Medical Scribes and the EHR in the Small Physician Practice

Although small physician practices are a cornerstone of health services in many communities, small physician practices (defined as a practice with one to four physicians) continue to be on the decline.(1) From 1983 to 2014, the number of practices consisting of 10 or fewer physicians decreased from 80% to 60%, with solo practices going from 44% to 19%.(1) Physician burnout also continues to increase, in part due to lowered reimbursements, increased documentation requirements, and other rapid, unpredictable changes.(2,3) Physicians continue to be worried about how much time is spent face-to-face with patients due to the adoption of the electronic health record (EHR) to meet Meaningful Use standards.(4) Physicians can spend upward of eight hours a day with an EHR.(5) Physicians and office staff frequently describe the EHR as “difficult to use, inefficient, disruptive to face-to-face encounters with patients, and a hindrance to the clinical documentation process.”(6) Since the introduction of the EHR, physicians spend only about 27% of their time with face-to-face patient encounters, whereas they spend 49% on the EHR and other clerical duties.(7) Concerns also exist as to the effect of the EHR on patient volumes, with many physicians seeing an initial decrease in patient encounters and a concurrent increase in expenses.(6) Although these concerns exist across all physician environments, research has been minimal regarding the EHR and the small physician practice.

With the rise of the EHR, new healthcare roles are emerging.(8) One such role is that of the medical scribe. There is no consistent definition of what a medical scribe is or what a medical scribe does,(3) but they generally perform clerical and documentation work alongside a physician, documenting the patient encounter, laboratory results, and other data entry tasks.(4) They do not provide direct patient care. Although medical scribes have a strong history in emergency departments, their use in smaller, clinical settings is less well established and with limited focus on productivity.(9) Estimates are that by 2020, there will be one scribe for every nine physicians.(4) By reducing physician stressors, medical scribes may decrease burnout, leading to less severe physician shortages.(3,10)

Methods

A modified Delphi design was selected for this study, which examined the possible effects of the EHR on the small physician practice. The Delphi design was chosen because of the incomplete nature of the EHR. We explained the methods for this study in detail in a previous publication.(11) The criteria for expert panelists focused on four primary needs:

1. A pool of U.S. physicians (MD and DO) with a practice size of one to four physicians was necessary to understand the EHR’s impact on the small physician practice in the United States.

2. The study focused on those who had been in a small practice for at least five years to ensure adequate experience in this subset of practices.

3. Experience of at least one year with a certified EHR ensured that each participant was knowledgeable on the features of the EHR and its effect on the small physician practice.

4. The panel of invited experts included only physicians who were decision-makers in the practice. The requirement that the physician be a decision-maker ensured that the participant would have a broad understanding of the topic.

These panelists were able to expound on the issue from the perspective of both the physician who understands the patient care aspect and the businessperson who understands the financial effects of cost and revenue. Fifteen participants from various specialties and geographic locations were selected to participate.

Panelists completed three rounds of surveys. Participants were given seven days to complete each survey. The initial open-ended question was designed to probe for themes to explore in successive rounds. The research question asked of the experts was, “How do you believe the implementation of an electronic health records system will affect the management of small physician practices? Consider the entire practice operations, including but not limited to the patients, the physicians, and the financial implications to the practice.” The objective of Round 1 was to determine the most common themes to explore in successive rounds. The purpose of Round 2 was to gauge the degree of consensus on each theme. Common themes were assessed using a Likert-type scale to determine agreement. Typical percentages for consensus range from 51%(12) to 70%(13) and upwards of 80%.(14) For this study, a consensus was determined to have been reached with 80% agreement or disagreement, as determined by the sum of the “somewhat agree/disagree” and “strongly agree/disagree” responses. All themes reached consensus in Round 2. The results from Round 2 were presented as a qualitative survey in Round 3 for discussion of consensus as well as outliers. The purpose of Round 3 was to generate robust debate on the outcomes, including the development of additional insights into each theme.

Results

Fifteen panelists responded to three rounds of surveys. Rounds 1 and 2 indicated physicians were highly concerned about reduced patient volumes due to the EHR as well as decreased face-to-face time with each patient due to data entry.(11) In Round 3, the panelists discussed the use of a medical scribe as a potential solution for these concerns. Forty-seven percent of the panelists stated that a medical scribe or additional data entry person would need to be present to prevent the reduction of face-to-face time with the patient. The use of a medical scribe to prevent changes in the workflow has been discussed in the literature and remains a frequent topic.(15,16) One panelist stated that a medical scribe maintained patient face time, a statement that agreed with the premise that face-to-face time could be reduced with the EHR assuming no intervention.

Panelists stated the need for a medical scribe to assist in data entry, with several stating this would be needed to prevent a loss of volume and, ultimately, revenue. One panelist stated “without a scribe, patient volumes are very likely to decrease. For many, this has been happening since the introduction of the EHR. It is not known if this will change over time.” Another stated that “there appears to be no way that a physician is going to be able to see more patients while also inputting into an EHR product.” One panelist disagreed about the reduction in volume, but it was unclear if this physician used a scribe. In this case, it is feasible more patients could be seen.

