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Effects of medical scribes on physician productivity in a Canadian emergency department: a pilot study.

ABSTRACT: BACKGROUND:Emergency department efficiency is a priority across Canada. In the United States, scribes may increase the number of patients seen per hour per physician; however, Canadian data are lacking. We sought to implement scribes in a Canadian emergency department with the hypothesis that scribes would increase the number of patients seen per hour per physician. METHODS:We conducted a 4-month quality improvement pilot study in a community emergency department in Ottawa, Ontario. Data collection began January 2015 after scribe training. Physicians received shifts with and without a scribe for a period of 4 months. Across the study, the mean number of patients seen per hour was determined for each physician during shifts with and without a scribe. We compared mean (± standard deviation [SD]) number of patients seen per hour based on presence or absence of a scribe by 2-tailed paired-samples t test. RESULTS:Eleven scribes participated and ranged in age from 18 to 23 years. Twenty-two full- or part-time emergency physicians were followed. We documented 463 physician-hours without use of a scribe and 693.75 physician-hours with use of a scribe. Across all 22 physicians, 18 (81.8%) saw more patients per hour with use of a scribe. Overall, the number of patients seen per hour per physician was significantly greater (+12.9%) during shifts with a scribe (mean [± SD] 2.81 [± 0.78]) than during shifts without a scribe (mean [± SD] 2.49 [± 0.60]; p = 0.006). INTERPRETATION:In this pilot study, the use of scribes resulted in an increased number of patients seen per hour per physician. Because this was a small study at a single centre, further research on the effects of scribes in Canada is warranted.

SUBMITTER: Graves PS

PROVIDER: S-EPMC6182119 | biostudies-literature | 2018 Jul-Sep

REPOSITORIES: biostudies-literature

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Effects of medical scribes on physician productivity in a Canadian emergency department: a pilot study.

Graves Peter S PS Graves Stephen R SR Minhas Tanvir T Lewinson Rebecca E RE Vallerand Isabelle A IA Lewinson Ryan T RT

CMAJ open 20180701 3

<h4>Background</h4>Emergency department efficiency is a priority across Canada. In the United States, scribes may increase the number of patients seen per hour per physician; however, Canadian data are lacking. We sought to implement scribes in a Canadian emergency department with the hypothesis that scribes would increase the number of patients seen per hour per physician.<h4>Methods</h4>We conducted a 4-month quality improvement pilot study in a community emergency department in Ottawa, Ontari ...[more]

PMID: 30181347

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Project description:BackgroundUse of electronic health records (EHRs) is associated with physician stress and burnout. While emergency departments and subspecialists have used scribes to address this issue, little is known about the impact of scribes in academic primary care.ObjectiveAssess the impact of a scribe on physician and patient satisfaction at an academic general internal medicine (GIM) clinic.DesignProspective, pre-post-pilot study. During the 3-month pilot, physicians had clinic sessions with and without a scribe. We assessed changes in (1) physician workplace satisfaction and burnout, (2) time spent on EHR documentation, and (3) patient satisfaction.ParticipantsSix GIM faculty and a convenience sample of their patients (N = 325) at an academic GIM clinic.Main measuresA 21-item pre- and 44-item post-pilot survey assessed physician workplace satisfaction and burnout. Physicians used logs to record time spent on EHR documentation outside of clinic hours. A 27-item post-visit survey assessed patient satisfaction during visits with and without the scribe.Key resultsOf six physicians, 100% were satisfied with clinic workflow post-pilot (vs. 33% pre-pilot), and 83% were satisfied with EHR use post-pilot (vs. 17% pre-pilot). Physician burnout was low at baseline and did not change post-pilot. Mean time spent on post-clinic EHR documentation decreased from 1.65 to 0.76 h per clinic session (p = 0.02). Patient satisfaction was not different between patients who had clinic visits with vs. without scribe overall or by age, gender, and race. Compared to patients 65 years or older, younger patients were more likely to report that the physician was more attentive and provided more education during visits with the scribe present (p = 0.03 and 0.02, respectively). Male patients were more likely to report that they disliked having a scribe (p = 0.03).ConclusionIn an academic GIM setting, employment of a scribe was associated with improved physician satisfaction without compromising patient satisfaction.

Project description:ObjectivesTo evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput.DesignRandomised, multicentre clinical trial.SettingFive emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit.Participants88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site.InterventionsPhysicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018.Main outcome measuresPhysicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done.ResultsData were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes.ConclusionsScribes improved emergency physicians' productivity, particularly during primary consultations, and decreased patients' length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia's.Trial registrationACTRN12615000607572 (pilot site); ACTRN12616000618459.

Project description:ImportanceWidespread 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.ObjectiveTo evaluate the association of use of medical scribes with primary care physician (PCP) workflow and patient experience.Design, setting, and participantsThis 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.InterventionsThe 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 measuresPCP-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.ResultsOf 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 relevanceMedical 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.

