Scribe Utilization in the Primary Care Environment

Clinical Scribe Overview

The use of clinical scribes is increasing across the spectrum of clinical medicine, with the objective of improving the efficiency of care delivery and simultaneously enhancing physician practice satisfaction.(1-4) The Joint Commission(5) describes a medical scribe as follows:

A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) 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.

The use of scribes in medicine is a relatively new phenomenon; few examples of contemporary scribe use can be cited before the year 2000.(3) However, this role has grown rapidly in the last decade, and it is now estimated that more than 10,000 scribes are currently working in the U.S. healthcare system.(6) Most scribes work in emergency departments; however, their implementation in other specialties is being explored.(3,4) Scribes tend to be college graduates who seek to enter medical professions, and typically earn $10 to $25 per hour.(6)

The principle goal of scribe use is to reduce the EMR documentation burden.

The growth in the use of scribes closely parallels contemporary medicine’s transition to the use of electronic medical records (EMRs).(3,7,8) Physicians commonly report that documentation burdens have increased with the advent of EMRs, and that this burden diminishes their clinical productivity and professional satisfaction.(3,7-10) The principle goal of scribe use is to reduce this EMR documentation burden, thereby allowing physicians to reallocate their time to other care delivery tasks, potentially increasing the volume of patients who can be treated in a given period or the time invested in each patient encounter. Increases in both patient volume and physician professional satisfaction have been demonstrated in recent scribe trials.(1-4,7,9,11)

Roles of Clinical Scribes

Scribes accompany physicians during patient examinations and unobtrusively observe and document the encounter. Scribes typically are responsible for producing a clinical visit note, which the physician subsequently reviews and signs. Scribes also may complete standing orders such as ordering laboratory tests, immunizations, and medications, which further reduces the physician’s administrative burden. They also may reply on behalf of physicians to routine messages and inquiries, and complete other clerical tasks historically requiring physician attention, such as chart maintenance.

Effects of Clinical Scribe Use

The most commonly reported effect of scribe use is a decrease in the time physicians spend using the EMR, and, secondarily, an increase in patient contact time or volume.(1-4,6) Physicians commonly spend two to four hours completing clinical records during each clinic day,(6) and the use of a scribe can dramatically reduce this burden.(1,3,4,11) Functionally, this permits physicians to complete their work sooner or increase their volume of patients.(4,6) Physicians also report that scribes are able to produce documentation that is at least as thorough as would be produced otherwise.(2-4,7) Reallocation of this time to more productive or satisfying pursuits is additionally expected to reduce physician “burnout” rates.(8,12) The sum of these effects may be useful in achieving the Triple Aim of healthcare systems, in addition to improving the work life of healthcare providers.(4,10)

Koshy et al.(2) reported a dramatic increase in physician satisfaction with their office hours when a scribe was used (69% vs. 19%), and Bank et al.(1) reported a 59% increase in the number of patients seen per hour, a 57% increase in the number of work relative value units (wRVUs) per hour, and an increase in the time the physician spent interacting with the patient once freed from computer use (6.7 vs. 1.5 minutes).

A common critique of the use of a scribe is that it may degrade the physician–patient interaction because patients may feel uncomfortable disclosing sensitive information in the presence of a third party. However, recent studies using patient surveys have demonstrated that the presence of a scribe does not negatively affect patient satisfaction, and may, in fact, increase it by allowing the physician to concentrate on the patient for a greater period of time rather than having his or her attention diverted to EMR documentation.(1,2,4,6)

Data regarding clinical scribe utilization are scare, and tend to focus on scribe use within emergency departments.(3) A review published in May 2015 found only five experimental studies of the topic: three studied emergency departments; one studied a urology clinic; and one studied a cardiology clinic.(3)

Our Study

Design

Our study was designed to assess whether clinical scribes would be useful and economically viable in primary care family medicine clinics. To accomplish this, we attempted to assess the amount of time physicians save when utilizing a scribe, and used this to determine the number of additional patients who could be cared for in this time.

In our study, one scribe was assigned to several family medicine physicians. The scribe observed a randomly selected group of patient visits and produced the clinical note for each visit. The amount of time the physician spent completing documentation for each eligible patient was recorded for both scribe and non-scribe visits. Scribes had been performing their duties with each physician for a period of four months before the study began.

The scribe also assumed additional responsibilities, such as pre-ordering routine laboratory tests and immunizations for patients by following a standard protocol. Our study did not attempt to assess the relative time savings of these additional activities. All scribe entries into patient charts were reviewed, modified as necessary, and signed by the physician.

Setting and Electronic Medical Record Software

This study was conducted at clinics operated by UNC Physicians Network (UNCPN), a subsidiary of the University of North Carolina healthcare system that includes 40 outpatient clinics that provide predominantly primary care services.

