Effect of Medical Scribes on Throughput, Revenue, and Patient and Provider Satisfaction: A Systematic Review and Meta-analysis

Physician EHR Time and Visit Volume Following Adoption of Team-Based Documentation Support

Importance

Physicians spend the plurality of active electronic health record (EHR) time on documentation. Excessive documentation limits time spent with patients and is associated with burnout. Organizations need effective strategies to reduce physician documentation burden; however, evidence on team-based documentation (eg, medical scribes) has been limited to small, single-institution studies lacking rigorous estimates of how documentation support changes EHR time and visit volume.

Objectives

To analyze how EHR documentation time and visit volume change following the adoption of team-based documentation approaches.

Design, Setting, and Participants

This national longitudinal cohort study analyzed physician-week EHR metadata from September 2020 through April 2021. A 2-way fixed-effects difference-in-differences regression approach was used to analyze changes in the main outcomes after team-based documentation support adoption. Event study regression models were used to examine variation in changes over time and stratified models to analyze the moderating role of support intensity. The sample included US ambulatory physicians using the EHR. Data were analyzed between October 2022 and September 2023.

Exposure

Team-based documentation support, defined as new onset and consistent use of coauthored documentation with another clinical team member.

Main Outcomes and Measures

The main outcomes included weekly visit volume, EHR documentation time, total EHR time, and EHR time outside clinic hours.

Results

Of 18 265 physicians, 1024 physicians adopted team-based documentation support, with 17 241 comparison physicians who did not adopt such support. The sample included 57.2% primary care physicians, 31.6% medical specialists, and 11.2% surgical specialists; 40.0% practiced in academic settings and 18.4% in outpatient safety-net settings. For adopter physicians, visit volume increased by 6.0% (2.5 visits/wk [95% CI, 1.9-3.0]; P < .001), and documentation time decreased by 9.1% (23.3 min/wk [95% CI, -30.3 to -16.2]; P < .001). Following a 20-week postadoption learning period, visits per week increased by 10.8% and documentation time decreased by 16.2%. Only high-intensity adopters (>40% of note text authored by others) realized reductions in documentation time, both for the full postadoption period (-53.9 min/wk [95% CI, -65.3 to -42.4]; 21.0% decrease; P < .001) and following the learning period (-72.2 min/wk; 28.1% decrease). Low adopters saw no meaningful change in EHR time but realized a similar increase in visit volume.

Conclusions and Relevance

In this national longitudinal cohort study, physicians who adopted team-based documentation experienced increased visit volume and reduced documentation and EHR time, especially after a learning period.

Resident physician depression: systemic challenges and possible solutions

Resident physicians face intense stressors that significantly heighten their depression risk. This article discusses research findings on critical factors contributing to depression among resident physicians. Understanding these factors is essential to developing targeted interventions, fostering healthy work environments, and ultimately improving physician wellbeing and patient care.

Effect of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act Scribes Trial on Emergency Department Provider Productivity and Patient Throughput Times

BACKGROUND

To help improve access to care, section 507 of the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act of 2018 mandated a 2-year trial of medical scribes in the Veterans Health Administration (VHA).

OBJECTIVE

The impact of scribes on provider productivity and patient throughput time in VHA emergency departments (EDs) was evaluated.

METHODS

A clustered randomized trial was designed using intent-to-treat difference-in-differences analysis. The intervention period was from June 30, 2020 to July 1, 2022. The trial included six intervention and six comparison ED clinics. Two ED providers who volunteered to participate in the trial were assigned two scribes each. Scribes assisted providers with documentation and visit-related activities. The outcomes were provider productivity and patient throughput time per clinic-pay period.

RESULTS

Randomization to intervention resulted in decreased provider productivity and increased patient throughput time. In adjusted regression models, randomization to scribes was associated with a decrease of 8.4 visits per full-time equivalent (95% confidence interval [CI] 12.4-4.3; p < 0.001) and 0.5 patients per day per provider (95% CI 0.8-0.3; p < 0.001). Intervention was associated with increases in length of stay of 29.1 min (95% CI 21.2-36.9 min; p < 0.001), 6.3 min in door to doctor (95% CI 2.9-9.6 min; p < 0.001), 19.5 min in door to disposition (95% CI 13.2-25.9 min; p < 0.001), and 13.7 min in doctor to disposition (95% CI 8.8-18.6 min; p < 0.001).

CONCLUSIONS

Scribes were associated with decreased provider productivity and increased patient throughput time in VHA EDs. Although scribes may have contributed to improvements in other dimensions of quality, further examination of the ways in which scribes were used is advisable before widespread adoption in VHA EDs.

