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Original Investigation
Physician Work Environment and Well-Being
November 2018

Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience

Author Affiliations
  • 1Division of Research, Kaiser Permanente Northern California, Oakland
  • 2Oakland Medical Center, Kaiser Permanente Northern California, Oakland
JAMA Intern Med. 2018;178(11):1467-1472. doi:10.1001/jamainternmed.2018.3956
Key Points

Question  Can the use of medical scribes decrease electronic health record documentation burden, improve productivity and patient communication, and enhance job satisfaction among primary care physicians?

Findings  In this crossover study of 18 primary care physicians, use of scribes was associated with significant reductions in electronic health record documentation time and significant improvements in productivity and job satisfaction.

Meaning  Use of medical scribes to reduce the increasing electronic health record documentation burden faced by primary care physicians could potentially reduce physician burnout.

Abstract

Importance  Widespread adoption of electronic health records (EHRs) in medical care has resulted in increased physician documentation workload and decreased interaction with patients. Despite the increasing use of medical scribes for EHR documentation assistance, few methodologically rigorous studies have examined the use of medical scribes in primary care.

Objective  To evaluate the association of use of medical scribes with primary care physician (PCP) workflow and patient experience.

Design, Setting, and Participants  This 12-month crossover study with 2 sequences and 4 periods was conducted from July 1, 2016, to June 30, 2017, in 2 medical center facilities within an integrated health care system and included 18 of 24 eligible PCPs.

Interventions  The PCPs were randomly assigned to start the first 3-month period with or without scribes and then alternated exposure status every 3 months for 1 year, thereby serving as their own controls. The PCPs completed a 6-question survey at the end of each study period. Patients of participating PCPs were surveyed after scribed clinic visits.

Main Outcomes and Measures  PCP-reported perceptions of documentation burden and visit interactions, objective measures of time spent on EHR activity and required for closing encounters, and patient-reported perceptions of visit quality.

Results  Of the 18 participating PCPs, 10 were women, 12 were internal medicine physicians, and 6 were family practice physicians. The PCPs graduated from medical school a mean (SD) of 13.7 (6.5) years before the study start date. Compared with nonscribed periods, scribed periods were associated with less self-reported after-hours EHR documentation (<1 hour daily during week: adjusted odds ratio [aOR], 18.0 [95% CI, 4.7-69.0]; <1 hour daily during weekend: aOR, 8.7; 95% CI, 2.7-28.7). Scribed periods were also associated with higher likelihood of PCP-reported spending more than 75% of the visit interacting with the patient (aOR, 295.0; 95% CI, 19.7 to >900) and less than 25% of the visit on a computer (aOR, 31.5; 95% CI, 7.3-136.4). Encounter documentation was more likely to be completed by the end of the next business day during scribed periods (aOR, 2.8; 95% CI, 1.2-7.1). A total of 450 of 735 patients (61.2%) reported that scribes had a positive bearing on their visits; only 2.4% reported a negative bearing.

Conclusions and Relevance  Medical scribes were associated with decreased physician EHR documentation burden, improved work efficiency, and improved visit interactions. Our results support the use of medical scribes as one strategy for improving physician workflow and visit quality in primary care.

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    2 Comments for this article
    EXPAND ALL
    Ahh but the quality...
    Mitchel Galishoff, MD | Private Practice
    Physician satisfaction may have been positively affected but what was the quality of the documentation? Medical documentation and communication between providers in the EHR era has clearly deteriorated. A well thought out note communicating a clear evaluation and management plan seems to have become a relic of bygone days. The chart note is the primary means of communication to current and future caregivers. I have personally found scribe notes lacking as both a referring physician and a patient.
    CONFLICT OF INTEREST: None Reported
    Many other benefits
    Paul Reiss, MD | Family medicine group practice, Evergreen Family Health
    Over 5 years and on fourth scribe... three went on to PA school.
    The study misses out on some of the most important benefits. Continuity and other tasks.

    Also, the study did not define scribe duties and functions

    I introduce the scribe as my assistant. She preps chart, reviews preventive and chronic care alerts, prints and delivers AVS, patient education,, and retrieves liq NO2, injection tray, etc.

    We get much better documentation, and more time to address prevention and new problems.
    Patients get to know her as a member of the team, and she augments
    the visit interaction. Each MD trains their own, and uses them differently. That's the best way.
    I would have retired years ago without scribe. Yet now at 21 face-to face hours, I am the highest biller in large practice.

    Pays for itself, personally and financially. Best innovation in primary care!

    CONFLICT OF INTEREST: None Reported
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