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Can scribes reduce doctors’ job stress?
Physician stress and burnout remain major concerns for the U.S. health care system, with frustrations over the electronic health record (EHR) driving much of the dissatisfaction experienced by hospitalists and other physicians in the hospital.1 Underlying the EHR conundrum is a deeper question: Is entering clinical data on a computer the best use of a doctor’s time and professional skills? Or could a portion of that clerical function be delegated to nonphysicians?
Trained medical scribes, charting specialists who input EHR data for physicians on rounds, have been offered as a solution to potentially affect job stress for physicians and shorten their work days. But while scribes have been used and tested by different hospitalist groups around the country, the concept has not taken off in hospital medicine the way it has in certain other settings, such as emergency departments.
“The demand for scribes doesn’t seem to have materialized in a big way for hospital medicine,” said John Nelson, MD, MHM, a hospitalist and consultant in Bellevue, Wash., and a cofounder of the Society of Hospital Medicine. “I’m not convinced that scribes have had a big impact on hospitalist burnout.” It’s difficult to share scribes between doctors on a shift, and it’s a problem if the scribe and doctor get physically separated in the hospital. There’s also the question of who should pay the scribe’s salary, Dr. Nelson said.
Frustrations with the EHR can be a major factor in the experience of physician burnout, but Dr. Nelson said hospitalists can get proficient more quickly because they’re using the same computer system all day. “The bigger problem is that other doctors like surgeons don’t learn how to use the EHR and dump their routine tasks involving the EHR on the hospitalist, which means more work that is less satisfying.”
Could pairing a scribe with a hospitalist improve efficiency and decrease costs relative to the expense of employing the scribe? Are there specific settings, applications, and caseloads in hospital medicine where it makes more sense to use a scribe to support and assist doctors while they’re meeting with patients, with the doctor reviewing and editing the scribe’s work for accuracy? Could the scribe even help with physician staffing shortages by making doctors more productive?
TeamHealth, a national physician services company based in Knoxville, Tenn., has used scribes in emergency departments for years but had concluded that they made less sense for its hospitalist groups after a failure to document significant net increases in productivity, according to a 2015 report in The Hospitalist.2 Michael Corvini, MD, FACP, FACEP, TeamHealth’s new regional medical director for acute care services, said he brought extensive positive experience with scribes to his new job and is quite excited about their potential for hospital medicine. “When I came to TeamHealth in July, I began to suggest that there was unrealized potential for scribes,” he said.
Dr. Corvini noted that a potential benefit of scribes for patients is that their presence may allow for more face time with the doctor. Providers, relieved of worrying about completing the chart in its entirety would be more able to focus on the patient and critical thinking. There are even benefits for scribes themselves. Often scribes are medical students, and those who are interested in pursuing a future in the health professions gain invaluable experience in the workings of medicine. “They are making a real contribution to patient care. They are a member of the health care team,” he said.
Dr. Corvini sees two primary areas in which scribes can contribute to hospital medicine. The first is shadowing the physician who is admitting patients during a high-volume admissions shift. Regular tasks like capturing the patient’s medication list and populating the History and Physical document lend themselves well to data entry by scribes, in contrast to completing more routine daily progress notes, which does not.
“They can also be helpful when there is a major transition from paper charting to the EHR or from one EHR system to another, when there is a lot of stress on the physician and risk for lost billing revenue,” Dr. Corvini said. “If scribes are trained in a particular EHR, they could help teach the physician how to use it.” TeamHealth is now in the process of running a trial of scribes at one of its sites, and the organization plans to measure productivity, provider satisfaction, and HCAHPS patient satisfaction scores.
A workaround – or a problem solver?
In a 2015 Viewpoint article in JAMA,3 George Gellert, MD, MPH, MPA, former chief medical information officer for the CHRISTUS Santa Rosa health system in San Antonio, Texas, and his coauthors labeled the use of scribes as a “workaround” that could curtail efforts to make EHRs more functionally operational because their use allows physicians to be satisfied with inferior EHR products.
In an interview, Dr. Gellert stated that he hasn’t changed his views about the negative consequences of scribes on EHR improvement. “The work of clinicians in using and advancing EHR technology is presently the only method we have for massively distributing and ensuring the use of evidence-based medicine,” he said. “That in turn is a critical strategy for reducing high rates of medical errors through a variety of decision-support applications.”