Costs and Productivity Benefits of the Department of Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act Scribes Trial

OBJECTIVES

To improve access, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 mandated a 2-year study of medical scribes in Veterans Health Administration specialty clinics and emergency departments. Medical scribes are employed in clinical settings with the goals of increasing provider productivity and satisfaction by minimizing physicians' documentation burden. Our objective is to quantify the economic outcomes of the MISSION Act scribes trial.

METHODS

A cluster-randomized trial was designed with 12 Department of Veterans Affairs (VA) medical centers randomized into the intervention. We estimated the total cost of the trial, cost per scribe-year, and projected cost of hiring additional physicians to achieve the observed scribe productivity benefits in relative value units and visits per full-time-equivalent over the 2-year intervention period (June 30, 2020 to July 1, 2022).

RESULTS

The estimated cost of the trial was $4.6 million, below the Congressional Budget Office estimate of $5 million. A full-time scribe-year cost approximately $74 600 through contracting and $62 900 through VA hiring. Randomization into the trial led to an approximate 30% increase in productivity in cardiology and 20% in orthopedics. The projected incremental cost of using additional physicians instead of scribes to achieve the same productivity benefits was nearly $1.7 million more, or 75% higher, than the observed cost of scribes in cardiology and orthopedics.

CONCLUSIONS

As the largest randomized trial of scribes to date, the MISSION Act scribes trial provides important evidence on the costs and benefits of scribes. Improving productivity enhances access and scribes may give VA a new tool to improve productivity in specialty care at a lower cost than hiring additional providers.

Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system

BACKGROUND

Globally, emergency departments (EDs) are overcrowded and unable to meet an ever-increasing demand for care. The aim of this study is to comprehensively review and synthesise literature on potential solutions and challenges throughout the entire health system, focusing on ED patient flow.

METHODS

An umbrella review was conducted to comprehensively summarise and synthesise the available evidence from multiple research syntheses. A comprehensive search strategy was employed in four databases alongside government or organisational websites in March 2023. Gray literature and reports were also searched. Quality was assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses. We summarised and classified findings using qualitative synthesis, the Population-Capacity-Process (PCP) model, and the input/throughput/output (I/T/O) model of ED patient flow and synthesised intervention outcomes based on the Quadruple Aim framework.

RESULTS

The search strategy yielded 1263 articles, of which 39 were included in the umbrella review. Patient flow interventions were categorised into human factors, management-organisation interventions, and infrastructure and mapped to the relevant component of the patient journey from pre-ED to post-ED interventions. Most interventions had mixed or quadruple nonsignificant outcomes. The majority of interventions for enhancing ED patient flow were primarily related to the 'within-ED' phase of the patient journey. Fewer interventions were identified for the 'post-ED' phase (acute inpatient transfer, subacute inpatient transfer, hospital at home, discharge home, or residential care) and the 'pre-ED' phase. The intervention outcomes were aligned with the aim (QAIM), which aims to improve patient care experience, enhance population health, optimise efficiency, and enhance staff satisfaction.

CONCLUSIONS

This study found that there was a wide range of interventions used to address patient flow, but the effectiveness of these interventions varied, and most interventions were focused on the ED. Interventions for the remainder of the patient journey were largely neglected. The metrics reported were mainly focused on efficiency measures rather than addressing all quadrants of the quadruple aim. Further research is needed to investigate and enhance the effectiveness of interventions outside the ED in improving ED patient flow. It is essential to develop interventions that relate to all three phases of patient flow: pre-ED, within-ED, and post-ED.

Using K-Means Clustering to Identify Physician Clusters by Electronic Health Record Burden and Efficiency

Objectives: Electronic health records (EHRs) have transformed the way modern medicine is practiced, but they remain a major source of documentation burden among physicians. This study aims to use data from Signal, a tool provided by the Epic EHR, to analyze physician metadata in the Montefiore Health System via cluster analysis to assess EHR burden and efficiency. Methods: Data were obtained for a one-month period (July 2020) representing a return to normal operation post-telemedicine implementation. Six metrics from Signal were used to phenotype physicians: time on unscheduled days, pajama time, time outside of 7 AM to 7 PM, turnaround time, proficiency score, and visits closed the same day. k-Means clustering was employed to group physicians, and the clusters were assessed overall and by sex and specialty. Results: Our results demonstrate the partitioning of physicians into a higher-efficiency, lower-time outside of scheduled hours (TOSH) cluster and a lower-efficiency, higher-TOSH cluster even when stratified by sex and specialty. Intra-cluster comparisons showed general homogeneity of physician metrics with the exception of the higher-efficiency, lower-TOSH cluster when stratified by sex. Conclusions: Taken together, the clusters uniquely reflect the EHR efficiency-burden of the Montefiore Health System. Applying k-means clustering to readily available EHR data allows for a scalable, efficient, and adaptable approach of assessing physician EHR burden and efficiency, allowing health systems to examine documentation trends and target wellness interventions.

