Original Research
Medical scribes: How do their notes stack up?
Their outpatient notes stack up well, according to this small, retrospective review. Scribes’ notes were rated slightly higher in overall quality...
METHODS
The study took place at the Barre Family Health Center (BFHC), a rural, freestanding family health center/residency site owned and operated by UMassMemorial Health Care (UMMHC), the major teaching/clinical affiliate of the University of Massachusetts Medical School. The health care providers of BFHC conduct 40,000 patient visits annually. Without scribes, the physicians typically dictated their notes at the end of the day, and they became available for review/sign off usually within 24 hours.
Six of the 7 faculty physicians working at BFHC in 2014 (including the lead author) participated in the pilot study (the seventh declined to participate). Three male and 3 female physicians between the ages of 34 and 65 years participated; they had been in practice between 5 and 40 years. All of the physicians had used an EMR for 5 years or more, and all but 2 had previously used a paper record. Residents and advanced practitioners did not participate because limited funding allowed for the hiring of only 2 full-time equivalent (FTE; 4 part-time) scribes.
Contracting for services. We contracted with an outside vendor for scribe services. Prior to their arrival at our health care center, the scribes received online training on medical vocabulary, note structure, billing and coding, and patient confidentiality (HIPAA). Once they arrived, on-site training detailed workflow, precharting, use of templates, the EMR and chart organization, and billing. In addition to typing notes into the EMR during patient visits, the scribes helped develop processes for scheduling, alerting patients to the scribe’s role, and defining when scribes should and should not be present in the exam room. The chief scribe created a monthly schedule, which enabled staff to determine which physician schedules should have extra appointment slots added. This was imperative because our parent institution mandated that new initiatives yield a 25% return on investment (ROI).
Using standard scripting and consent methods, nursing staff informed patients during rooming that the provider was working with a scribe, explained the scribe’s role, and asked about any objections to the scribe’s presence. Patients could decline scribe involvement, and all scribes were routinely excused during genital and rectal examinations.
Data collection
Data were collected during the 6-month trial period from May through October of 2014. The number of hours physicians spent at BFHC and at home working on clinical documentation was collected using a smartphone time-tracking application for two 3-week periods: the first period was in April 2014, before the scribes came on board; the second period was at the end of the 6-month scribe implementation period. In order to assess effects on productivity and whether the project was meeting the required ROI for continuation, we included a retrospective review of the EMR for both of the 3-week periods to document total clinical hours, number of clinic sessions (blocks of consecutive, uninterrupted appointments), average hours per session, the number of patient appointments scheduled per session, and the number of patient visits actually conducted per session (accounting for no-shows and unused appointments).
Physician work-life balance. We utilized 19 questions most relevant to this project’s focus from the 36-item Physician Work-Life Survey.15 Items were scored on a 5-point Likert scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5). The BFHC ambulatory manager distributed surveys to physicians immediately prior to the trial with scribes and 2 weeks after the conclusion of the 6-month trial.
Patient and provider satisfaction. During the 6-month intervention period, satisfaction surveys9 were distributed to patients by scribes at the end of the office visit and to physicians at the end of each scribed session, after notes were completed and reviewed. Patient surveys consisted of 6 closed-end questions regarding comfort level with the scribe in the exam room, willingness to have a scribe present for subsequent visits, importance of the scribe being the same gender/age as the patient, and overall satisfaction with the scribe’s presence (TABLE 1).
Physician surveys included 5 closed-end questions9 regarding comfort level with the scribe’s presence, ease of EMR documentation, change in office hours with having a scribe for that day’s session(s), and overall helpfulness of the scribe (TABLE 2). Open-ended questions on both surveys asked for additional comments or concerns regarding scribes and the scribe’s impact on patient encounters.
Our goal was to collect a minimum of 100 completed patient surveys and 50 completed physician surveys representing as many different patient demographics, visit types, days of the week, and times of day as possible. Surveys were anonymous and distributed during the second and third months of the trial, giving the scribes a one-month training and adjustment period.
Impact assessment, professional development needs. At the end of the 6-month study period, we held 2 focus groups—one with nurses and one with scribes. From the nurses, we solicited insights regarding the impact of scribes on patient volume, patient satisfaction, visit flow, and EMR documentation.
Scribes were asked about job skills needed, amount of training received, comfort in the exam room (both for themselves and patients), frequency of feedback received, balancing physician style with EMR documentation needs, and lessons learned.