For better or worse, EHRs are an essential part of the solution to the epidemic of preventable, medical error–caused patient deaths, Dr. Gellert said. He also believes that substantial progress has already been made in advancing EHR usability, as reflected in the most recent product releases by leading EHR companies. However, considerable evolution is still needed in both usability and optimization of clinical decision support.
“With respect to your readers, my recommendation is to not use medical scribes, or else delimit their use to only where absolutely required. Instead, develop systematic processes to regularly capture specific physician concerns with the EHR being used, and transmit that critical information to their EHR vendor with a clear expectation that the manufacturer will address the issue in the near term, or at least in their next major product iteration or generation,” Dr. Gellert said.
By contrast, at the Management of the Hospitalized Patient conference in San Francisco in October 2015, Christine Sinsky, MD, FACP, vice president for professional satisfaction at the American Medical Association, identified documentation assistance as a helpful intervention for physician stress and burnout.4 In a recent email, Dr. Sinsky called documentation assistance “the most powerful intervention to give patients the time, attention, and care they need from their physicians. The data entry and data retrieval work of health care has grown over the last decade. Sharing this work with nonphysicians allows society to get the most value for its investment in physicians’ training.”
Dr. Sinsky calls documentation assistance – such as that provided by medical scribes – “a logical and strategic delegation of work according to ability for greater value,” not a workaround. She said it makes patient care safer by allowing physicians to focus on medical decision making and relationship building – rather than record keeping.
Experience from the front lines
Eric Edwards, MD, FAAP, FHM, of the division of hospital medicine at the University of North Carolina’s Hillsborough Hospital campus, recently presented a poster on his group’s experience with medical scribes at a meeting of the North Carolina Triangle Chapter of SHM. Their research concluded that scribes can be successfully incorporated into an inpatient hospital medicine practice and thus increase provider satisfaction and decrease the time clinicians spend charting.
“We were able to get the support of the hospital administration to pilot the use of scribes 3 days per week, which we’ve now done for almost a year,” Dr. Edwards said. Scribes are employed through a local company, MedScribes, and they work alongside admitting hospitalists during their 10-hour shifts. The hospitalists have been overwhelmingly positive about their experience, he said. “We established that it saves the physician 15 minutes per patient encounter by helping with documentation.”
It’s important that the scribe gets to know an individual provider’s personal preferences, Dr. Edwards said. Some hospitalists create their own charting templates. There’s also a need to train the clinician in how to use the medical scribe. For example, physicians are instructed to call out physical findings during their exam, which simultaneously informs the patient while allowing the scribe to document the exam.
“We are working on getting more formal data about the scribe experience,” he added. “But we have found that our providers love it, and it improves their efficiency and productivity. The danger is if the physician becomes too reliant on the scribe and fails to exercise due diligence in reviewing the scribe’s notes to ensure that all relevant information is in the chart and irrelevant information is not. We need to make sure we are carefully reviewing and signing off on the scribe’s notes,” he explained.
“I think we’re years away from improving the EHR to the point that would allow us to call it doctor friendly,” Dr. Edwards said. “For now, the scribe is a great way to alleviate some of the physician’s burden. But for hospitalist groups to use scribes successfully, it can’t be done haphazardly. We are lucky to have an experienced local scribe company to partner with. They provide systematic training and orientation. It’s also important that scribes are trained in the specific EHR that they will be using.”
Christine Lum Lung, MD, SFHM, CEO and medical director of Northern Colorado Hospitalists, a hospital medicine group at the University of Colorado’s North Campus hospitals in Fort Collins, has been studying the use of scribes since 2014. “We had a gap in bringing on new doctors fast enough for our group’s needs, so I looked into the return on investment from scribes and pitched it to our group,” she said. “It’s difficult to say what has been the actual impact on caseload, but we all think it has reduced physician workdays by an hour or greater.”
The 32-member hospitalist group, which covers two facilities, has a designated director of scribes who periodically surveys the hospitalists’ satisfaction with the scribes. “Now we all embrace the use of scribes. Satisfaction is high, and quality of life has improved,” Dr. Lum Lung said. “It’s hard to quantify, but we feel like it helps with burnout for us to be able to leave work earlier, and it alleviates some of the other stresses in our workday.”
She said scribes are important to the medical team not just with managing the EHR but also with other burdens such as documenting compliance with code status, VTEs, and other quality requirements, and to help with other regulatory issues. Scribes can look up lab values and radiology reports. When there are downtimes, they can prepare discharge plans.