Effect of a National VHA Medical Scribe Pilot on Provider Productivity, Wait Times, and Patient Satisfaction in Cardiology and Orthopedics

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.

Impact of a Medical Scribe Program on the Educational Trajectory of Prehealth and Underrepresented in Medicine Students

BACKGROUND AND OBJECTIVES

Sparse research exists on evaluating the effects of medical scribing programs on the educational trajectory of prehealth students. This study assesses the impact of the Stanford Medical Scribe Fellowship (COMET) on its prehealth participants' educational goals, preparation for graduate training, and acceptance into health professional schools.

METHODS

We distributed a 31-question survey with both closed- and open-ended questions to 96 alumni. The survey collected participant demographics, self-reported underrepresented in medicine (URM) status, pre-COMET clinical experiences and educational goals, application to and acceptance at health professional schools, and perceived impact of COMET on their educational trajectory. SPSS was used to complete the analyses.

RESULTS

The survey had a 97% (93/96) completion rate. Among all respondents, 69% (64/93) applied to a health professional school and 70% (45/64) were accepted. Among URM respondents, 68% (23/34) applied to a health professional school and 70% (16/23) were accepted. Overall acceptance rates for MD/DO and PA/NP programs were 51% (24/47) and 61% (11/18), respectively. URM acceptance rates for MD/DO and PA/NP programs were 43% (3/7) and 58% (7/12), respectively. For current or recently graduated health professional school respondents, 97% (37/38) "strongly agreed" or "agreed" that COMET helped them succeed in their training.

CONCLUSIONS

COMET is associated with a positive impact on the educational trajectory of its prehealth participants and a higher acceptance rate into health professional schools than the national rates for both overall and URM applicants. Scribing programs may serve as pipeline development and help increase the diversity of the future health care workforce.

Definitions and factors associated with emergency physician productivity: a scoping review

PURPOSE

There currently exists no standard productivity measure for emergency physicians. The objectives of this scoping review were to synthesize the literature to identify components of definitions and measurements of emergency physician productivity and to evaluate factors associated with productivity.

METHODS

We searched Medline, Embase, CINAHL, and ProQuest One Business from inception to May 2022. We included all studies that reported on emergency physician productivity. We excluded studies that only reported departmental productivity, studies with non-emergency providers, review articles, case reports, and editorials. Data were extracted into predefined worksheets and a descriptive summary was presented. Quality analysis was performed with Newcastle-Ottawa Scale.

RESULTS

After screening 5521 studies, 44 studies met full inclusion criteria. Components of the definition for emergency physician productivity included: number of patients managed, revenue generated, patient processing time, and a standardization factor. Most studies measured productivity using patients per hour, relative value units per hour, and provider-to-disposition time. The most studied factors influencing productivity included scribes, resident learners, electronic medical record implementation, and faculty teaching scores.

CONCLUSION

Emergency physician productivity is heterogeneously defined, but includes common elements such as patient volume, complexity, and processing time. Commonly reported productivity metrics include patients per hour and relative value units that incorporate patient volume and complexity, respectively. The findings of this scoping review can guide ED physicians and administrators to measure the impact of QI initiatives, promote efficient patient care, and optimize physician staffing.

Medical Scribes: Symptom or Cause of Impeded Evolution of a Transformative Artificial Intelligence in the Electronic Health Record?

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.

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

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

Assessment of the Relationship Between an Adverse Impact of Work on Physicians' Personal Relationships and Unsolicited Patient Complaints

OBJECTIVE

To evaluate the relationship between an adverse impact of work on physicians' personal relationships and unsolicited patient complaints about physician behavior - a well-established indicator of patient care quality.

PARTICIPANTS AND METHODS

We paired data from a physician wellness survey collected in April and May 2013 with longitudinal unsolicited patient complaint data collected independently from January 1, 2013, to December 31, 2016. Unsolicited patient complaints were used to calculate the Patient Advocacy Reporting System (PARS) score, an established predictor of clinical outcomes and malpractice suits. The primary outcome was PARS score tercile. Ordinal logistic regression mixed effects models were used to assess the association between the impact of work on a physician's personal relationships and PARS scores.

