Medical Scribes in an Academic Dermatology Practice

Electronic medical records (EMRs) have resulted in increased documentation burden, with physicians spending up to 2 hours on EMR-related tasks for every 1 patient-care hour.¹ Although EMRs offer care delivery integration, they have decreased physician job satisfaction and increased physician burnout across multiple fields, including dermatology.^2,3 Employing medical scribes has enhanced clinical documentation, improved revenue collection, increased physician satisfaction, and reduced burnout in other specialties^4-6; however, dermatology-specific data are lacking. We implemented a multipractice quality improvement pilot program evaluating medical scribe impact on dermatologist documentation time and physician satisfaction.

In May 2015, our institution introduced a new EMR (Epic Systems). Hospital funding supported a 12-month quality improvement pilot program of scribe implementation in our department comprising 39 dermatologists and 11 distinct practice locations. Twelve dermatologists received scribe support in 19 weekly half-day general dermatology sessions across 3 clinical sites beginning February 2016. Scribes were hired from ScribeAmerica and underwent dermatology-specific classroom training. Each scribe was then floor trained by a lead scribe who had shadowed each physician to learn physician-specific workflow and documentation preferences. Scribes used dedicated laptops carried between rooms. After achieving documentation competency, scribes also pended orders (eg, pathology requisitions), medications, and diagnoses for physician approval. Two months after implementation, 2 additional patients per scribe-supported session were added to physician schedules.

Department members completed preimplementation (December 2015) and postimplementation surveys (October 2016) assessing physician satisfaction and clinical workflow. Each scribe-supported physician performed self-timed clinical documentation audits using stopwatches for 3 prescribe (December 2015) and 3 postscribe (March 2016-November 2016) sessions. Descriptive and comparative statistics were performed. This project was a Quality Improvement initiative, and thus was not formally supervised by our institutional review board per their policies.

Prescribe clinical documentation time was most frequently reported as 60 to 89 minutes per session, with 6 (30%) of 20 respondents spending over 2 hours per session. Most respondents reported more than 80% of clinical documentation completion outside allotted clinical session time, and nearly all noted clinical documentation was sometimes, often, or always an issue. Respondents expressed interest in scribes, anticipating decreased documentation burden and increased job satisfaction, but were unsure of patients’ perceptions.

Across 690 prescribe time-audited encounters, dermatologists averaged 6.1 minutes of clinical documentation per patient and 75 minutes of documentation per half-day session. Across 695 postscribe visits, physician documentation time significantly decreased, averaging 3.0 minutes per patient and 36 minutes per session (3.2 fewer minutes per patient encounter; 95% CI, 2.66-3.63; P < .001) (Figure).

Given positive feedback, scribe support was expanded to 44 scribe-supported sessions weekly by October 2016. Dermatologists reported significantly decreased clinical documentation time, and less documentation time outside clinical hours after implementation. Dermatologists’ perceptions of scribe usefulness improved over baseline, more strongly agreeing with decreased documentation burden and increased job satisfaction after implementation (Table). Of 19 respondents, 15 (79%) reported willingness to increase patient volume with scribe support. Overall, there was a 7.7% increase in revenue comparing each physician’s scribe-supported sessions to unsupported sessions in the last quarters of 2016 to 2015 respectively, which more than off-set the cost of the scribes. Overall, roughly 1 additional patient per session covered the hospital’s scribe costs.

Our scribe pilot program achieved significant documentation time savings and reduction of physician burnout factors. Dermatologists’ willingness to see additional patients with scribe support reflected enhanced physician efficiency, improved patient access, and increased clinical revenue. A third-party contractor overseeing scribe hiring, training, and management enabled rapid implementation, minimized quality variability, and minimized impedance of physician workflow. Scribes were well received by patients, with few refusals and unchanged overall patient satisfaction scores.

Other solutions combatting physician documentation burdens, such as real-time dictation software or conventional transcription services, have been employed particularly successfully in diagnostic specialties, such as pathology and radiology, which have limited point-of-care patient interaction.

Scribes enable dermatologists to achieve real-time documentation, thereby improving physician efficiency and freeing time for scholarly, leadership, teaching, or personal pursuits. Our initiative’s limitations include its single-institutional nature, though we achieved scalable implementation across multiple practices. Our observation that dermatologists did not report increased time with patients following scribe-support likely reflects our baseline findings and those in the literature¹ that most documentation is occurring outside clinical time.

Corresponding Author: Vinod E. Nambudiri, MD, MBA, 221 Longwood Ave, Boston, MA 02115 (vnambudiri@bwh.harvard.edu).

Accepted for Publication: July 30, 2017.

Published Online: November 1, 2017. doi:10.1001/jamadermatol.2017.3658

Author Contributions: Drs Nambudiri and Yang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Watson, Buzney, Kupper, Rubenstein, Yang.

Acquisition, analysis, or interpretation of data: Nambudiri, Watson, Kupper, Rubenstein, Yang.

Drafting of the manuscript: Nambudiri, Yang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Nambudiri.

Obtained funding: Kupper.

Administrative, technical, or material support: Kupper, Rubenstein, Yang.

Study supervision: Watson, Kupper, Rubenstein, Yang.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported exclusively through hospital funding from Brigham and Women’s Hospital. Funding for the support of scribes detailed in this work was provided through internal department and hospital funding.

Role of the Funder/Sponsor: Brigham and Women’s Hospital was not involved in design and conduct of the study; collection, management, analysis and interpretation of data; preparation, review, or approval of the manuscript; nor decision to submit the manuscript for publication.

Additional Contributions: We thank the administrators who were essential in the implementation of the scribe project: Krystyna Prokopiuk, LPN, Tamara Lugdon, BS, Debby Smith, Koravee Xeung, BA, and Philip Harper, BS, and Tamara Lugdon, BS, and Johanna McArdle, BA, for their help with financial analysis. All are affiliated with Brigham and Women's Hospital, Department of Dermatology. They were not compensated.