Typically, there are five scribes on duty for 18 hours a day at each hospital, Dr. Lum Lung said. But only those doctors primarily doing admissions are assured of having a scribe to round with them. “Most doctors in the group would say the greatest efficiency of scribes is with admitting,” she said. The company that provides scribes to the UC hospitals, ScribeAmerica, handles administration, training, and human resource issues, and the scribe team has a designated Lead Scribe and Quality Scribe at their facility.
Studying the benefits
Andrew Friedson, PhD, a health care economist at the University of Colorado in Denver, recently conducted a 9-month randomized experiment in three hospital emergency rooms in the Denver area to determine the effects of scribes on measures of emergency physician productivity.5 He found that scribes reduced patient wait times in the emergency department by about 13 minutes per patient, while greatly decreasing the amount of time physicians spent after a shift completing their charting, which thus lowered overtime costs for ED physicians.
“This is one of the first times medical scribes have been studied with a randomized, controlled trial,” Dr. Friedson said. “I tracked the amount of overtime, patient waiting, and charge capture for each encounter. These were hospitals where the emergency doctors weren’t allowed to go home until their charting was done.” He discovered that there was a large drop in the time between when patients arrived at the ED and when a decision was made regarding whether to admit them. Additionally, charge capture increased significantly, and physicians had more time to perform medical procedures. Dr. Friedson believes that his findings hold implications for other settings and medical groups, including hospital medicine. To the extent that scribes free up hospitalists to perform tasks other than charting, they should provide an efficiency benefit.
So why hasn’t the medical scribe caught on in a bigger way for hospitalists, compared with ED physicians? For Dr. Corvini, the ED is an obvious, high-pressure, high-volume setting where the cost of the scribe can be easily recouped. “That doesn’t exist in such an obvious fashion in hospital medicine, except where high-volume admissions are concentrated in a single physician’s caseload,” he said. Not all hospitalist groups will fit that model. Some may divide admissions between hospitalists on a shift, and others may not be large enough to experience significant caseload pressures.
“EDs are obviously time pressured, and once scribes demonstrate the ability to produce documentation in a high-quality fashion, they are quickly accepted. In hospital medicine, the time pressures are different – not necessarily less, but different,” Dr. Corvini said. There are also differences in physician responsibilities between the ED and hospital medicine, as well as in physicians’ willingness to let go of documentation responsibilities. “My prediction, if the scribe test is rolled out successfully in TeamHealth, with measurable benefits, it will be adopted in other settings where it fits.”
References
1. Shanafelt TD et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48.
2. Collins TR. Use of medical scribes spurs debate about costs, difficulties of electronic health records. The Hospitalist; 2015 Oct.
3. Gellert GA et al. The rise of the medical scribe industry: Implications for the advancement of electronic health records. JAMA; 2015;313(13):1315-6.
4. Beresford L. Electronic Health Records Key Driver of Physician Burnout. The Hospitalist; 2015 Dec.
5. Friedson AI. Medical scribes as an input in healthcare production: Evidence from a randomized experiment. Am J Health Econ. 2017 Oct 2. doi: /10.1162/ajhe_a_00103.
Can scribes reduce doctors’ job stress?
Can scribes reduce doctors’ job stress?
Physician stress and burnout remain major concerns for the U.S. health care system, with frustrations over the electronic health record (EHR) driving much of the dissatisfaction experienced by hospitalists and other physicians in the hospital.1 Underlying the EHR conundrum is a deeper question: Is entering clinical data on a computer the best use of a doctor’s time and professional skills? Or could a portion of that clerical function be delegated to nonphysicians?
Trained medical scribes, charting specialists who input EHR data for physicians on rounds, have been offered as a solution to potentially affect job stress for physicians and shorten their work days. But while scribes have been used and tested by different hospitalist groups around the country, the concept has not taken off in hospital medicine the way it has in certain other settings, such as emergency departments.
“The demand for scribes doesn’t seem to have materialized in a big way for hospital medicine,” said John Nelson, MD, MHM, a hospitalist and consultant in Bellevue, Wash., and a cofounder of the Society of Hospital Medicine. “I’m not convinced that scribes have had a big impact on hospitalist burnout.” It’s difficult to share scribes between doctors on a shift, and it’s a problem if the scribe and doctor get physically separated in the hospital. There’s also the question of who should pay the scribe’s salary, Dr. Nelson said.
Frustrations with the EHR can be a major factor in the experience of physician burnout, but Dr. Nelson said hospitalists can get proficient more quickly because they’re using the same computer system all day. “The bigger problem is that other doctors like surgeons don’t learn how to use the EHR and dump their routine tasks involving the EHR on the hospitalist, which means more work that is less satisfying.”
