguyen C, Teng V. Five Years' Experience With a Medical Scribe Fellowship: Shaping Future Health Professions Students While Addressing Provider Burnout. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:671-679. [PMID: 32969839 DOI: 10.1097/acm.0000000000003757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Professional burnout has reached epidemic levels among U.S. medical providers. One key driver is the burden of clinical documentation in the electronic health record, which has given rise to medical scribes. Despite the demonstrated benefits of scribes, many providers-especially those in academic health systems-have been unable to make an economic case for them. With the aim of creating a cost-effective scribe program in which premedical students gain skills that better position them for professional schooling, while providers at risk of burnout obtain documentation support, the authors launched the Clinical Observation and Medical Transcription (COMET) Program in June 2015 at Stanford University School of Medicine. COMET is a new type of postbaccalaureate premedical program that combines an apprenticeship-like scribing experience and a package of teaching, advising, application support, and mentored scholarship that is supported by student tuition. Driven by strong demand from both participants and faculty, the program grew rapidly during its first 5 years (2015-2020). Program evaluations indicated high levels of satisfaction among participants and faculty with their mentors and mentees, respectively; that participants felt the experience better positioned them for professional schooling; and that faculty reported improved joy of practice. In summary, tuition-supported medical scribe programs, like COMET, appear to be feasible and cost-effective. The COMET model may have the potential to help shape future health professions students, while simultaneously combating provider burnout. While scalability and generalizability remain uncertain, this model may be worth exploring at other institutions.
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Affiliation(s)
- Steven Lin
- S. Lin is clinical associate professor and executive director, Stanford Medical Scribe Fellowship, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Anthony Duong
- A. Duong is program manager, Stanford Medical Scribe Fellowship, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Cathina Nguyen
- C. Nguyen is research associate, Stanford Medical Scribe Fellowship, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Valerie Teng
- V. Teng is clinical assistant professor and associate director, Stanford Medical Scribe Fellowship, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
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Abid R, Salzman G. Evaluating Physician Burnout and the Need for Organizational Support. MISSOURI MEDICINE 2021; 118:185-190. [PMID: 34149071 PMCID: PMC8211002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Rayyan Abid
- Senior, Blue Valley West High School, Overland Park, Kansas
| | - Gary Salzman
- Professor, Department of Internal Medicine-Division of Pulmonary and Critical Care Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Moy AJ, Schwartz JM, Chen R, Sadri S, Lucas E, Cato KD, Rossetti SC. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. J Am Med Inform Assoc 2021; 28:998-1008. [PMID: 33434273 PMCID: PMC8068426 DOI: 10.1093/jamia/ocaa325] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 12/04/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND . OBJECTIVE Electronic health records (EHRs) are linked with documentation burden resulting in clinician burnout. While clear classifications and validated measures of burnout exist, documentation burden remains ill-defined and inconsistently measured. We aim to conduct a scoping review focused on identifying approaches to documentation burden measurement and their characteristics. MATERIALS AND METHODS Based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews (ScR) guidelines, we conducted a scoping review assessing MEDLINE, Embase, Web of Science, and CINAHL from inception to April 2020 for studies investigating documentation burden among physicians and nurses in ambulatory or inpatient settings. Two reviewers evaluated each potentially relevant study for inclusion/exclusion criteria. RESULTS Of the 3482 articles retrieved, 35 studies met inclusion criteria. We identified 15 measurement characteristics, including 7 effort constructs: EHR usage and workload, clinical documentation/review, EHR work after hours and remotely, administrative tasks, cognitively cumbersome work, fragmentation of workflow, and patient interaction. We uncovered 4 time constructs: average time, proportion of time, timeliness of completion, activity rate, and 11 units of analysis. Only 45.0% of studies assessed the impact of EHRs on clinicians and/or patients and 40.0% mentioned clinician burnout. DISCUSSION Standard and validated measures of documentation burden are lacking. While time and effort were the core concepts measured, there appears to be no consensus on the best approach nor degree of rigor to study documentation burden. CONCLUSION Further research is needed to reliably operationalize the concept of documentation burden, explore best practices for measurement, and standardize its use.