Epic EMR software (Verona, Wisconsin) was the EMR used in this study, and had been in use in each clinic for at least 10 months before the study began. The physicians participating in this study traditionally conducted 18 to 24 patient visits per eight-hour working day, approximately three patients per hour.

Scribe

The scribe who was used in this study was trained by undergoing physician-level EMR training and by reviewing prior notes produced by the practice’s physicians. A medical vocabulary was developed by performing word frequency analysis of 100 recent physicians’ notes. The most frequently used clinical terms were extracted from this analysis, and the scribe committed the terms and definitions to memory. The scribe was a recent university graduate who intended to become a physician.

Results

Two trials were conducted with separate physicians. In each trial, the time required to complete documentation for each patient was recorded. Randomly selected visits were completed with the assistance of the scribe, and the remaining visits were completed without scribe assistance. Figure 1 summarizes the collected data for these trials.

Figure 1. Trial 1 (A) and Trial 2 (B). A comparison of the time required to complete visit documentation with and without scribe assistance.

Trial 1

The time required to complete documentation for each patient (n = 138 patient visits) was recorded over a period of 12 days. Seventy-eight visits were completed with the assistance of the scribe, and 60 visits were completed without scribe assistance. Of the 60 visits completed without scribe assistance, 17 visits were excluded from subsequent calculations, because they were a type in which the scribe was ineligible to participate (i.e., well child or obstetrics visit; “excluded visits”).

During the 12-day observation period, the daily mean time physicians spent on documentation per patient without a scribe ranged between 5.3 and 8.2 minutes, whereas the time spent with scribe assistance was between 2.6 and 4.5 minutes (Figure 1A). Time savings ranged between 1.3 and 4.5 minutes per patient visit, with a mean savings of 2.8 minutes.

Trial 2

In Trial 2, 182 patient visits were recorded over a period of 17 days. Of these, 120 visits were completed with the assistance of the scribe, and 62 visits were completed without scribe assistance. No visits were excluded in this trial.

During the observation period, the daily mean time physicians spent on documentation per patient without a scribe ranged between 3.9 and 8.0 minutes, whereas the time spent by the physician on such activities with scribe assistance was between 1.6 and 3.0 minutes (Figure 1B). Thus time savings ranged between 1.8 and 6.7 minutes per patient, with a mean of 4.0 minutes.

Discussion

Physician Time Savings

Based on our data, we realized a 41% (Trial 1) and 66% (Trial 2) reduction in physician documentation time when a scribe was used. During a typical 18- to 22-patient day, it would be expected that one scribe would be capable of seeing approximately 15 patients (given allowances for excluded visits and scribe writing time), therefore leading to an approximate time savings for the physician of 42 to 60 minutes for the day, based on per-patient time savings of 2.8 to 4.0 minutes. Further time savings that resulted from ancillary scribe activities (such as ordering laboratory tests and immunization pre-entry) are not included in this assessment. In total, it was estimated that use of a scribe saved physicians approximately 60 minutes per day, or approximately five hours per week.

Other Observations

In our experience, we found that although the use of scribes may be justifiable solely on the basis of increased physician productivity, another important factor is the effect of scribes on a physician’s professional satisfaction. All physicians who participated in this study noted improved professional satisfaction when using a scribe. Scribes perform tasks that physicians find to be dull and time consuming, and several studies have corroborated the notion that delegating the burden of documentation to a scribe increases physicians’ satisfaction with their medical practice.(1,4,13) If physician satisfaction, fulfillment, and, ultimately, retention can be increased by the use of scribes, the expense associated with hiring new physicians and the cost of interruption in patient care could also be avoided.

Several other benefits attributed to scribe use include increased patient satisfaction, improved patient outcomes, and improvements in team-based care. Several studies have indicated that patient satisfaction may be increased as a direct result of a physicians’ ability to spend more time conducting examinations and providing consultation, rather than entering data into EMR software. Freedom from the distraction of dealing with the computer during examination facilitates increased eye contact with patients, which has been linked with increased patient satisfaction.(1,2,4,13)

The use of scribes may improve revenue collections as a result of more thorough visit documentation and improved coding.

Additionally, improvement in patient outcomes may be achieved by more thorough implementation of standing orders and identification of areas requiring closures in care gaps. Scribes may also be involved in pre-visit planning, authoring patient instructions, and coordination of care with other team members. Finally, the use of scribes may improve revenue collections as a result of more thorough visit documentation and improved coding, especially if they receive training regarding medical coding and the required supporting documentation. This may prove especially important as clinics transition to ICD-10. We expect that the sum of these secondary value added factors will further justify and enhance scribe use.

