The Use of Medical Scribes in Health Care Settings
The Use of Medical Scribes in Health Care Settings
Background Electronic health records (EHRs) hold promise to improve productivity, quality, and outcomes; however, using EHRs can be cumbersome, disruptive to workflow, and off-putting to patients and clinicians. One proposed solution to this problem is the use of medical scribes. The purpose of this systematic review is to summarize the literature investigating the effect of medical scribes on health care productivity, quality, and outcomes. Implications for future research are discussed.
Methods A keyword search of the Cochrane Library, OvidSP Medline database, and Embase database from January 2000 through September 2014 was performed using the terms scribe or scribes in the title or abstract. To ensure no potentially eligible articles were missed, a second search was done using Google Scholar. English-language, peer-reviewed studies assessing the effect of medical scribes on health care productivity, quality, and outcomes were retained. Identified studies were assessed and the findings reported.
Results Five studies were identified. Three studies assessed scribe use in an emergency department, 1 in a cardiology clinic, and 1 in a urology clinic. Two of 3 studies reported scribes had no effect on patient satisfaction; 2 of 2 reported improved clinician satisfaction; 2 of 3 reported an increase in the number of patients; 2 of 2 reported an increase in the number of relative value units per hour; 1 of 1 reported increased revenue; 3 of 4 reported improved time-related efficiencies; and 1 of 1 reported improved patient-clinician interactions.
Conclusions Available evidence suggests medical scribes may improve clinician satisfaction, productivity, time-related efficiencies, revenue, and patient–clinician interactions. Because the number of studies is small, and because each study suffered important limitations, confidence in the reliability of the evidence is significantly constrained. Given the nascent state of the science, methodologically rigorous and sufficiently powered studies are greatly needed.
Electronic health records (EHRs) are frequently recognized as a promising tool to help improve health care quality, safety, outcomes, and productivity. In the United States (US), the Health Information Technology for Economic and Clinical Health Act of 2009 established incentive programs to promote meaningful use of EHRs within primary care and other health care settings. As of 2012, 72% of US office-based physicians described using some type of EHR or electronic medical record system: 40% described using a basic EHR system, and 24% reported a fully functional system. Among US general, acute care hospitals in 2012, 27% reported using a basic EHR system and 17% reported a comprehensive system. By 2019, an estimated 80% of physicians in large group practices, 65% in small group practices, and 66% of all other specialists are expected to have achieved meaningful use.
Emerging evidence indicates there may be important advantages to EHR adoption, including structural- and process-related benefits and enhanced patient care. Despite their promise to improve clinic-related efficiencies, recent findings indicate EHRs can, over the short-term, reduce productivity while at the same time add to expenses. While productivity is likely to recover after clinicians and support staff acclimate to the system, clinician engagement and administrative practice issues remain as commonly identified problems.
Many physicians describe challenges with the current state of the technology: EHRs can be difficult to use, time consuming, inefficient, disruptive to face-to-face encounters with patients, and a hindrance to the clinical documentation process. These challenges may be especially pronounced among those who lack support to help manage the flow of information. Difficulty associated with the usability of EHRs remains an important source of professional dissatisfaction; early adopters report the technology can at times interfere with communication during visits and patient–clinician eye contact. Evidence suggests some physicians using EHRs may also engage patients in fewer physician-initiated gaze patterns (signaling a lack of attention toward the patient), and that EHR use may contribute to a sense of separation among some patients when the EHR monitor is kept away from the patient's view. In response to concerns like these, a recently published primary care consensus statement concluded that many EHR systems need marked refinement to promote greater patient engagement.
One proposed solution to improve patient engagement and the flow of information while using EHRs during the clinical encounter is the use of medical scribes. While the roles of scribes can vary based on the nuances of a given clinical setting, in general scribes are personnel specifically hired to chart patient–clinician encounters in real time, from the beginning of the encounter to its end. As defined by the Joint Commission:
A scribe is an unlicensed person hired to enter information into the EHR or chart at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant). It is the Joint Commission's stand that the scribe does not and may not act independently but can document the previously determined physician's or practitioner's dictation and/or activities.
Many personnel types with different levels of training can work as a medical scribe, including nursing, medical students, or individuals whose only medical training is limited to that of being a scribe. Importantly, the identification of a person as a scribe is not dependent on their training per se, but the person's predefined role. If a medical student is learning note-taking skills by documenting clinical encounters under the guidance of a physician in a student–preceptor relationship, then the student in this case is not acting as a medical scribe. If, however, a hired note taker also happens to be a medical student, and the purpose of the student's role in the clinical setting is to document the clinical encounter (and not to receive teaching or mentoring), then the student in this case is a medical scribe.
In some settings medical scribe services may be contractually arranged with an independently operated scribe company, whereas in other settings scribes may be direct employees of the health system or clinic. Likewise, the tasks performed by the scribe can vary from setting to setting. In settings with fully functional EHRs the scribe might actively participate in the clinical encounter, serving as an interface between the EHR and the clinician; for example, the scribe could communicate to the clinician information generated by the EHR such as automatic warnings, prompts, or reminders. In other settings the scribes' role could be essentially invisible, where direct interactions with the clinician or patient are kept to a minimum.
After the scribe's documentation is complete, the clinician must authenticate the scribe's entry via signing and dating/timing. The Joint Commission does not support the use of scribes for entering orders on behalf of the clinician, given the additional risk for error; if, however, the person serving as a scribe also happens to be a licensed health care professional, they could perform duties commensurate with their licensure.
Although reports on the use of medical scribes date back to the mid-1970s and early 1980s, to our knowledge a summary of the evidence on the topic has never been published. The purpose of this systematic review, therefore, is to summarize the literature investigating the effect of medical scribes on health care productivity, quality, and outcomes.