RESULTS

Of 2384 physicians eligible to participate, 831 (34.9%) returned surveys including 429 (51.6%) who consented for their survey responses to be linked to independent data and had associated PARS scores. In a multivariate model adjusting for gender and specialty category, each 1-point higher impact of work on personal relationships score (0-10 scale; higher score unfavorable) was associated with a 19% greater odds of being in the next higher PARS score tercile of unsolicited patient complaints (odds ratio, 1.19; 95% CI, 1.07-1.33) during the subsequent 4-year study period.

CONCLUSION

An adverse impact of work on physicians' personal relationships is associated with independently assessed, unsolicited patient complaints. Organizational efforts to mitigate an adverse impact of work on physicians' personal relationships are warranted as part of efforts to improve the quality of patient experience and malpractice risk.

Interfacing With the Electronic Health Record (EHR): A Comparative Review of Modes of Documentation

Electronic health records (EHRs) have provided physicians with a systematic framework for collecting patient data, organizing notes from the healthcare team, and managing the daily workflow in the modern era of healthcare. Despite these advantages, EHRs have proven to be problematic for clinicians. The burdensome regulations requiring increased documentation with the EHR paradigm have led to inefficiencies from data-entry requirements forcing physicians to spend an inordinate amount of time on it, affecting the time available for direct patient care as well as leading to professional burnout. As a result, new modalities such as speech recognition, medical scribes, pre-made EHR templates, and digital scribes [a form of artificial intelligence (AI) based on ambient speech recognition] are increasingly being used to reduce charting time and increase the time available for patient care. The purpose of our review is to provide an up-to-date review of the literature on these modalities including their benefits and shortcomings, to help physicians and other medical professionals choose the best methods to document their patient-care encounters efficiently and effectively.

Medical Scribes in an Orthopedic Sports Medicine Clinic Improve Productivity and Physician Well-Being

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.

A Latent Profile Analysis of Chinese Physicians' Workload Tethered to Paperwork During Outpatient Encounters

Background

Physician dissatisfaction with more time spent on related paperwork but less time available for direct interaction with patients is increasing internationally. Increased physician workload resulting from paperwork might negatively affect their interaction with patients and increase the risk for burnout. This study aimed to investigate the level of physician workload tethered to paperwork during outpatient encounters and explore its latent workload subgroups among Chinese physicians.

Methods

A cross-sectional survey was conducted via online questionnaire primarily in 24 hospitals in 6 provinces in Eastern, Central, and Western China from November 2020 to February 2021. The Chinese physician mental workload scale developed by our research team was used for assessment of physician workload tethered to paperwork. Physicians were categorized into different subgroups of workload via latent profile analysis. Multinomial logistic regression was subsequently performed to examine how demographic variables differ among physicians belonging to different subgroups.

Results

A total of 1,934 valid questionnaires were received. Chinese physicians reported medium levels of workload while performing non-physician-patient communication work tasks characterized by paperwork during outpatient encounters. Four latent workload subgroups were identified: "low workload group" (8.8%), "medium workload group" (34.0%), "high workload group" (42.1%) and "very high workload group" (15.1%). Compared with the other latent workload subgroups, physicians belonging to the "very high workload group" were more likely to be younger, married, those who had worse health status, lower educational levels and lower average monthly incomes, those who worked more years in the current institution, more hours per week and longer outpatient hours per week, and those who worked in public general hospitals, tertiary B hospitals and Obstetrics and Gynecology, and saw more than 50 outpatients per day, with more time spent on per patient.

Conclusions

There exit four latent workload subgroups among Chinese physicians tethered to paperwork during outpatient encounters along with great individual variations among these subgroups. The characteristics of the latent "very high workload group" can help permit more targeted guidance for developing interventions with optimized human resource allocation to, in turn, increase the time available for direct interaction with patients, thereby resulting in improved quality of physician-patient interactions and decreased risk for physician burnout.

The implementation of scribing within a medical school's pre-clinical curriculum: pilot study

BACKGROUND

Medical students matriculating from their preclinical curriculum into clinical clerkships face a significant learning curve when using an electronic medical record (EMR) system for clinical documentation. With the trend toward reduction in preclinical medical education, students now have fewer opportunities to optimize their note-writing and overall clinical skills before transitioning to patient-care settings.