Could pairing a scribe with a hospitalist improve efficiency and decrease costs relative to the expense of employing the scribe? Are there specific settings, applications, and caseloads in hospital medicine where it makes more sense to use a scribe to support and assist doctors while they’re meeting with patients, with the doctor reviewing and editing the scribe’s work for accuracy? Could the scribe even help with physician staffing shortages by making doctors more productive?
TeamHealth, a national physician services company based in Knoxville, Tenn., has used scribes in emergency departments for years but had concluded that they made less sense for its hospitalist groups after a failure to document significant net increases in productivity, according to a 2015 report in The Hospitalist.2 Michael Corvini, MD, FACP, FACEP, TeamHealth’s new regional medical director for acute care services, said he brought extensive positive experience with scribes to his new job and is quite excited about their potential for hospital medicine. “When I came to TeamHealth in July, I began to suggest that there was unrealized potential for scribes,” he said.
Dr. Corvini noted that a potential benefit of scribes for patients is that their presence may allow for more face time with the doctor. Providers, relieved of worrying about completing the chart in its entirety would be more able to focus on the patient and critical thinking. There are even benefits for scribes themselves. Often scribes are medical students, and those who are interested in pursuing a future in the health professions gain invaluable experience in the workings of medicine. “They are making a real contribution to patient care. They are a member of the health care team,” he said.
Dr. Corvini sees two primary areas in which scribes can contribute to hospital medicine. The first is shadowing the physician who is admitting patients during a high-volume admissions shift. Regular tasks like capturing the patient’s medication list and populating the History and Physical document lend themselves well to data entry by scribes, in contrast to completing more routine daily progress notes, which does not.
“They can also be helpful when there is a major transition from paper charting to the EHR or from one EHR system to another, when there is a lot of stress on the physician and risk for lost billing revenue,” Dr. Corvini said. “If scribes are trained in a particular EHR, they could help teach the physician how to use it.” TeamHealth is now in the process of running a trial of scribes at one of its sites, and the organization plans to measure productivity, provider satisfaction, and HCAHPS patient satisfaction scores.
A workaround – or a problem solver?
In a 2015 Viewpoint article in JAMA,3 George Gellert, MD, MPH, MPA, former chief medical information officer for the CHRISTUS Santa Rosa health system in San Antonio, Texas, and his coauthors labeled the use of scribes as a “workaround” that could curtail efforts to make EHRs more functionally operational because their use allows physicians to be satisfied with inferior EHR products.
In an interview, Dr. Gellert stated that he hasn’t changed his views about the negative consequences of scribes on EHR improvement. “The work of clinicians in using and advancing EHR technology is presently the only method we have for massively distributing and ensuring the use of evidence-based medicine,” he said. “That in turn is a critical strategy for reducing high rates of medical errors through a variety of decision-support applications.”
For better or worse, EHRs are an essential part of the solution to the epidemic of preventable, medical error–caused patient deaths, Dr. Gellert said. He also believes that substantial progress has already been made in advancing EHR usability, as reflected in the most recent product releases by leading EHR companies. However, considerable evolution is still needed in both usability and optimization of clinical decision support.
“With respect to your readers, my recommendation is to not use medical scribes, or else delimit their use to only where absolutely required. Instead, develop systematic processes to regularly capture specific physician concerns with the EHR being used, and transmit that critical information to their EHR vendor with a clear expectation that the manufacturer will address the issue in the near term, or at least in their next major product iteration or generation,” Dr. Gellert said.
By contrast, at the Management of the Hospitalized Patient conference in San Francisco in October 2015, Christine Sinsky, MD, FACP, vice president for professional satisfaction at the American Medical Association, identified documentation assistance as a helpful intervention for physician stress and burnout.4 In a recent email, Dr. Sinsky called documentation assistance “the most powerful intervention to give patients the time, attention, and care they need from their physicians. The data entry and data retrieval work of health care has grown over the last decade. Sharing this work with nonphysicians allows society to get the most value for its investment in physicians’ training.”
Dr. Sinsky calls documentation assistance – such as that provided by medical scribes – “a logical and strategic delegation of work according to ability for greater value,” not a workaround. She said it makes patient care safer by allowing physicians to focus on medical decision making and relationship building – rather than record keeping.
