Effects of medical scribes on physician productivity in a Canadian emergency department: a pilot study

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.

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 improve documentation consistency and efficiency in an otolaryngology clinic

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.

Documentation of paediatric head injuries in a mixed metropolitan emergency department

OBJECTIVE

Head injuries are a common presentation of children to Australian EDs. Healthcare documentation is an important tool for enhancing patient care. In our study, we aimed to assess the adequacy of paediatric head injury documentation in a mixed ED.

METHODS

A retrospective analysis of presentations to a mixed ED between 2017 and 2018. Children aged <16 years old with a primary diagnosis of head injury were included. Documentation items based on local head injury guidelines were assessed in both medical and nursing documentation. We compared cases aged <1 and ≥1 year.

RESULTS

There were 427 presentations that met the case definition. Medical documentation was present in 422 cases and nursing documentation in 310 cases. In combined medical and nursing documentation, items poorly documented include blood pressure (BP; 21.3%) and secondary survey (16.9%). In solely medical documentation, least commonly documented items are high-risk bony injuries (22.5%), high-risk soft tissue injuries (22.3%), seizure (22.0%) and non-accidental injury (3.6%). Glasgow Coma Scale (GCS) was poorly documented in cases aged <1 year (10.9%, P < 0.001).

CONCLUSIONS

The largest gaps in the documentation of paediatric head injuries were BP and paediatric GCS in infants. Future audits and educational strategies should focus on targeting clinically relevant items that are predictive of serious outcomes.

Medical Scribe Impact on Provider Efficiency in Outpatient Radiation Oncology Clinics Before and During the COVID-19 Pandemic

Purpose/Objectives: Medical documentation has become increasingly challenging for providers, particularly with changes to telemedicine visit formats during the ongoing COVID-19 pandemic. Medical scribes may help mitigate this burden. Our objective was to determine how scribes affect provider efficiency during the COVID-19 pandemic. Materials/Methods: Providers completed a survey in February 2020 (S1, prepandemic) and 1 year into the COVID-19 pandemic in February 2021 (S2, during pandemic). S1 evaluated perceived impact of scribes on clerical work, medical documentation, and efficiency during office visits using the Likert scale. S2 also addressed scribe use during telemedicine visits. Provider time spent on documentation with or without a scribe was evaluated using a five-level ordinal scale. Provider response was assessed using descriptive frequency statistics. Fisher's exact test was used to compare categorical variables. Analysis was performed using SAS version 9.4 (SAS Institute, Inc., Cary, NC). All tests were two sided with an alpha level of 0.05. Results: Fifty-eight providers responded to the surveys: 36 (62%) for S1 and 22 (38%) for S2. Scribe use decreased perceived clerical work and facilitated chart review, and recording of physical examination findings, note documentation, and improved efficiency, both before and during the pandemic (p = 0.5, p = 0.7, p = 0.8, p = 0.8, p = 0.9, respectively). Scribe use significantly decreased time to complete documentation prepandemic (p = 0.002) and during the pandemic for both in-person (p ≤ 0.0001) and telemedicine visits (p = 0.0004). More providers took >60 min to complete medical documentation without the use of a scribe prepandemic (72% vs. 30% with a scribe, p = 0.006) and during the pandemic, after both in-person (40% vs. 0% with a scribe, p = 0.002) and telemedicine visits (35% vs. 0% with a scribe, p = 0.002). Conclusions: Scribe use decreases provider time spent on medical documentation and improves overall efficiency before and during the COVID-19 pandemic for both in-person and telemedicine visits. Integration of scribes into radiation oncology in-person and telemedicine clinics may improve provider satisfaction by reducing burden of documentation.

Design and implementation of a cluster randomized trial measuring benefits of medical scribes in the VA

BACKGROUND

Medical scribes are trained professionals who assist health care providers by administratively expediting patient encounters. Section 507 of the MISSION Act of 2018 mandated a 2-year study of medical scribes in VA Medical Centers (VAMC). This study began in 2020 in the emergency departments and specialty clinics of 12 randomly selected VAMCs across the country, in which 48 scribes are being deployed.

METHODS

We are using a cluster randomized trial to assess the effects of medical scribes on productivity (visits and relative value units [RVUs]), wait times, and patient satisfaction in selected specialties within the VA that traditionally have high wait times. Scribes will be assigned to emergency departments and/or specialty clinics (cardiology, orthopedics) in VAMCs randomized into the intervention. Remaining sites that expressed interest but were not randomized to the intervention will be used as a comparison group.

RESULTS

Process measures from early implementation of the trial indicate that contracting may hold an advantage over direct hiring in terms of reaching staffing targets, although onboarding contractor scribes has taken somewhat longer (from job posting to start date).

CONCLUSIONS

Our evaluation findings will provide insight into whether scribes can increase provider productivity and decrease wait times for high demand specialties in the VA without adversely affecting patient satisfaction.

IMPLICATIONS

As a learning health care system, this trial has great potential to increase our understanding of the potential effects of scribes while also informing a real policy problem in high wait times and provider administrative burdens.

The Effect of Medical Scribes in Emergency Departments: A Systematic Review

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.

Five Years' Experience With a Medical Scribe Fellowship: Shaping Future Health Professions Students While Addressing Provider Burnout

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.