METHODS

This study sought to investigate how a structured medical scribing program in an outpatient clinic helps bridge the gap between traditional preclinical and clinical curricula in medical education. A small cohort of medical students were trained in medical scribing within our institutions' existing preclinical preceptorship program. We surveyed students, preceptors, and patients during the project to better understand confidence around documentation, the EMR, and the impact of the scribing program on workflow efficiency and patient satisfaction.

RESULTS

There was no significant difference between the scribe and non- scribe students in their confidence documenting a patient encounter or navigating EMR (all p > .05). Our study demonstrated that preceptors for scribe students reported a significant decrease in documentation time compared to non-scribes (Mdiff = - 5.75, p = .02), with no negative impact on patient satisfaction.

CONCLUSIONS

Medical scribing can be a tool to further develop medical trainees in clinical documentation and help prepare them for the responsibilities during clinical years. When summing the per encounter time savings over the course of a half or full clinic day, scribing can return a significant amount of time back to preceptors. The time saved by the preceptor needs to be further investigated to determine if the time can lend itself towards better patient care, student-specific feedback, focused teaching, or even mentoring.

Chart Completion Time of Attending Physicians While Using Medical Scribes

Medical scribes have become a widely used strategy to optimize how providers document in the electronic health record. To date, literature regarding the impact of scribes on time to complete documentation is limited. We conducted a retrospective, descriptive study of chart completion time among providers using scribes at our organization. A total of 148,410 scribed encounters, across 55 different clinics, were analyzed to determine variations in chart completion time. There was a significant variance in completion time between specialty groups and clinics within each specialty. Additionally, chart completion time was highly variable between providers working in the same clinic. These patterns were observed across all specialties included in our analysis. Our results suggest a higher level of variability with respect to chart completion when utilizing scribes than previously anticipated.

Comparing International Experiences With Electronic Health Records Among Emergency Medicine Physicians in the United States and Norway: Semistructured Interview Study

Background

The variability in physicians’ attitudes regarding electronic health records (EHRs) is widely recognized. Both human and technological factors contribute to user satisfaction. This exploratory study considers these variables by comparing emergency medicine physician experiences with EHRs in the United States and Norway.

Objective

This study is unique as it aims to compare individual experiences with EHRs. It creates an opportunity to expand perspective, challenge the unknown, and explore how this technology affects clinicians globally. Research often highlights the challenge that health information technology has created for users: Are the negative consequences of this technology shared among countries? Does it affect medical practice? What determines user satisfaction? Can this be measured internationally? Do specific factors account for similarities or differences? This study begins by investigating these questions by comparing cohort experiences. Fundamental differences between nations will also be addressed.

Methods

We used semistructured, participant-driven, in-depth interviews (N=12) for data collection in conjunction with ethnographic observations. The conversations were recorded and transcribed. Texts were then analyzed using NVivo software (QSR International) to develop codes for direct comparison among countries. Comprehensive understanding of the data required triangulation, specifically using thematic and interpretive phenomenological analysis. Narrative analysis ensured appropriate context of the NVivo (QSR International) query results.

Results

Each interview resulted in mixed discussions regarding the benefits and disadvantages of EHRs. All the physicians recognized health care’s dependence on this technology. In Norway, physicians perceived more benefits compared with those based in the United States. Americans reported fewer benefits and disproportionally high disadvantages. Both cohorts believed that EHRs have increased user workload. However, this was mentioned 2.6 times more frequently by Americans (United States [n=40] vs Norway [n=15]). Financial influences regarding health information technology use were of great concern for American physicians but rarely mentioned among Norwegian physicians (United States [n=37] vs Norway [n=6]). Technology dysfunctions were the most common complaint from Norwegian physicians. Participants from each country noted increased frustration among older colleagues.

Conclusions

Despite differences spanning geographical, organizational, and cultural boundaries, much is to be learned by comparing individual experiences. Both cohorts experienced EHR-related frustrations, although etiology differed. The overall number of complaints was significantly higher among American physicians. This study augments the idea that policy, regulation, and administration have compelling influence on user experience. Global EHR optimization requires additional investigation, and these results help to establish a foundation for future research.

Patient Throughput Initiatives in Ambulatory Care Organizations during the COVID-19 Pandemic: A Systematic Review

BACKGROUND AND OBJECTIVES

Ambulatory (outpatient) health care organizations continue to respond to the COVID-19 global pandemic using an array of initiatives to provide a continuity of care for both COVID-19 and non-COVID-19 patients. The purpose of this study is to systematically identify the facilitators and barriers experienced by outpatient health care organizations in an effort to maintain effective and efficient patient throughput during the pandemic.

