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Research ArticleOriginal Research

Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial

Risha Gidwani, Cathina Nguyen, Alexis Kofoed, Catherine Carragee, Tracy Rydel, Ian Nelligan, Amelia Sattler, Megan Mahoney and Steven Lin
The Annals of Family Medicine September 2017, 15 (5) 427-433; DOI: https://doi.org/10.1370/afm.2122
Risha Gidwani
1Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford University, Stanford, California
2Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
DrPH
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Cathina Nguyen
3Division of Epidemiology, Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, California
MPH
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Alexis Kofoed
2Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
MPH
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Catherine Carragee
2Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
BA
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Tracy Rydel
2Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
MD
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Ian Nelligan
2Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
MD, MPH
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Amelia Sattler
2Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
MD
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Megan Mahoney
2Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
MD
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Steven Lin
2Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
MD
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  • For correspondence: stevenlin@stanford.edu
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  • Author Response to Dr. Misra-Hebert's Letter
    Steven Y. Lin
    Published on: 13 October 2017
  • Medical Scribes: Part of the Solution for Primary Care Redesign?
    Anita D. Misra-Hebert, MD, MPH
    Published on: 12 October 2017
  • Published on: (13 October 2017)
    Page navigation anchor for Author Response to Dr. Misra-Hebert's Letter
    Author Response to Dr. Misra-Hebert's Letter
    • Steven Y. Lin, Medical Director

    We appreciate Dr. Misra-Hebert for her thoughtful comments.

    With respect to the comment that time to chart close within 48 hours was only slightly improved, we believe that our inability to detect a more significant difference was due to the way we measured this outcome, which was via EHR timestamps. Anecdotally, our study physicians reported that their scribed charts were often complete and ready to be signed of...

    Show More

    We appreciate Dr. Misra-Hebert for her thoughtful comments.

    With respect to the comment that time to chart close within 48 hours was only slightly improved, we believe that our inability to detect a more significant difference was due to the way we measured this outcome, which was via EHR timestamps. Anecdotally, our study physicians reported that their scribed charts were often complete and ready to be signed off by the end of each 4-hour clinic, sometimes by the end of each encounter. However, 2 of our 4 study physicians had the habit of batching their notes, which meant that there was often a significant time lag before the completed notes were electronically signed. We believe that this skewed our data and diminished the positive effects observed for charting efficiency, although we were encouraged to find a statistically significant improvement despite this data limitation. To get a more accurate measurement for charting efficiency, we plan to conduct a larger trial using EHR event log data, which was recently reported by Arndt et al.[1] as a reliable source of data for physician time allocation validated against direct time-motion observations.

    We agree that team-based documentation models using medical assistants or licensed practical nurses as scribes are promising. Dr. Misra-Hebert has described in her work how such a model can benefit care teams in ways beyond just reducing documentation burden. We find these results fascinating. We have also found similar benefits with non-licensed scribes. Using a longitudinal observational design with an ethnographic approach, we found that non-licensed scribes may improve patient experience, quality of care, clinic operations, and joy of practice. This manuscript is in press and will be published soon[2].

    For future research, we believe it would be interesting to compare team-based documentation models using medical assistants or licensed practical nurses as scribes versus non-licensed scribes (i.e. students in pre-medical or medical training). We suspect that there are distinct advantages and disadvantages for each model that are worth exploring so that different practices can decide which model fits their needs best. Both models exist at our institution and we plan on starting a study soon to directly compare them. We are also very interested in collaborating with other institutions.

    Lastly, Dr. Misra-Hebert brings up an excellent point about funding for scribe programs. The question of how primary care practices can make the economic argument for scribes remains unanswered. Thus far, much of the focus has been on paying for scribes using revenue generated by additional visits afforded by increased efficiency. If primary care physicians want to argue for scribes in their practices, we believe that the justification should expand beyond just higher visit volumes to include potential benefits in joy of practice, clinic operations, quality of care, patient experience, pipeline development, and education.

    Steven Lin, MD
    Stanford Family Medicine, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine

    References
    1. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med. 2017;15(5):419-426.

    2. Sattler AL, Rydel T, Nguyen CT, Lin S. An Ethnographic Study of Primary Care Physicians and Medical Scribes. J Am Board Fam Med. Manuscript in press.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (12 October 2017)
    Page navigation anchor for Medical Scribes: Part of the Solution for Primary Care Redesign?
    Medical Scribes: Part of the Solution for Primary Care Redesign?
    • Anita D. Misra-Hebert, MD, MPH, Physician

    I appreciated reading this report by Gidwani et al.[1] describing the results of a randomized trial of scribe use in the primary care setting. The study design involved 4 physicians and 2 scribes in one clinic who were randomized to 1 week on and 1 week off charting with a scribe for 12 months. The participating physicians were part-time, with (4) four-hour clinic sessions per week where data were collected for the study, and...