Experience from the front lines
Eric Edwards, MD, FAAP, FHM, of the division of hospital medicine at the University of North Carolina’s Hillsborough Hospital campus, recently presented a poster on his group’s experience with medical scribes at a meeting of the North Carolina Triangle Chapter of SHM. Their research concluded that scribes can be successfully incorporated into an inpatient hospital medicine practice and thus increase provider satisfaction and decrease the time clinicians spend charting.
“We were able to get the support of the hospital administration to pilot the use of scribes 3 days per week, which we’ve now done for almost a year,” Dr. Edwards said. Scribes are employed through a local company, MedScribes, and they work alongside admitting hospitalists during their 10-hour shifts. The hospitalists have been overwhelmingly positive about their experience, he said. “We established that it saves the physician 15 minutes per patient encounter by helping with documentation.”
It’s important that the scribe gets to know an individual provider’s personal preferences, Dr. Edwards said. Some hospitalists create their own charting templates. There’s also a need to train the clinician in how to use the medical scribe. For example, physicians are instructed to call out physical findings during their exam, which simultaneously informs the patient while allowing the scribe to document the exam.
“We are working on getting more formal data about the scribe experience,” he added. “But we have found that our providers love it, and it improves their efficiency and productivity. The danger is if the physician becomes too reliant on the scribe and fails to exercise due diligence in reviewing the scribe’s notes to ensure that all relevant information is in the chart and irrelevant information is not. We need to make sure we are carefully reviewing and signing off on the scribe’s notes,” he explained.
“I think we’re years away from improving the EHR to the point that would allow us to call it doctor friendly,” Dr. Edwards said. “For now, the scribe is a great way to alleviate some of the physician’s burden. But for hospitalist groups to use scribes successfully, it can’t be done haphazardly. We are lucky to have an experienced local scribe company to partner with. They provide systematic training and orientation. It’s also important that scribes are trained in the specific EHR that they will be using.”
Christine Lum Lung, MD, SFHM, CEO and medical director of Northern Colorado Hospitalists, a hospital medicine group at the University of Colorado’s North Campus hospitals in Fort Collins, has been studying the use of scribes since 2014. “We had a gap in bringing on new doctors fast enough for our group’s needs, so I looked into the return on investment from scribes and pitched it to our group,” she said. “It’s difficult to say what has been the actual impact on caseload, but we all think it has reduced physician workdays by an hour or greater.”
The 32-member hospitalist group, which covers two facilities, has a designated director of scribes who periodically surveys the hospitalists’ satisfaction with the scribes. “Now we all embrace the use of scribes. Satisfaction is high, and quality of life has improved,” Dr. Lum Lung said. “It’s hard to quantify, but we feel like it helps with burnout for us to be able to leave work earlier, and it alleviates some of the other stresses in our workday.”
She said scribes are important to the medical team not just with managing the EHR but also with other burdens such as documenting compliance with code status, VTEs, and other quality requirements, and to help with other regulatory issues. Scribes can look up lab values and radiology reports. When there are downtimes, they can prepare discharge plans.
Typically, there are five scribes on duty for 18 hours a day at each hospital, Dr. Lum Lung said. But only those doctors primarily doing admissions are assured of having a scribe to round with them. “Most doctors in the group would say the greatest efficiency of scribes is with admitting,” she said. The company that provides scribes to the UC hospitals, ScribeAmerica, handles administration, training, and human resource issues, and the scribe team has a designated Lead Scribe and Quality Scribe at their facility.
Studying the benefits
Andrew Friedson, PhD, a health care economist at the University of Colorado in Denver, recently conducted a 9-month randomized experiment in three hospital emergency rooms in the Denver area to determine the effects of scribes on measures of emergency physician productivity.5 He found that scribes reduced patient wait times in the emergency department by about 13 minutes per patient, while greatly decreasing the amount of time physicians spent after a shift completing their charting, which thus lowered overtime costs for ED physicians.
“This is one of the first times medical scribes have been studied with a randomized, controlled trial,” Dr. Friedson said. “I tracked the amount of overtime, patient waiting, and charge capture for each encounter. These were hospitals where the emergency doctors weren’t allowed to go home until their charting was done.” He discovered that there was a large drop in the time between when patients arrived at the ED and when a decision was made regarding whether to admit them. Additionally, charge capture increased significantly, and physicians had more time to perform medical procedures. Dr. Friedson believes that his findings hold implications for other settings and medical groups, including hospital medicine. To the extent that scribes free up hospitalists to perform tasks other than charting, they should provide an efficiency benefit.
