Abstract
This study examines the implementation of a multipractice quality improvement pilot program evaluating medical scribe impact on dermatologist documentation time and physician satisfaction.
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. Although EMRs offer care delivery integration, they have decreased physician job satisfaction and increased physician burnout across multiple fields, including dermatology. Employing medical scribes has enhanced clinical documentation, improved revenue collection, increased physician satisfaction, and reduced burnout in other specialties; 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.
Methods
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.
Results
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).
Figure. Average Prescribe and Postscribe Documentation Time by Dermatologists per Clinical Encounter.
Dermatologists spent on average 6.1 minutes documenting per clinical encounter across 690 patient encounters. Following scribe introduction, dermatologists spent on average 3.0 minutes documenting per clinical encounter across 695 patient encounters (3.2 fewer minutes per encounter; 95% CI, 2.66-3.63; P < .001).
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.
Table. Prescribe and Postscribe Survey Responsesa.
| Prescribe Question | Prescribe, Mean (SD) [n = 20] |
Postscribe Question | Postscribe, Mean (SD) [n = 22] |
|---|---|---|---|
| Using a scribe will decrease my documentation burden. | 3.55 (0.51)b | Using a scribe has decreased my documentation burden. | 3.72 (0.63) |
| Using a scribe will increase my job satisfaction. | 3.40 (0.82) | Using a scribe has increased my job satisfaction. | 3.59 (0.79) |
| Having a scribe will allow me to increase the number of patients I see. | 3.10 (0.72) | Having a scribe has allowed me to increase the number of patients I see. | 3.22 (0.87) |
| Working with a scribe will allow me to spend more time working with patients. | 2.95 (0.69) | Having a scribe has allowed me to spend more time working with patients. | 3.00 (0.89) |
| A scribe will help me close out encounters in a more timely manner. | 3.25 (0.85) | A scribe has helped me close out encounters in a more timely manner. | 3.57 (0.81) |
| A scribe will allow more time for other academic mission tasks (research, teaching, etc). | 3.32 (0.75) | Having a scribe has allowed me more time for academic endeavors. | 3.24 (0.94) |
| My patients will be more comfortable with a scribe in the room. | 2.90 (0.55) | How have your patients responded to the scribe experience?c | 3.36 (0.53) |
| Using a scribe has increased my documentation accuracy. | 3.05 (0.79) | ||
| Using a scribe has increased my efficiency in clinic. | 3.27 (0.83) | ||
| Having a scribe has reduced my sense of burnout. | 3.45 (0.91) |
Dermatologists at a single academic institution completed the baseline prescribe survey regarding demographic factors and clinical documentation practices. Means and standard deviations of dermatologist responses to perceptions of medical scribes before and after quality improvement pilot project. Dermatologists strongly agreed with scribe use decreasing documentation burden, increasing job satisfaction, and decreasing burnout.
All responses on a 4-point Likert scale, 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree.
For this question, responses are on a 4-point Likert scale with the following options, 1 = strongly dissatisfied, 2 = dissatisfied, 3 = satisfied, 4 = very satisfied.
Discussion
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.
Conclusions
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 literature that most documentation is occurring outside clinical time.
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