Abstract and Introduction
Abstract
Background Electronic health records (EHRs) hold promise to improve productivity, quality, and outcomes; however, using EHRs can be cumbersome, disruptive to workflow, and off-putting to patients and clinicians. One proposed solution to this problem is the use of medical scribes. The purpose of this systematic review is to summarize the literature investigating the effect of medical scribes on health care productivity, quality, and outcomes. Implications for future research are discussed.
Methods A keyword search of the Cochrane Library, OvidSP Medline database, and Embase database from January 2000 through September 2014 was performed using the terms scribe or scribes in the title or abstract. To ensure no potentially eligible articles were missed, a second search was done using Google Scholar. English-language, peer-reviewed studies assessing the effect of medical scribes on health care productivity, quality, and outcomes were retained. Identified studies were assessed and the findings reported.
Results Five studies were identified. Three studies assessed scribe use in an emergency department, 1 in a cardiology clinic, and 1 in a urology clinic. Two of 3 studies reported scribes had no effect on patient satisfaction; 2 of 2 reported improved clinician satisfaction; 2 of 3 reported an increase in the number of patients; 2 of 2 reported an increase in the number of relative value units per hour; 1 of 1 reported increased revenue; 3 of 4 reported improved time-related efficiencies; and 1 of 1 reported improved patient-clinician interactions.
Conclusions Available evidence suggests medical scribes may improve clinician satisfaction, productivity, time-related efficiencies, revenue, and patient–clinician interactions. Because the number of studies is small, and because each study suffered important limitations, confidence in the reliability of the evidence is significantly constrained. Given the nascent state of the science, methodologically rigorous and sufficiently powered studies are greatly needed.
Introduction
Electronic health records (EHRs) are frequently recognized as a promising tool to help improve health care quality, safety, outcomes, and productivity. In the United States (US), the Health Information Technology for Economic and Clinical Health Act of 2009 established incentive programs to promote meaningful use of EHRs within primary care and other health care settings. As of 2012, 72% of US office-based physicians described using some type of EHR or electronic medical record system: 40% described using a basic EHR system, and 24% reported a fully functional system. Among US general, acute care hospitals in 2012, 27% reported using a basic EHR system and 17% reported a comprehensive system. By 2019, an estimated 80% of physicians in large group practices, 65% in small group practices, and 66% of all other specialists are expected to have achieved meaningful use.
Emerging evidence indicates there may be important advantages to EHR adoption, including structural- and process-related benefits and enhanced patient care. Despite their promise to improve clinic-related efficiencies, recent findings indicate EHRs can, over the short-term, reduce productivity while at the same time add to expenses. While productivity is likely to recover after clinicians and support staff acclimate to the system, clinician engagement and administrative practice issues remain as commonly identified problems.
Many physicians describe challenges with the current state of the technology: EHRs can be difficult to use, time consuming, inefficient, disruptive to face-to-face encounters with patients, and a hindrance to the clinical documentation process. These challenges may be especially pronounced among those who lack support to help manage the flow of information. Difficulty associated with the usability of EHRs remains an important source of professional dissatisfaction; early adopters report the technology can at times interfere with communication during visits and patient–clinician eye contact. Evidence suggests some physicians using EHRs may also engage patients in fewer physician-initiated gaze patterns (signaling a lack of attention toward the patient), and that EHR use may contribute to a sense of separation among some patients when the EHR monitor is kept away from the patient's view. In response to concerns like these, a recently published primary care consensus statement concluded that many EHR systems need marked refinement to promote greater patient engagement.
One proposed solution to improve patient engagement and the flow of information while using EHRs during the clinical encounter is the use of medical scribes. While the roles of scribes can vary based on the nuances of a given clinical setting, in general scribes are personnel specifically hired to chart patient–clinician encounters in real time, from the beginning of the encounter to its end. As defined by the Joint Commission:
A scribe is an unlicensed person hired to enter information into the EHR or chart at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant). It is the Joint Commission's stand that the scribe does not and may not act independently but can document the previously determined physician's or practitioner's dictation and/or activities.
Many personnel types with different levels of training can work as a medical scribe, including nursing, medical students, or individuals whose only medical training is limited to that of being a scribe. Importantly, the identification of a person as a scribe is not dependent on their training per se, but the person's predefined role. If a medical student is learning note-taking skills by documenting clinical encounters under the guidance of a physician in a student–preceptor relationship, then the student in this case is not acting as a medical scribe. If, however, a hired note taker also happens to be a medical student, and the purpose of the student's role in the clinical setting is to document the clinical encounter (and not to receive teaching or mentoring), then the student in this case is a medical scribe.
In some settings medical scribe services may be contractually arranged with an independently operated scribe company, whereas in other settings scribes may be direct employees of the health system or clinic. Likewise, the tasks performed by the scribe can vary from setting to setting. In settings with fully functional EHRs the scribe might actively participate in the clinical encounter, serving as an interface between the EHR and the clinician; for example, the scribe could communicate to the clinician information generated by the EHR such as automatic warnings, prompts, or reminders. In other settings the scribes' role could be essentially invisible, where direct interactions with the clinician or patient are kept to a minimum.
After the scribe's documentation is complete, the clinician must authenticate the scribe's entry via signing and dating/timing. The Joint Commission does not support the use of scribes for entering orders on behalf of the clinician, given the additional risk for error; if, however, the person serving as a scribe also happens to be a licensed health care professional, they could perform duties commensurate with their licensure.
Although reports on the use of medical scribes date back to the mid-1970s and early 1980s, to our knowledge a summary of the evidence on the topic has never been published. The purpose of this systematic review, therefore, is to summarize the literature investigating the effect of medical scribes on health care productivity, quality, and outcomes.
