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American Association for Physician Leadership
American Association for Physician Leadership

Scribes and Efficiency in the Medical Workplace

by Janis Coffin, DO, FAAFP, FACMPE | Callista Eckert | Ashkon Nehzati

June 8, 2020


Summary:

Medical scribes follow physicians around in their individual fields of practice, keeping detailed notes of every patient, their background, and their diagnosis at the end of the visit. The physician still signs patients out after reviewing each chart that the scribe has written, but the scribe is responsible for the note and ensuring that all appropriate information that the physician discussed has been documented. Scribes are essentially shadows that offer a way for physicians to focus more on their patients than on the paperwork that is often done in the patient’s room during that patient’s visit.



Medical scribes follow physicians around in their individual fields of practice, keeping detailed notes of every patient, their background, and their diagnosis at the end of the visit. The physician still signs patients out after reviewing each chart that the scribe has written, but the scribe is responsible for the note and ensuring that all appropriate information that the physician discussed has been documented. Scribes are essentially shadows that offer a way for physicians to focus more on their patients than on the paperwork that is often done in the patient’s room during that patient’s visit.

Charting is one of the most commonly cited reasons for physician burnout.

The amount of charting required in any medical workplace is staggering. With new technology that keeps EHRs online, the amount of information entered into these charts shows everything that the doctor needs to know for diagnosis. However, charting is one of the most commonly cited reasons for physician burnout.1 The term burnout refers to the feeling of mental, emotional, physical, and sometimes spiritual tiredness that results in a lack of drive or passion for one to complete tasks that they have done for years. Although EHRs are a good way to keep track of patients and, eventually, to bill them, physicians have to spend hours inputting information, long after the patient is gone.

A study performed from July 2016 to June 2017 showed that scribes reduced documentation burden, along with professional burnout, on the part of physicians.2 The study found that scribes significantly reduced the amount of time a physician spent on EHR documentation and contributed to increased patient and physician face-to-face time. Scribes gave the physician freedom to speak to the patient directly instead of typing on the computer in the exam room, which increased time with the patient by 75%. Most of the practicing physicians in the study (88%) reported that they were satisfied with a scribe working with them. Although the number of physicians surveyed was 18, that low number could be attributed to the low level of use of scribes worldwide. More surveys must be conducted to further investigate this study’s findings.

In one study, physicians were assigned a week with and a week without a scribe.3 At the end of the trial, overall physician satisfaction was higher during the week when they worked with a scribe. Scribes assisted with paperwork, increasing time efficiency for the physician. This allowed the physicians to spend more one-on-one time with their patients, where they claimed they felt more like doctors again.

With the use of scribes, patient care can improve, which will lead to an overall increase in providers’ satisfaction with the medical field.

These two studies suggest that the use of scribes positively affects the medical workplace. As discussed previously, this can lead to a reduction in physician burnout. Patients feel as though their physicians spend more time with them, focusing on what they need instead of typing away at a computer. With the use of scribes, patient care can improve, which will lead to an overall increase in providers’ satisfaction with the medical field.

There are a few drawbacks to using scribes. Some clinics are deterred from hiring them by the cost of training them. However, in one study, a 7.7% increase in the number of patients seen was observed after scribes were hired.4 The scribes helped increase the total billable hours for the clinic, which can balance out whatever costs were incurred in order to train them.

Another potential drawback of hiring scribes is the training time. Physicians who self-hire scribes might take longer to teach them the system and how to chart correctly. Some practices use hiring companies such as ScribeAmerica to ensure that the scribes have been trained before they are allowed to work with the physician on their own. Time spent on training scribes might not seem worth it, because many scribes are using the job as a stepping stone for another career in medicine, such as getting into medical or nursing school and, as a result, scribe turnover is high because of this. However, as discussed previously, the time spent on training scribes can pay out in the end.

Even when scribes come to a practice already trained, they do not always fully understand the clinical nuances of selecting various review of systems and physical exam findings. This issue arises from limited selection boxes in various EHRs as well as misunderstanding on the part of the scribe. If a patient comes into the emergency department inebriated and not willing to answer questions during the patient interview, the scribe might choose “lethargic” under the category “constitutional” for review of systems or physical exam. Further clinical training would help the scribe realize that this is not an appropriate representation of the patient, and the incorrect choice could imply that the patient is worse off than the scribe intended to indicate. During busy nights in the emergency department, review of these charts by physicians can become more a glance rather than a studied reading. Button clicks such as this example often can go overlooked and, if brought up during litigation, can lead to more trouble for physicians than if they had written the chart themselves.

Scribes are limited in what duties are included in their job, depending on the physician, clinic, or hospital policies. Many companies implement policies that prevent scribes from ever touching a patient and helping hospital staff, even in times of need or an emergency. Scribes are not medically trained, so they should not be allowed to touch patients. They are only allowed to chart, preventing them from entering orders for prescriptions, imaging, or laboratory tests. Physicians need to take this into account before deciding whether using a scribe is the right choice for them. Although many find this acceptable, smaller or understaffed clinics may not be able to afford to hire an individual with a single responsibility.

One of the least talked-about aspects of scribing is the ability for well-seasoned scribes to start templating portions of their charts. This practice is rather frowned upon, because it decreases tailoring of the chart for each patient. Various EHR systems have implemented features to allow templates that preselect button clicks for review of systems and physical exam. Scribes can template charts to meet billing requirements or to speed up inputting information. These practices need to be addressed ahead of time by the physician to ensure the scribe does not do this just for the sake of saving time. Templating charts can add an additional burden to the physician reviewing multiple charts at the end of the day, requiring the physician to ensure that pertinent positives and negatives have been appropriately added for each patient.