    Show More

    I appreciated reading this report by Gidwani et al.[1] describing the results of a randomized trial of scribe use in the primary care setting. The study design involved 4 physicians and 2 scribes in one clinic who were randomized to 1 week on and 1 week off charting with a scribe for 12 months. The participating physicians were part-time, with (4) four-hour clinic sessions per week where data were collected for the study, and were relatively recently out of training (mean 6 years of experience). Physician satisfaction was assessed with a questionnaire after each clinic session and patient satisfaction assessed after each visit. Charting efficiency was assessed based upon whether chart closure occurred within 48 hours. Physician satisfaction regarding the clinic session, face time with patients, and perceptions about documentation was improved, patient satisfaction was high with or without a scribe present, and chart closure within 48 hours was only slightly improved with the presence of a scribe.

    While these results are encouraging, I wonder to what degree these results can be extrapolated to real-world busy primary care clinics. Even with a group of 4 physicians who were relatively recently out of training (and possibly familiar with using electronic medical records(EMRs)), worked with one of two scribes for the entire study, and had less than half of a full week of clinic observed, the percent of chart closure times within 48 hours was only slightly improved (although statistically significant) and still low(28.5% vs 32.6% without and with a scribe, respectively). With a larger number of visits per week, it is not clear that the presence of a scribe would make a significant difference and the cost of having a scribe may not justify this small level of improvement in this metric.

    While the authors suggest that utilizing scribes during a clinic session may help mitigate physician dissatisfaction with the EMR, it is unclear to what degree scribes can contribute to improving physician work-life overall, as chart documentation is just one part of a practicing physician's interaction with the EMR. As primary care delivery moves to models focused on managing populations of patients, additional tasks unrelated to the actual visit time will be a greater expectation of the work of a primary care team. This work, often part of the in-box messages which can be time consuming,[2] includes answering patient phone calls or patient communication through the EMR, refill requests, completing paperwork, and participating in further outreach to patients in our newer population-based models of care. An unlicensed scribe can only contribute to a small part of that overall workload. The authors state that "Spending less time on documentation frees up the physician to pursue direct clinical care and care coordination, thus enhancing joy of practice and preventing burnout." It is not clear how much less time was spent documenting and physicians were still required to sign off on charts. While greater face time with patients in team-based models utilizing scribes, as we have also previously reported,[3] may foster improved physician-patient relationships and thereby improve work satisfaction, a non-licensed medical scribe model, as reported in this study, cannot be helpful with the large burden of after-visit work. We have studied a model at our institution that involves medical assistants or licensed practical nurses taking on scribing as part of their role,[4] who then also have the ability to develop relationships with patients and can assist with other non-scribing tasks. Innovative models that involve other clinical team members who can help physicians care for our patients through developing long-term relationships with patients and teams have the potential to affect both patient outcomes as well as physician satisfaction. The results of this study suggest that unlicensed medical scribes may be a promising part of the solution and I agree with the authors that scribes may "serve an important function in a multidisciplinary health care team."

    Anita D. Misra-Hebert MD, MPH
    Department of Internal Medicine and Center for Value-Based Care Research, Cleveland Clinic

    References
    1. 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(5):427-433. doi:10.1370/afm.2122.
    2. Murphy DR, Meyer AD, Russo E, Sittig DF, Wei L, Singh H. THe burden of inbox notifications in commercial electronic health records. JAMA Intern Med. March 2016. doi:10.1001/jamainternmed.2016.0209.
    3. Misra-Hebert AD, Rabovsky A, Yan C, Hu B, Rothberg MB. A Team-Based Model of Primary Care Delivery and Physician-Patient Interaction. Am J Med. April 2015. doi:10.1016/j.amjmed.2015.03.035.
    4. Yan C, Rose S, Rothberg MB, Mercer MB, Goodman K, Misra-Hebert AD. Physician, Scribe, and Patient Perspectives on Clinical Scribes in Primary Care. J Gen Intern Med. 2016;31(9):990-995. doi:10.1007/s11606-016-3719-x.

    Competing interests: Dr. Misra-Hebert is supported by an Agency for Healthcare Research and Quality grant K08HS024128.

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 15 (5)
The Annals of Family Medicine: 15 (5)
Vol. 15, Issue 5
September/October 2017
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Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial
Risha Gidwani, Cathina Nguyen, Alexis Kofoed, Catherine Carragee, Tracy Rydel, Ian Nelligan, Amelia Sattler, Megan Mahoney, Steven Lin
The Annals of Family Medicine Sep 2017, 15 (5) 427-433; DOI: 10.1370/afm.2122

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Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial
Risha Gidwani, Cathina Nguyen, Alexis Kofoed, Catherine Carragee, Tracy Rydel, Ian Nelligan, Amelia Sattler, Megan Mahoney, Steven Lin
The Annals of Family Medicine Sep 2017, 15 (5) 427-433; DOI: 10.1370/afm.2122
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