So why hasn’t the medical scribe caught on in a bigger way for hospitalists, compared with ED physicians? For Dr. Corvini, the ED is an obvious, high-pressure, high-volume setting where the cost of the scribe can be easily recouped. “That doesn’t exist in such an obvious fashion in hospital medicine, except where high-volume admissions are concentrated in a single physician’s caseload,” he said. Not all hospitalist groups will fit that model. Some may divide admissions between hospitalists on a shift, and others may not be large enough to experience significant caseload pressures.
“EDs are obviously time pressured, and once scribes demonstrate the ability to produce documentation in a high-quality fashion, they are quickly accepted. In hospital medicine, the time pressures are different – not necessarily less, but different,” Dr. Corvini said. There are also differences in physician responsibilities between the ED and hospital medicine, as well as in physicians’ willingness to let go of documentation responsibilities. “My prediction, if the scribe test is rolled out successfully in TeamHealth, with measurable benefits, it will be adopted in other settings where it fits.”
References
1. Shanafelt TD et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48.
2. Collins TR. Use of medical scribes spurs debate about costs, difficulties of electronic health records. The Hospitalist; 2015 Oct.
3. Gellert GA et al. The rise of the medical scribe industry: Implications for the advancement of electronic health records. JAMA; 2015;313(13):1315-6.
4. Beresford L. Electronic Health Records Key Driver of Physician Burnout. The Hospitalist; 2015 Dec.
5. Friedson AI. Medical scribes as an input in healthcare production: Evidence from a randomized experiment. Am J Health Econ. 2017 Oct 2. doi: /10.1162/ajhe_a_00103.
Physician stress and burnout remain major concerns for the U.S. health care system, with frustrations over the electronic health record (EHR) driving much of the dissatisfaction experienced by hospitalists and other physicians in the hospital.1 Underlying the EHR conundrum is a deeper question: Is entering clinical data on a computer the best use of a doctor’s time and professional skills? Or could a portion of that clerical function be delegated to nonphysicians?
Trained medical scribes, charting specialists who input EHR data for physicians on rounds, have been offered as a solution to potentially affect job stress for physicians and shorten their work days. But while scribes have been used and tested by different hospitalist groups around the country, the concept has not taken off in hospital medicine the way it has in certain other settings, such as emergency departments.
“The demand for scribes doesn’t seem to have materialized in a big way for hospital medicine,” said John Nelson, MD, MHM, a hospitalist and consultant in Bellevue, Wash., and a cofounder of the Society of Hospital Medicine. “I’m not convinced that scribes have had a big impact on hospitalist burnout.” It’s difficult to share scribes between doctors on a shift, and it’s a problem if the scribe and doctor get physically separated in the hospital. There’s also the question of who should pay the scribe’s salary, Dr. Nelson said.
Frustrations with the EHR can be a major factor in the experience of physician burnout, but Dr. Nelson said hospitalists can get proficient more quickly because they’re using the same computer system all day. “The bigger problem is that other doctors like surgeons don’t learn how to use the EHR and dump their routine tasks involving the EHR on the hospitalist, which means more work that is less satisfying.”
Could pairing a scribe with a hospitalist improve efficiency and decrease costs relative to the expense of employing the scribe? Are there specific settings, applications, and caseloads in hospital medicine where it makes more sense to use a scribe to support and assist doctors while they’re meeting with patients, with the doctor reviewing and editing the scribe’s work for accuracy? Could the scribe even help with physician staffing shortages by making doctors more productive?
TeamHealth, a national physician services company based in Knoxville, Tenn., has used scribes in emergency departments for years but had concluded that they made less sense for its hospitalist groups after a failure to document significant net increases in productivity, according to a 2015 report in The Hospitalist.2 Michael Corvini, MD, FACP, FACEP, TeamHealth’s new regional medical director for acute care services, said he brought extensive positive experience with scribes to his new job and is quite excited about their potential for hospital medicine. “When I came to TeamHealth in July, I began to suggest that there was unrealized potential for scribes,” he said.
Dr. Corvini noted that a potential benefit of scribes for patients is that their presence may allow for more face time with the doctor. Providers, relieved of worrying about completing the chart in its entirety would be more able to focus on the patient and critical thinking. There are even benefits for scribes themselves. Often scribes are medical students, and those who are interested in pursuing a future in the health professions gain invaluable experience in the workings of medicine. “They are making a real contribution to patient care. They are a member of the health care team,” he said.
