key: cord-253189-uba6dy08
authors: Walker, Katie; Heaton, Heather A.
title: The evidence base for scribes and the disruptions of COVID-19
date: 2020-09-21
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2020.09.438
sha: 
doc_id: 253189
cord_uid: uba6dy08

Gottleib et al present a systematic review with some economic evidence for using scribes. Improvements are seen in physician productivity and increased per-patient revenue in the United States of America, but not patient flow. The improvements are relatively small and this may or may not be economic for a facility depending on the location, true costs and gains/losses of the scribe program. Scribes are well tolerated by patients and most physicians have a better experience when allocated a scribe. There are gaps in our knowledge regarding scribes, including total costs of programs, quality and safety information, whether scribes reduce physician burnout and the impact of the role on the scribe. Scribe roles and locations of work have changed during the COVID-19 period. Future research should explore how best to spend health dollars to improve patient access to skilled providers in a timely fashion, including comparisons of various provider roles and explorations of how to make health information technologies work better for the end user.

Medical scribes have worked in emergency medicine (EM) for approximately 30 years.

Initially, they worked with paper medical records, but now the majority assist with data entry tasks electronically. There has been a major expansion of scribe programs in the United States of America (USA) both in terms of their employment locations, now moving outside the emergency department (ED), and numbers, despite attempts to streamline documentation in electronic health records (EHRs) so that clerical support is no longer required. In order to justify a scribe program, the role has to make economic sense. Scribes can't bill for their services and so income for scribes needs to be realised elsewhere. This is usually achieved in three ways: improving flow (assuming new patients are always waiting), J o u r n a l P r e -p r o o f improving physician productivity per unit of time, and increasing per-patient revenue. These improvements are balanced against scribe costs including equipment, recruitment, training, administration, and labor. Gottleib et al find that patient flow is unchanged when scribes are present. Physician productivity increases a little with scribes from 1.95 to 2.25 patients per hour (in both ED and non-ED settings). Per-patient income also increases a little in the USA, from 2.39 relative value units (RVUs) per patient without a scribe to 2.53 with a scribe.

In some settings, these gains will be enough to support a scribe program. Despite the large number of patients in the review, the level of evidence supporting scribes remains of very low quality according to GRADE criteria.

Patient tolerance of scribes is at least neutral with a tendency towards a positive experience for scribed consultations. Importantly, patients don't seem to withhold personal health information whilst a scribe is present. Physicians mainly enjoy working with scribes, with the majority of physicians supporting their use. In contrast, a few physicians prefer to work without a scribe.

Whilst most studies report financial benefits from using scribes, program impact is variable.

Some sites don't find a benefit, others report large gains, which demonstrates the importance of randomised multicentre studies and of monitoring scribe program performance at individual sites. 2, 9 Furthermore, understanding why some sites do not find benefit is limited, as few organizations closing scribe programs publish their experience.

Manuscripts evaluating scribes rarely undertake complete cost analyses. Labor costs are usually reported, however the costs of recruiting, training and managing scribes are usually omitted. Calculations accounting for the lag in physician productivity until a scribe gains adequate experience 10 are almost never provided.

Deficits in scribe research include quality and safety. There are two manuscripts that evaluate the quality of scribe notes; however the lack of a reliable research tool for documentation quality makes these evaluations hard to interpret. 11, 12 There is only one study that describes patient safety incidents related to scribes. The safety data relied on self-reporting by scribes and physicians, and didn't provide a systematic evaluation of harms J o u r n a l P r e -p r o o f related to scribes. 7 A well-planned, rigorous, safety study with sufficient numbers of patients, scribes, physicians and locations is needed.

Despite many statements discussing how scribes reduce physician burnout, this remains unproven. Whilst it seems intuitive to most that electronic medical records (EMRs) contribute to burnout, there haven't been any studies that critically examine the relationship between scribe presence and physician burnout prevalence or severity.

Many physicians work a considerable amount of unpaid overtime. Without a scribe, once a shift is ended, physicians often complete charts and this time isn't usually captured in administrative databases. Many studies note that physicians go home soon after completion of their shift when working with a scribe but can't report the magnitude of the impact. One study illustrates decreased documentation time both during and post shift with scribes, but is limited by size and power. 13 Calculating the true productivity of physicians with scribes is inaccurate for this reason, biasing many studies against scribe programs.

Medical scribes are often people who wish to become healthcare professionals. There are very few studies reporting the experiences of scribes and whether the role provides them with education or career benefits that travel with them into their future careers. A longitudinal study would be welcomed. Impact of COVID19 on scribe programs 2020 has provided significant challenges for EM and for all other medical settings as well.

There have been varied impacts on patient volumes across practices, from 25-50% reductions [14] [15] [16] to overwhelming volumes of patients, disaster conditions and personal protective equipment shortages. All settings have experienced unease about the transmission of COVID19 to healthcare workers, particularly in EM 17 and so scribes and other support personnel have been removed from many EDs.

Demand for scribes and the role and location of scribes has also changed in many facilities, with many scribes unemployed or redeployed. Some scribes are still working in their original position at the bedside, others assist with transcribing telehealth evaluations and work J o u r n a l P r e -p r o o f remotely. There is a lack of published information on these role changes to date and the long-term impact on scribe responsibilities is yet to be determined.

In summary, there is now some limited economic evidence for using scribes, with small improvements seen in physician productivity and increased per-patient revenue in the USA, but not patient flow. The improvements must be compared to true costs of the scribe program. Scribes are well tolerated by patients and most physicians have a better experience when allocated a scribe. Surprisingly, there still remains limited peer-reviewed literature supporting scribes in health care despite rapid uptake of the role; the impact of the scribe role must be critically examined to inform health administrators and physicians who are considering employing scribes and developing scribe programs. There are too many gaps in our knowledge to fully endorse such a health care team member role.

The role of the scribe has been changed by COVID19 pandemic. Whereas literature to date has focused on scribes at the bedside, we suspect the scribe industry will evolve with virtual options becoming standard. There is no research into the value of virtual scribes versus inperson scribes; this will provide another interesting angle for future researchers to evaluate.

The silent elephant in the room remains the EMR. Despite major advances in technology, clinical documentation remains enough of a burden that a significant number of clinicians are forced to outsource the task. Additional focus on understanding the challenges of efficient documentation is important. There should also be evaluations of EMR software and its cost to the care team. If every provider loses productivity every shift due to struggles with EMR inefficiencies, EMRs are very expensive. We must understand why these systems demand the addition of workforce to mitigate clerical challenges and what improvements are needed from the EMR software to retire the scribe profession.

Moving forward in improving physician productivity, there should be a critical and broader look at how and where to spend money to improve patient access to suitably skilled providers in a safe way. Comparisons should be made between costs and patient safety J o u r n a l P r e -p r o o f 6 regarding scribes verses added additional direct care clinical staff. Would new efficiencies be gained by the addition of another nurse or alternate provider instead of a scribe?

Ultimately, future work should explore how best to spend health dollars to improve patient access to skilled providers in a safe and timely fashion, including comparisons of various provider roles and explorations of how to make EMRs work better for the clinician end user.

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Time Motion Analysis: Impact of Scribes on Provider Time Management

Hong Kong emergency department attendance plummets during COVID-19

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