Scribe Training Observations

After the initial training described earlier, it was noted that a “warm up” period (typically two to four weeks) is required before use of the scribe begins to make meaningful reductions in documentation burdens. It is important, therefore, for physicians to expend time and effort training scribes in their documentation style and preferences during this period. We observed that one of the most important methods to increase efficiency during this period was for the scribe to carefully review the physician’s note modifications. This allowed the scribe to better understand and gradually assimilate the physician’s style.

Scribe Recruitment

Scribes must develop an advanced medical vocabulary and assimilate the physician’s writing style. They must be capable of developing a trusted working relationship with physicians. Having a strong interest in medicine and high motivation is also important.

Based on our study, scribes were capable of saving approximately 60 minutes of physician time per day, a period equal to two to three patient visit slots. The resulting increase in patient volume may be sufficient to pay the scribe’s wages, and several studies have demonstrated that scribe use can be profitable.(1,2,9)

Achieving profitability with scribe use is predicated on relatively low compensation for scribes, given the modest increase in physician productivity. One group that is willing to work for this relatively low pay consists of individuals who wish to pursue a career in a health profession and are seeking patient care experiences. Recent university graduates seeking to enter healthcare graduate programs may be ideal candidates for scribe roles. In particular, scribing provides an excellent pipeline for premedical students interested in augmenting their clinical experiences in preparation for application to medical school. Scribing offers these persons unprecedented access to observe physician–patient interactions while simultaneously facilitating meaningful contributions to the healthcare system.

Merely a Crutch?

Some have suggested that shifting the burdens of documentation away from physicians will lead to complacency in those physicians’ documentation skills.(8) We observed, however, that the opposite may be true; well-trained scribes collaborating closely with physicians facilitated an exchange of knowledge about using the EMR system efficiently, and may have increased the physician’s documentation proficiency and efficiency.

Which Providers Will Benefit Most by Using a Scribe?

We found that several factors determine which physicians are best suited to utilize a scribe. Scribes may be most useful to physicians:

• Who report lower comfort levels using EMR software;

• Who would like to increase the volume of patients they are capable of seeing;

• Who are at risk of “burnout”; or

• Who spend unusually long periods of time documenting patient visits.

Positive effects may be realized more rapidly when scribes are assigned to highly productive physicians, because the larger number of patients seen per day offers a greater number of opportunities for the scribe to make a positive contribution. However, it is also possible that physicians of lower productivity could gradually see more patients by collaborating with a scribe.

Conclusions

In this study, we found compelling evidence that the use of scribes in family medicine may considerably reduce physician documentation burdens and increase physician professional satisfaction. We noted a decrease of 41% to 66% in the time physicians spent completing patient documentation, equivalent to a daily time savings of 60 minute. Larger studies will be useful to further explore the positive effects of scribe use in primary care.

References

1. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clin Outcomes Res CEOR. 2013;5:399-406.

2. Koshy S, Feustel PJ, Hong M, Kogan BA. Scribes in an ambulatory urology practice: patient and physician satisfaction. J Urol. 2010;184:258-262.

3. Shultz CG, Holmstrom HL. The use of medical scribes in health care settings: a systematic review and future directions. J Am Board Fam Med JABFM. 2015;28:371-381.

4. Miller N, Howley I, McGuire M. Five lessons for working with a scribe. Fam Pract Manag. 2016;23(4):23-27.

5. The Joint Commission. Standards Interpretation: Standards FAQ Details | Joint Commission [Internet]. Available from: https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=1206. Accessed July 25, 2017.

6. Bank AJ. In praise of medical scribes. Wall Street Journal. April 6, 2014. www.wsj.com/articles/SB10001424052702304418404579469371577995400 . Accessed July 16, 2015.

7. Hafner K. A busy doctor’s right hand, ever ready to type. The New York Times. January 12, 2014. www.nytimes.com/2014/01/14/health/a-busy-doctors-right-hand-ever-ready-to-type.html . Accessed June 16, 2015.

8. Joseph A. EMR scribes: crutch or cure for documentation burdens? www.advisory.com/research/medical-group-strategy-council/practice-notes/2014/january/are-ehr-scribes-a-crutch-or-cure . Accessed June 16, 2015.

9. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Corporation. 2013. www.rand.org/pubs/research_reports/RR439.html . Accessed June 16, 2015.

10. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.

11. Fleming NS, Becker ER, Culler SD, et al. The impact of electronic health records on workflow and financial measures in primary care practices. Health Serv Res. 2014;49(1pt2):405-420.

12. Shipman SA, Sinsky CA. Expanding primary care capacity by reducing waste and improving the efficiency of care. Health Aff (Millwood). 2013;32:1990-1997.

13. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.