Dr. Corvini sees two primary areas in which scribes can contribute to hospital medicine. The first is shadowing the physician who is admitting patients during a high-volume admissions shift. Regular tasks like capturing the patient’s medication list and populating the History and Physical document lend themselves well to data entry by scribes, in contrast to completing more routine daily progress notes, which does not.
“They can also be helpful when there is a major transition from paper charting to the EHR or from one EHR system to another, when there is a lot of stress on the physician and risk for lost billing revenue,” Dr. Corvini said. “If scribes are trained in a particular EHR, they could help teach the physician how to use it.” TeamHealth is now in the process of running a trial of scribes at one of its sites, and the organization plans to measure productivity, provider satisfaction, and HCAHPS patient satisfaction scores.
A workaround – or a problem solver?
In a 2015 Viewpoint article in JAMA,3 George Gellert, MD, MPH, MPA, former chief medical information officer for the CHRISTUS Santa Rosa health system in San Antonio, Texas, and his coauthors labeled the use of scribes as a “workaround” that could curtail efforts to make EHRs more functionally operational because their use allows physicians to be satisfied with inferior EHR products.
In an interview, Dr. Gellert stated that he hasn’t changed his views about the negative consequences of scribes on EHR improvement. “The work of clinicians in using and advancing EHR technology is presently the only method we have for massively distributing and ensuring the use of evidence-based medicine,” he said. “That in turn is a critical strategy for reducing high rates of medical errors through a variety of decision-support applications.”
For better or worse, EHRs are an essential part of the solution to the epidemic of preventable, medical error–caused patient deaths, Dr. Gellert said. He also believes that substantial progress has already been made in advancing EHR usability, as reflected in the most recent product releases by leading EHR companies. However, considerable evolution is still needed in both usability and optimization of clinical decision support.
“With respect to your readers, my recommendation is to not use medical scribes, or else delimit their use to only where absolutely required. Instead, develop systematic processes to regularly capture specific physician concerns with the EHR being used, and transmit that critical information to their EHR vendor with a clear expectation that the manufacturer will address the issue in the near term, or at least in their next major product iteration or generation,” Dr. Gellert said.
By contrast, at the Management of the Hospitalized Patient conference in San Francisco in October 2015, Christine Sinsky, MD, FACP, vice president for professional satisfaction at the American Medical Association, identified documentation assistance as a helpful intervention for physician stress and burnout.4 In a recent email, Dr. Sinsky called documentation assistance “the most powerful intervention to give patients the time, attention, and care they need from their physicians. The data entry and data retrieval work of health care has grown over the last decade. Sharing this work with nonphysicians allows society to get the most value for its investment in physicians’ training.”
Dr. Sinsky calls documentation assistance – such as that provided by medical scribes – “a logical and strategic delegation of work according to ability for greater value,” not a workaround. She said it makes patient care safer by allowing physicians to focus on medical decision making and relationship building – rather than record keeping.
Experience from the front lines
Eric Edwards, MD, FAAP, FHM, of the division of hospital medicine at the University of North Carolina’s Hillsborough Hospital campus, recently presented a poster on his group’s experience with medical scribes at a meeting of the North Carolina Triangle Chapter of SHM. Their research concluded that scribes can be successfully incorporated into an inpatient hospital medicine practice and thus increase provider satisfaction and decrease the time clinicians spend charting.
“We were able to get the support of the hospital administration to pilot the use of scribes 3 days per week, which we’ve now done for almost a year,” Dr. Edwards said. Scribes are employed through a local company, MedScribes, and they work alongside admitting hospitalists during their 10-hour shifts. The hospitalists have been overwhelmingly positive about their experience, he said. “We established that it saves the physician 15 minutes per patient encounter by helping with documentation.”
It’s important that the scribe gets to know an individual provider’s personal preferences, Dr. Edwards said. Some hospitalists create their own charting templates. There’s also a need to train the clinician in how to use the medical scribe. For example, physicians are instructed to call out physical findings during their exam, which simultaneously informs the patient while allowing the scribe to document the exam.
“We are working on getting more formal data about the scribe experience,” he added. “But we have found that our providers love it, and it improves their efficiency and productivity. The danger is if the physician becomes too reliant on the scribe and fails to exercise due diligence in reviewing the scribe’s notes to ensure that all relevant information is in the chart and irrelevant information is not. We need to make sure we are carefully reviewing and signing off on the scribe’s notes,” he explained.
