By Elsa Pearson, MPH, and Austin Frakt, PhD
A more productive work environment and a more satisfied workforce often go hand in hand. As the burden of documentation required by electronic health records (EHRs) increases, clinicians’ frustrations and lists of obligations grow. Medical scribes may offer reprieve.
Scribes are nonclinical professionals who assume documentation responsibilities for clinicians, usually in outpatient or emergency department settings. The practice is popular among aspiring clinicians—typically, those between undergraduate studies and professional schooling—to gain clinical experience. The relationship is mutually beneficial: as the scribe gains experience, the clinician gains bandwidth to focus on clinical decision making.
Study is needed to assess the quality of scribe documentation. However, the current literature, though limited, suggests that scribes may decrease clinician time spent with EHRs and improve clinician productivity and satisfaction.
Electronic health records are intended to improve efficiency and organization, but they have also proved cumbersome. Clinicians often lament the time spent charting rather than spent with patients. Scribes may alleviate some of this burden. In a recent New Yorker article, Atul Gawande, MD, MPH, wrote, “This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans. And it sort of works.”
A recent study published in JAMA Internal Medicine noted a reduction in time spent by clinicians on EHR documentation, both during clinics and after hours, when scribes were used. Another study found use of scribes was associated with less self-reported after-hours documenting EHRs by primary care physicians at 2 medical center facilities. However, a study on the effect of scribes in a pediatric emergency department found that the time required to complete patient charts did not decrease. This suggests scribes do not reduce the documentation burden overall, they simply shift the responsibility from the clinician to themselves.
Productivity measures how much work is done per unit of input and is measured in a variety of ways across studies. However measured, the literature suggests that scribes are associated with an increase in physician productivity.
For example, several studies found that scribe use increased the number of patients seen per hour. The number of work relative value units (RVUs) completed per hour often increased as well. (Although imperfect, RVUs are a way to measure the amount of work associated with a procedure or clinical activity relative to others. More RVUs per hour means more work per hour.) That division of labor—physicians focused on clinical responsibilities and scribes on administrative ones—seems to be more productive than physicians doing both.
Even further, scribe use decreased documented physician overtime. Physicians using scribes were more administratively efficient during shifts, reducing the need to complete charts after hours.
Perhaps a byproduct of increased productivity, net revenue also increased with scribe use. Scribes in the United States earn about $12 an hour. Because of low costs and increased productivity, clinicians can see more patients or accomplish more with ones they do see, increasing net revenue. Scribes may also increase revenue by simply ensuring more comprehensive coding, billing at a higher level separate from changes in productivity.
Satisfaction and Related Measures
Clinician and patient satisfaction are important health care system outcomes. Although harder to assess than quantitative variables, current literature suggests medical scribes may improve clinician satisfaction while having an unclear effect on patient satisfaction.
Clinician satisfaction is measured in a variety of ways. For example, some physicians found scribe use improved clinic flow. Other clinicians reported they could fully focus on the patient instead of charting and could spend more time with their patients. Many clinicians preferred having and felt more effective with a scribe.
In contrast, however, a qualitative study in Australia reported a few emergency department physicians believed time spent charting allowed for cognitive processing, something that was lost when a scribe charted on their behalf.
The impact of scribe use on patient (and parent, in the case of pediatric clinics) satisfaction was less conclusive. A recent US study observed a small but statistically significant reduction in patient satisfaction with the use of scribes, although it did remain high overall. Others noted an improvement while some found patient or parent satisfaction relatively unchanged.
The physical environment may also affect satisfaction. A 2018 study at an urban safety net health clinic found that the proportion of patients comfortable with the number of people in the room during a visit declined when scribes were present. Interestingly, comfort levels with the scribes themselves remained high. This suggests the physical implications of another person in the examination room will be increasingly important as scribes become more common, even if patients are comfortable with the idea of scribes.
As clinicians struggle with the demands of the EHR and burnout rates soar, the health care system must invest in both long-term and short-term interventions. Although medical scribes do not address systemic complexity, they do offer immediate relief to clinicians by assuming documentation responsibilities. This alone may justify their use while efforts to simplify and streamline the EHR continue.
About the authors:
Elsa Pearson, MPH, is a policy analyst with the Boston University School of Public Health. She tweets at @epearsonbusph. (Image: Boston University)
Austin B. Frakt, PhD, is the Director of the Partnered Evidence-based Policy Resource Center, Veterans Health Administration; an Associate Professor at Boston University’s School of Public Health; and an Adjunct Associate Professor with the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. He blogs about health economics and policy at The Incidental Economist, tweets at @afrakt, and is a regular contributor fo the New York Times. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs, Boston University, or Harvard University. (Image: Doug Levy)
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