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

Educational Objective
To evaluate the association of use of medical scribes with primary care physician (PCP) workflow and patient experience.
1 Credit CME
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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Article Information

Accepted for Publication: June 23, 2018.

Corresponding Author: Pranita Mishra, MPP, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 (pranita.mishra@kp.org).

Published Online: September 17, 2018. doi:10.1001/jamainternmed.2018.3956

Author Contributions: Ms Mishra and Dr Kiang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kiang, Grant.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Mishra, Grant.

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

Statistical analysis: Mishra, Kiang.

Obtained funding: Kiang.

Administrative, technical, or material support: Kiang, Grant.

Supervision: Grant.

Conflict of Interest Disclosures: None reported.

Additional Contributions: David Velek, MD, Pinole Medical Center, Kaiser Permanente, Pinole, California, inspired this project. Jay Yadegar, MD, Saralinda Jackson, Linda Carnes, RN, Christine Hartlove, Kara Durand, MD, and Aida Sadikovic, MD, Oakland Medical Center, Kaiser Permanente, Oakland, California, and Maya Shaw, MD, Pinole Medical Center, Kaiser Permanente, Pinole, California, provided leadership and support. We thank the physicians, medical assistants, and patients from our 2 primary care practices for their participation in this project. These individuals were not compensated for their work.

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