“I think we’re years away from improving the EHR to the point that would allow us to call it doctor friendly,” Dr. Edwards said. “For now, the scribe is a great way to alleviate some of the physician’s burden. But for hospitalist groups to use scribes successfully, it can’t be done haphazardly. We are lucky to have an experienced local scribe company to partner with. They provide systematic training and orientation. It’s also important that scribes are trained in the specific EHR that they will be using.”
Christine Lum Lung, MD, SFHM, CEO and medical director of Northern Colorado Hospitalists, a hospital medicine group at the University of Colorado’s North Campus hospitals in Fort Collins, has been studying the use of scribes since 2014. “We had a gap in bringing on new doctors fast enough for our group’s needs, so I looked into the return on investment from scribes and pitched it to our group,” she said. “It’s difficult to say what has been the actual impact on caseload, but we all think it has reduced physician workdays by an hour or greater.”
The 32-member hospitalist group, which covers two facilities, has a designated director of scribes who periodically surveys the hospitalists’ satisfaction with the scribes. “Now we all embrace the use of scribes. Satisfaction is high, and quality of life has improved,” Dr. Lum Lung said. “It’s hard to quantify, but we feel like it helps with burnout for us to be able to leave work earlier, and it alleviates some of the other stresses in our workday.”
She said scribes are important to the medical team not just with managing the EHR but also with other burdens such as documenting compliance with code status, VTEs, and other quality requirements, and to help with other regulatory issues. Scribes can look up lab values and radiology reports. When there are downtimes, they can prepare discharge plans.
Typically, there are five scribes on duty for 18 hours a day at each hospital, Dr. Lum Lung said. But only those doctors primarily doing admissions are assured of having a scribe to round with them. “Most doctors in the group would say the greatest efficiency of scribes is with admitting,” she said. The company that provides scribes to the UC hospitals, ScribeAmerica, handles administration, training, and human resource issues, and the scribe team has a designated Lead Scribe and Quality Scribe at their facility.
Studying the benefits
Andrew Friedson, PhD, a health care economist at the University of Colorado in Denver, recently conducted a 9-month randomized experiment in three hospital emergency rooms in the Denver area to determine the effects of scribes on measures of emergency physician productivity.5 He found that scribes reduced patient wait times in the emergency department by about 13 minutes per patient, while greatly decreasing the amount of time physicians spent after a shift completing their charting, which thus lowered overtime costs for ED physicians.
“This is one of the first times medical scribes have been studied with a randomized, controlled trial,” Dr. Friedson said. “I tracked the amount of overtime, patient waiting, and charge capture for each encounter. These were hospitals where the emergency doctors weren’t allowed to go home until their charting was done.” He discovered that there was a large drop in the time between when patients arrived at the ED and when a decision was made regarding whether to admit them. Additionally, charge capture increased significantly, and physicians had more time to perform medical procedures. Dr. Friedson believes that his findings hold implications for other settings and medical groups, including hospital medicine. To the extent that scribes free up hospitalists to perform tasks other than charting, they should provide an efficiency benefit.
So why hasn’t the medical scribe caught on in a bigger way for hospitalists, compared with ED physicians? For Dr. Corvini, the ED is an obvious, high-pressure, high-volume setting where the cost of the scribe can be easily recouped. “That doesn’t exist in such an obvious fashion in hospital medicine, except where high-volume admissions are concentrated in a single physician’s caseload,” he said. Not all hospitalist groups will fit that model. Some may divide admissions between hospitalists on a shift, and others may not be large enough to experience significant caseload pressures.
“EDs are obviously time pressured, and once scribes demonstrate the ability to produce documentation in a high-quality fashion, they are quickly accepted. In hospital medicine, the time pressures are different – not necessarily less, but different,” Dr. Corvini said. There are also differences in physician responsibilities between the ED and hospital medicine, as well as in physicians’ willingness to let go of documentation responsibilities. “My prediction, if the scribe test is rolled out successfully in TeamHealth, with measurable benefits, it will be adopted in other settings where it fits.”
References
1. Shanafelt TD et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48.
2. Collins TR. Use of medical scribes spurs debate about costs, difficulties of electronic health records. The Hospitalist; 2015 Oct.
3. Gellert GA et al. The rise of the medical scribe industry: Implications for the advancement of electronic health records. JAMA; 2015;313(13):1315-6.
4. Beresford L. Electronic Health Records Key Driver of Physician Burnout. The Hospitalist; 2015 Dec.
5. Friedson AI. Medical scribes as an input in healthcare production: Evidence from a randomized experiment. Am J Health Econ. 2017 Oct 2. doi: /10.1162/ajhe_a_00103.