Medical and Undergraduate Student Perceptions on Scribing in an Emergency Department

Background 

A shift towards electronic medical records (EMR) has increased physician burnout and decreased physician satisfaction and productivity. One solution to alleviate EMR stressors is the implementation of medical scribes. Scribes have been shown to increase physician productivity and satisfaction. The study objective was to elucidate medical and undergraduate student scribing experience to determine if that experience can incentivize scribes to work in the emergency department.

Methods 

Ten students scribed and shadowed at a tertiary ED between July 4, 2019, and August 10, 2019. Medical students participated in two scribing and two non-scribing (shadowing) sessions, each lasting four hours. Undergraduate students only had a scribing condition. To facilitate scribing, a laptop with a wireless keyboard was provided, as well as a stand-up laptop tray. 

An exit survey and semi-structured interviews were conducted after the scribing experience. The majority of insights were extracted from interviews. Transcripts were coded into thematic coding trees and analyzed using thematic analysis. 

Results 

All undergraduate students preferred volunteering in the ED over other volunteer experiences. All undergraduates cited direct access to the medical field, resume building, and perceived value added to the health care team as motivators to continue scribing. Most students credited demystification of the medical profession as a motivator. Most medical students felt scribing should be integrated into their curriculum. Based on survey results, five undergraduate students would volunteer 40 hours/week.

Conclusion

Our study showed that a volunteer model of scribing is feasible. Importantly, scribing may be an invaluable experience for directing career goals and ensuring that students intrinsically interested in medicine pursue the profession. Although a volunteer model may not provide the desired benefit in terms of ED efficiency, it may be an integral part of training the next wave of physicians.

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

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.

Physician use of speech recognition versus typing in clinical documentation: A controlled observational study

IMPORTANCE

Speech recognition (SR) is increasingly used directly by clinicians for electronic health record (EHR) documentation. Its usability and effect on quality and efficiency versus other documentation methods remain unclear.

OBJECTIVE

To study usability and quality of documentation with SR versus typing.

DESIGN

In this controlled observational study, each subject participated in two of five simulated outpatient scenarios. Sessions were recorded with Morae® usability software. Two notes were documented into the EHR per encounter (one dictated, one typed) in randomized order. Participants were interviewed about each method's perceived advantages and disadvantages. Demographics and documentation habits were collected via survey. Data collection occurred between January 8 and February 8, 2019, and data analysis was conducted from February through September of 2019.

SETTING

Brigham and Women's Hospital, Boston, Massachusetts, USA.

PARTICIPANTS

Ten physicians who had used SR for at least six months.

MAIN OUTCOMES AND MEASURES

Documentation time, word count, vocabulary size, number of errors, number of corrections and quality (clarity, completeness, concision, information sufficiency and prioritization).

RESULTS

Dictated notes were longer than typed notes (320.6 vs. 180.8 words; p = 0.004) with more unique words (170.9 vs. 120.4; p = 0.01). Documentation time was similar between methods, with dictated notes taking slightly less time to complete than typed notes. Typed notes had more uncorrected errors per note than dictated notes (2.9 vs. 1.5), although most were minor misspellings. Dictated notes had a higher mean quality score (7.7 vs. 6.6; p = 0.04), were more complete and included more sufficient information.

CONCLUSIONS AND RELEVANCE

Participants felt that SR saves them time, increases their efficiency and allows them to quickly document more relevant details. Quality analysis supports the perception that SR allows for more detailed notes, but whether dictation is objectively faster than typing remains unclear, and participants described some scenarios where typing is still preferred. Dictation can be effective for creating comprehensive documentation, especially when physicians like and feel comfortable using SR. Research is needed to further improve integration of SR with EHR systems and assess its impact on clinical practice, workflows, provider and patient experience, and costs.

How does medical scribes' work inform development of speech-based clinical documentation technologies? A systematic review

OBJECTIVE

Use of medical scribes reduces clinician burnout by sharing the burden of clinical documentation. However, medical scribes are cost-prohibitive for most settings, prompting a growing interest in developing ambient, speech-based technologies capable of automatically generating clinical documentation based on patient-provider conversation. Through a systematic review, we aimed to develop a thorough understanding of the work performed by medical scribes in order to inform the design of such technologies.

MATERIALS AND METHODS

Relevant articles retrieved by searching in multiple literature databases. We conducted the screening process following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) in guidelines, and then analyzed the data using qualitative methods to identify recurring themes.

RESULTS

The literature search returned 854 results, 65 of which met the inclusion criteria. We found that there is significant variation in scribe expectations and responsibilities across healthcare organizations; scribes also frequently adapt their work based on the provider's style and preferences. Further, scribes' job extends far beyond capturing conversation in the exam room; they also actively interact with patients and the care team and integrate data from other sources such as prior charts and lab test results.

DISCUSSION

The results of this study provide several implications for designing technologies that can generate clinical documentation based on naturalistic conversations taking place in the exam room. First, a one-size-fits-all solution will be unlikely to work because of the significant variation in scribe work. Second, technology designers need to be aware of the limited role that their solution can fulfill. Third, to produce comprehensive clinical documentation, such technologies will likely have to incorporate information beyond the exam room conversation. Finally, issues of patient consent and privacy have yet to be adequately addressed, which could become paramount barriers to implementing such technologies in realistic clinical settings.

CONCLUSIONS

Medical scribes perform complex and delicate work. Further research is needed to better understand their roles in a clinical setting in order to inform the development of speech-based clinical documentation technologies.