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Affiliation(s)
- Amanda J Moy
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | | | - RuiJun Chen
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
- Department of Translational Data Science and Informatics, Geisinger, Danville, Pennsylvania, USA
| | - Shirin Sadri
- Vagelos School of Physicians and Surgeons, Columbia University New York, New York, USA
| | - Eugene Lucas
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Kenrick D Cato
- School of Nursing, Columbia University, New York, New York, USA
| | - Sarah Collins Rossetti
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
- School of Nursing, Columbia University, New York, New York, USA
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van Buchem MM, Boosman H, Bauer MP, Kant IMJ, Cammel SA, Steyerberg EW. The digital scribe in clinical practice: a scoping review and research agenda. NPJ Digit Med 2021; 4:57. [PMID: 33772070 PMCID: PMC7997964 DOI: 10.1038/s41746-021-00432-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/25/2021] [Indexed: 01/05/2023] Open
Abstract
The number of clinician burnouts is increasing and has been linked to a high administrative burden. Automatic speech recognition (ASR) and natural language processing (NLP) techniques may address this issue by creating the possibility of automating clinical documentation with a "digital scribe". We reviewed the current status of the digital scribe in development towards clinical practice and present a scope for future research. We performed a literature search of four scientific databases (Medline, Web of Science, ACL, and Arxiv) and requested several companies that offer digital scribes to provide performance data. We included articles that described the use of models on clinical conversational data, either automatically or manually transcribed, to automate clinical documentation. Of 20 included articles, three described ASR models for clinical conversations. The other 17 articles presented models for entity extraction, classification, or summarization of clinical conversations. Two studies examined the system's clinical validity and usability, while the other 18 studies only assessed their model's technical validity on the specific NLP task. One company provided performance data. The most promising models use context-sensitive word embeddings in combination with attention-based neural networks. However, the studies on digital scribes only focus on technical validity, while companies offering digital scribes do not publish information on any of the research phases. Future research should focus on more extensive reporting, iteratively studying technical validity and clinical validity and usability, and investigating the clinical utility of digital scribes.
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Affiliation(s)
- Marieke M van Buchem
- Department of Information Technology & Digital Innovation, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
- CAIRELab, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
| | - Hileen Boosman
- CAIRELab, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Quality & Patient Safety, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Martijn P Bauer
- CAIRELab, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Ilse M J Kant
- Department of Information Technology & Digital Innovation, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- CAIRELab, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Simone A Cammel
- Department of Information Technology & Digital Innovation, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- CAIRELab, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Ewout W Steyerberg
- CAIRELab, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Gottlieb M, Palter J, Westrick J, Peksa GD. Effect of Medical Scribes on Throughput, Revenue, and Patient and Provider Satisfaction: A Systematic Review and Meta-analysis. Ann Emerg Med 2021; 77:180-189. [PMID: 32868143 PMCID: PMC9756438 DOI: 10.1016/j.annemergmed.2020.07.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE Documentation in the medical record increases clerical burden to clinicians and reduces time available to spend with patients, thereby leading to less efficient care and increased clinician stress. Scribes have been proposed as one approach to reduce this burden on clinicians and improve efficiency. The primary objective of this study is to assess the effect of scribes on throughput, revenue, provider satisfaction, and patient satisfaction in both the emergency department (ED) and non-ED setting. METHODS PubMed, Scopus, the Cumulative Index of Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature database, Google Scholar, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched for studies assessing the effect of scribes versus no scribes on the following outcomes: patients per hour, relative value units (RVUs) per hour, RVUs per encounter, clinic length of stay, time to disposition, ED length of stay, ED length of stay for admitted patients, ED length of stay for discharged patients, provider satisfaction, and patient satisfaction. Data were dual extracted into a predefined work sheet, and quality analysis was performed with the Newcastle-Ottawa Scale or Cochrane Risk of Bias Tool. Subgroup analyses were planned between ED versus non-ED studies. RESULTS We identified 39 studies comprising greater than 562,682 patient encounters. Scribes increased patients treated per hour by 0.30 (95% confidence interval [CI] 0.10 to 0.51). Scribes increased RVUs per encounter by 0.14 (95% CI 0.03 to 0.24) and RVUs per hour by 0.55 (0.30 to 0.80). There was no difference in time to disposition (5.74 minutes; 95% CI -2.63 to 14.10 minutes) or ED length of stay (-3.44 minutes; 95% CI -7.68 to 0.81 minutes), although a difference was found in clinic length of stay (5.74 minutes; 95% CI 0.42 to 11.05 minutes). Fourteen of 16 studies reported favorable provider satisfaction with a scribe. Seven of 18 studies reported favorable patient satisfaction with a scribe. No studies reported negative provider or patient satisfaction with scribes. CONCLUSION Overall, we found that scribes improved RVUs per hour, RVUs per encounter, patients per hour, provider satisfaction, and patient satisfaction. However, we did not identify an improvement in ED length of stay. Future studies are needed to determine the cost-benefit effect of scribes and ED volume necessary to support their use.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL.
| | - Joseph Palter
- Department of Emergency Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL
| | - Jennifer Westrick
- Library of Rush University Medical Center, Rush University, Chicago, IL
| | - Gary D. Peksa
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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Affiliation(s)
- Jennifer Claytor
- Department of Internal Medicine, University of California, San Francisco.,Editorial Fellow, JAMA Internal Medicine
| | - Richard W Grant
- Division of Research, Kaiser Permanente Northern California, Oakland.,Associate Editor, JAMA Internal Medicine
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