A consistent assertion was that the EHR will require medical scribes or some other new position to handle data entry to allow the physician to continue to focus on the patient.(15,17,18) The panelists believed a scribe was a necessity to maintain workflow and reduce the likelihood of a decrease in patient volume. Of note, no expert mentioned the scribe in a way that suggested the scribe would increase patient volumes beyond pre-EHR levels. All references were to maintaining volumes or minimizing decreases in patient volumes.

Panelist responses were consistent in addressing the single outlier who did not think that the EHR would affect the physician’s focus. As one panelist stated, “[the outlier] must either employ a scribe, be seeing fewer patients during any given day to allow the same amount of time to focus on the patient or be inexperienced and simply projecting the utilization of an ideal EHR not yet in existence.” The concept of an additional staff member being required continued throughout the survey and was consistent with the literature.(17)

A concern for ongoing cost control is another argument for the need for a medical scribe.

The dissenting panelist did mention medical scribes as a means to prevent a reduction of face time. This statement, in fact, could be argued to agree with the premise. If additional staffing is necessary to prevent physicians from losing face time, the statement of potential volume decreases is correct. A research study into the use of medical scribes and their effect on office protocols in an EHR setting could shed light on the topic from both a workflow and revenue perspective.

A concern for ongoing cost control is another argument for the need for a medical scribe. Throughout the surveys, the expert panel consistently pointed to the need for a medical scribe to prevent a loss of face time as well as to prevent a loss of patient volume. Research is inconsistent as to whether a medical scribe will benefit the EHR process.(18) With an annual cost of $20,000 to $40,000 per medical scribe(17) and the possibility that each physician will need a personal medical scribe, the cost of using medical scribes would require a substantial increase in patient volumes or reduction in costs.

Discussion

The use of medical scribes is the result of the inherent inefficiency of using an EHR.(4) Despite the time physicians spend interacting with an EHR, the technology is still in a primitive stage.(5) New systems are not necessarily patient-focused and continue to add additional encounter requirements, making healthcare delivery more burdensome for physicians.(2)

Physicians report increased satisfaction when using a medical scribe as more time can be spent on patient care versus data entry.

Physicians report increased satisfaction when using a medical scribe as more time can be spent on patient care versus data entry.(8) Bank and Gage(9) reported a 10% increase in patients seen per hour in a cardiology clinic with a corresponding increase of about 14.1-times return on investment for a practice that used scribes for 10 of its 25 physicians. Although the clinic is not a small physician practice, the significant increase in patient encounters is significant enough to warrant research for smaller practices.

Research indicates that although the use of medical scribes do not seem to increase patient satisfaction, it does not decrease it either because of concerns of additional individuals in the room.(10) Some other research indicates the presence of a medical scribe may have no impact on patient satisfaction,(19) whereas still other research indicates it improves patient satisfaction.(20) With a neutral to positive impact on patient satisfaction, medical scribe viability can focus on the impact on volume and face-to-face time.

Conclusion

Although medical scribes may be one way to increase the efficiency of healthcare, small practice physicians should demand more efficient EHR systems geared toward optimizing the use of these systems and enabling the physician to focus more attention on the patient.(4) Healthcare roles will continue to evolve, and more training is needed to prepare for changes in healthcare documentation.(8) Struggles with the EHR also may be generational, with older practitioners struggling to master the new technology.(2) As Ornstein et al.(21) demonstrate, the continued use of health information technology relies on a team approach.

”Medical scribes may improve clinician satisfaction, productivity, time-related efficiencies, revenue, and patient–clinician interactions” although data is limited and study methodologies inconsistent.(6) Arguably, a potential complexity in determining the effect of a medical scribe on the EHR system is the lack of a universal, consistent job description for the medical scribe. Inconsistent reporting of the financial effects (e.g., changes in patients seen, services billed, and other cost impactors) of the medical scribe make it challenging to put firm financial indicators on the position.(3) Scribes appear to improve physician satisfaction considerably, in part due to the improved quality of documentation.(10)

The future of the EHR is still being written. Physicians who meet Stage 1 of Meaningful Use have higher quality documentation than those who do not.(22) Research also indicates that the EHR can increase the amount of charge captures and collections.(23) Despite the positive changes, the EHR can negatively alter the patient–physician dynamic during patient encounters.(24) The use of a medical scribe has the potential to offset this concern, allowing for a more traditional encounter where the physician focuses on the patient while the medical scribe focuses on the health record.(25,26) Because of this potential, the medical scribe position in the small physician practice deserves additional research. The medical scribe industry has been growing and evolving rapidly since the introduction of the EHR,(8) and more focused research on the medical scribe and the small physician practice is needed.

References

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