The Triple Aim, intended to optimize healthcare system performances,3 is used within healthcare systems to redirect focus onto three goals: improving patient care; reducing medical costs; and improving population health. Teamwork is strongly emphasized in order to achieve each of these goals. However, physician burnout is cited as one of the biggest obstacles to achieving all three goals. More expectations are placed on physicians, which increases the likelihood of physician burnout. With the introduction of scribes, teamwork is increased, and physicians are allowed to move some of the responsibility onto the scribes. In turn, physician burnout is decreased, and the goals of the Triple Aim can be met with fewer obstacles. This Triple Aim improves many aspects of the performance of medical clinics, as well as the lives of physicians. Scribes can only increase the chances of Triple Aim goals being met within various medical professions.

The Fourth Aim, improvement of the clinician’s experience, is hoped to be achieved after the Triple Aim is met (Figure 1).5 This fourth aim is the attempt to improve the lives of physicians and clinical staff. One of the ways that has been recommended to accomplish this is team documentation, a process that can be made easier on both staff and physicians by the introduction of scribes in the workplace. If medical clinics can achieve the Triple Aim and then increase their productivity to achieve the fourth aim, those clinics will improve in many departments. These goals can be achieved through the use of scribes in the workplace.

The Quadruple Aim of medical clinics

Figure 1. The Quadruple Aim of medical clinics.

Personal Accounts

Report from a Physician

Dan Smith,6 a practicing physician, wrote an article that details his own viewpoints on how scribes can be a positive addition to the medical workplace. His main goal, like all physicians, is to take care of his patients. He states that the use of EHRs makes taking care of patients more challenging, because the systems are not completely reliable in their usage. He finds the EHR a great way to keep track of patient paperwork, but inputting information and the time it takes is overwhelming. Smith credits the use of scribes as a way to decrease the workload and manage time better at work. He does caution against hiring scribes without planning for training and initial costs.

Report from a Working Scribe

As a part-time working scribe, I [author CE] have seen a number of ways scribes can benefit physicians in the emergency room, a setting that can become chaotic at a moment’s notice. Physicians and physician assistants work in tandem in order to see and diagnose patients as efficiently as they can. As a scribe, I help the physician reduce the amount of paperwork he or she has to go through in a night. The physician reads over every chart that I create to ensure that I properly documented everything. Observing other physicians and medical professionals who do not have scribes has led me to agree that the use of scribes has a positive effect, because I see how much work I help with when the physician is not seeing patients. Physicians who do not have a scribe often have to spend hours in the emergency room after their shift is over in order to complete their paperwork. I can see how a couple hours of additional work after every shift can lead to burnout rather quickly.

Conclusion

The use of scribes in the medical field is becoming more common. They can reduce the amount of paperwork a physician has to do and improve the quality of care between physician and patient. As a result, the number of scribes employed across different medical specialties is increasing.3 Although more research is still required on how hiring scribes can positively affect all medical fields, the current research is showing that scribes are helping physicians, in turn, help patients.

Take-Home Points for Practicing Physicians

Scribes are an investment that has been shown to increase the number of patients seen, increasing the overall efficiency of any particular practice. The studies mentioned in this article have suggested that patients are more pleased with the increased face-to-face interactions with the physician, due to decreased time in front of a computer. Overall, scribes can increase workplace efficiency in the medical field, improving physician and patient experience by taking some of the burden off the physicians, and allowing them to focus solely on their patients.

References

1.    The Clinical Documentation Conundrum. HealthLeaders.com.
www.healthleadersmedia.com/innovation/clinical-documentation-conundrum. Accessed January 30, 2020.

2.    Cheney C. Scribes Slash EHR Physician EHR Burden, Boost Efficiency, Improve Patient Visits. HealthLeaders.com. www.healthleadersmedia.com/clinical-care/scribes-slash-physician-ehr-burden-boost-efficiency-improve-patient-visits. Accessed January 30, 2020.

3.    Gidwani R, Nguyen C, Kofoed A, et al. Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial. Ann Fam Med. 2017;15:427-433. www.ncbi.nlm.nih.gov/pmc/articles/PMC5593725/. Accessed January 30, 2020.

4.    Robeznieks A. The overlooked benefits of medical scribes. AMA.
www.ama-assn.org/practice-management/sustainability/overlooked-benefits-medical-scribes. Accessed January 30, 2020.

5.    ACTS supports the Quadruple Aim. Agency for Healthcare Research and Quality.
https://digital.ahrq.gov/acts/quadruple-aim. Accessed January 30, 2020.

6.    Smith D. Use scribes to improve efficiency and reduce burnout. Becker’s Hospital Review. June 19, 2018. www.beckershospitalreview.com/hospital-physician-relationships/use-scribes-to-improve-efficiency-and-reduce-burnout.html. Accessed January 30, 2020.


Janis Coffin, DO, FAAFP, FACMPE

Chief Transformation Officer, Augusta University, 1120 15th St HB 3042, Augusta, GA 30912; e-mail: jcoffin@augusta.edu.




Callista Eckert

Third Year Medical Student, Kansas City University, Kansas City, Missouri




Ashkon Nehzati

Third Year Medical Student, Kansas City University, Kansas City, Missouri



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