Project description:BackgroundEstablishing rapport and empathy between patients and their health care provider is important but challenging in the context of a busy and crowded emergency department (ED).ObjectiveWe explore the hypotheses that rapport building, documentation, and time efficiency might be improved in the ED by providing patients a digital tool that uses Bayesian reasoning-based techniques to gather relevant symptoms and history for handover to clinicians.MethodsA 2-phase pilot evaluation was carried out in the ED of a German tertiary referral and major trauma hospital that treats an average of 120 patients daily. Phase 1 observations guided iterative improvement of the digital tool, which was then further evaluated in phase 2. All patients who were willing and able to provide consent were invited to participate, excluding those with severe injury or illness requiring immediate treatment, with traumatic injury, incapable of completing a health assessment, and aged <18 years. Over an 18-day period with 1699 patients presenting to the ED, 815 (47.96%) were eligible based on triage level. With available recruitment staff, 135 were approached, of whom 81 (60%) were included in the study. In a mixed methods evaluation, patients entered information into the tool, accessed by clinicians through a dashboard. All users completed evaluation Likert-scale questionnaires rating the tool's performance. The feasibility of a larger trial was evaluated through rates of recruitment and questionnaire completion.ResultsRespondents strongly endorsed the tool for facilitating conversation (61/81, 75% of patients, 57/78, 73% of physician ratings, and 10/10, 100% of nurse ratings). Most nurses judged the tool as potentially time saving, whereas most physicians only agreed for a subset of medical specialties (eg, surgery). Patients reported high usability and understood the tool's questions. The tool was recommended by most patients (63/81, 78%), in 53% (41/77) of physician ratings, and in 76% (61/80) of nurse ratings. Questionnaire completion rates were 100% (81/81) by patients and 96% (78/81 enrolled patients) by physicians.ConclusionsThis pilot confirmed that a larger study in the setting would be feasible. The tool has clear potential to improve patient-health care provider interaction and could also contribute to ED efficiency savings. Future research and development will extend the range of patients for whom the history-taking tool has clinical utility.Trial registrationGerman Clinical Trials Register DRKS00024115; https://drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00024115.

Project description:Several prior studies have examined the impact of learners (medical students or residents) on overall emergency department (ED) flow as well as the impact of resident training level on the number of patients seen by residents per hour. No study to date has specifically examined the impact of learners on emergency medicine (EM) attending physician productivity, with regards to patients per hour (PPH). We sought to evaluate whether learners increase, decrease, or have no effect on the productivity of EM attending physicians in a teaching program with one student or resident per attending.This was a retrospective database review of an urban, academic tertiary care center with 3 separate teams on the acute care side of the ED. Each team was staffed with one attending physician paired with either one resident, one medical student or with no learners. All shifts from July 1, 2008 to June 30, 2010 were reviewed using an electronic database. We predefined a shift as "Resident" if > 5 patients were seen by a resident, "Medical Student" if any patients were seen by a medical student, and "No Learners" if no patients were seen by a medical student or resident. Shifts were removed from analysis if more than one learner saw patients during the shift. We further stratified resident shifts by EM training level or off-service rotator. For each type of shift, the total number of patients seen by the attending physician was then divided by 8 hours (shift duration) to arrive at number of patients per hour.We analyzed a total of 7,360 shifts with 2,778 removed due to multiple learners on a team. For the 2,199 shifts with attending physicians with no learners, the average number of PPH was 1.87(95% confidence interval [CI] 1.86,1.89). For the 514 medical student shifts, the average PPH was 1.87(95% CI 1.84,1.90), p = 0.99 compared with attending with no learner. For the 1,935 resident shifts, the average PPH was 1.99(95% CI 1.97,2.00). Compared with attending physician with no learner, attending physicians with a resident saw more PPH (1.99 vs 1.87, p<0.005). There was no statistically significant difference found between EM1: 1.98PPH, EM2: 1.99PPH, EM3: 1.99PPH, and off-service rotators: 1.99PPH.EM attending physicians paired with a resident in a one-on-one teaching model saw statistically significantly more patients per hour (0.12 more patients per hour) than EM attending physicians alone. EM attending physicians paired with a medical student saw the same number of patients per hour compared with working alone.

Project description:BACKGROUND:Shopping for health insurance is encouraged as a way to find the most affordable coverage that best meets an enrollee's needs. However, the extent to which individuals switch insurance and subsequent changes in health care utilization that might arise, particularly new physician visits, are not well understood. OBJECTIVE:To examine the relationship between insurance switching and new physician and emergency department visits around the time of a switch. DESIGN:Observational study using a difference-in-differences design to compare those switching insurance carriers with propensity score-matched controls who did not switch, stratified based on whether individuals initially had private or Medicaid insurance coverage. All analyses adjusted for individual and insurance characteristics. PARTICIPANTS:Continuously insured, non-elderly individuals with private or Medicaid insurance coverage in Massachusetts from 2010 to 2013. MAIN MEASURES:Rates of new primary care and specialist physician visits, as well as rates of emergency department visits. KEY RESULTS:Before matching, among 1,628,057 continuously insured individuals, 418,231 (26%) switched insurance carriers during a 2-year period. Characteristics of switchers and non-switchers were similar after matching (n = 316,343 in each group). After matching, switching plans was associated with a 203% and 47.5% increase in the rate of new primary care physician visits following switching for those initially with Medicaid or private coverage, respectively (both p < 0.001), with a large short-term increase, diminishing over time. Among those with Medicaid coverage, switching was associated with a 14.9% higher rate of ED visits during the month of switching (p < 0.001), but otherwise decreased modestly after switching. CONCLUSIONS:Insurance switching is common, and is associated with increased new physician visits and temporarily increased ED use among the publicly insured. As insurance markets become more volatile in the current policy environment, understanding changes in utilization after insurance switching may become increasingly important.

Dataset Information

Effects of medical scribes on physician productivity in a Canadian emergency department: a pilot study.

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Effects of medical scribes on physician productivity in a Canadian emergency department: a pilot study.

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