MATERIALS AND METHODS

This study systematically reviewed articles focused on initiatives taken by ambulatory care organizations to maintain optimal outpatient throughput levels while balancing pandemic precautions, published during 2020.

RESULTS

Among the 30 articles that met the inclusion criteria, three initiatives healthcare organizations have taken to maintain throughput were identified: the use (and enhanced use) of telehealth, protocol development, and health care provider training. The research team also identified three barriers to patient throughput: lack of telehealth, lack of resources, and overall lack of knowledge.

CONCLUSIONS

To maintain patient throughput during the COVID-19 pandemic, healthcare organizations need to develop strategies such as the use of virtual consultation and follow-up, new guidelines to move patients along the care delivery value-chain, and ongoing training of providers. Additionally, the availability of required technology for telehealth, availability of resources, and adequate knowledge are vital for continuous patient throughput to ensure continuity of care during a pandemic.

Future Directions in Artificial Intelligence

No one knows what the paradigm shift of artificial intelligence will bring to medical imaging. In this article, we attempt to predict how artificial intelligence will impact radiology based on a critical review of current innovations. The best way to predict the future is to anticipate, prepare, and create it. We anticipate that radiology will need to enhance current infrastructure, collaborate with others, learn the challenges and pitfalls of the technology, and maintain a healthy skepticism about artificial intelligence while embracing its potential to allow us to become more productive, accurate, secure, and impactful in the care of our patients.

The impact of medical scribes on emergency physician diagnostic testing and diagnosis charting

OBJECTIVES

Since the widespread adoption of electronic medical records (EMRs), medical scribes have been increasingly utilized in emergency department (ED) settings to offload the documentation burden of emergency physicians (EPs). Scribes have been shown to increase EP productivity and satisfaction; however, little is known about their effects on the EP's diagnostic process. We aimed to assess what effect, if any, scribes have on EP diagnostic test ordering and their documentation of differential diagnoses.

METHODS

We conducted a retrospective cohort study utilizing a chart review to compare diagnostic practices of EPs working both with and without scribes. We analyzed the number of laboratory and radiologic diagnostic studies ordered per encounter as well as characteristics of differential diagnosis documentation.

RESULTS

Scribes did not affect laboratory studies ordered per encounter (mean 6.31 by scribes vs. 7.35 by EPs, difference -1.04; 95% confidence interval [CI] -2.34 to 0.26) or radiologic studies ordered per encounter (mean 1.49 by scribes vs. 1.39 by EPs, difference 0.10; 95% CI -0.15 to 0.35). Scribes did not affect the frequency of documenting a differential diagnosis or the number of diagnoses considered in each differential, but they were associated with higher word counts in EP differentials (mean 72.29 by scribes vs. 50.00 by EPs, mean difference 22.79; 95% CI 6.77 to 38.81).

CONCLUSIONS

Scribe use does not appear to affect EP diagnostic test ordering but may have a small effect on their documentation of differential diagnoses.

A national assessment of residency wellness initiatives in emergency medicine

BACKGROUND

Wellness is increasingly recognized as an important component of graduate medical education. However, there are limited data regarding how wellness initiatives are enacted in practice. This study aimed to survey emergency medicine (EM) residency programs to identify current, previous, and planned wellness initiatives as well as barriers to implementation and resources utilized.

METHODS

This was a cross-sectional survey study performed from November 2019 through January 2020. A literature search was performed to identify existing published wellness interventions and existing barriers, and these interventions and barriers were compiled to create a survey. The survey was piloted among five program directors and assistant program directors in person with feedback directly incorporated into the survey. The survey was sent to program leadership at all 223 Accreditation Council for Graduate Medical Education-accredited EM residency programs across the United States.

RESULTS

Of the programs surveyed, 95 (42.6%) were included. The most common current wellness interventions reported were resident retreats (91%), group events (90%), formal mentorship (74%), and wellness committees (66%). Reported factors that contributed to the successful implementation of wellness interventions were faculty involvement (78%), resident involvement (78%), department chair support (51%), institutional support (44%), and financial support (36%). Lack of financial support (65%) and limited time (62%) were the most commonly reported barriers that prevented the implementation of wellness interventions.

CONCLUSIONS

Resident wellness is an important aspect of residency training. Survey respondents generally perceived that wellness interventions were associated with wellness improvement. Successful programs have financial, institutional, and chair support.