The Case

Your democratic ED group has embraced electronic medical records (EMRs). You have been doing computer physician order entry and full electronic documentation for a few years. Some members of the group are complaining about being expensive data entry clerks, and the metrics demonstrate a decrease in patient throughput. Is there a solution that can unburden physicians and increase productivity?

Background

It can take 4,000 clicks to get through a busy ED shift. Physicians spend more time on the EMR (40 percent) than performing direct patient care (30 percent).¹ EMRs have been cited as an important cause of burnout, which is associated with lower quality of care.^2,3

Scribes have been suggested as a possible solution by helping physicians with various EMR tasks (information retrieval, clinical encounter documentation, and discharge preparation). Most patients permit scribe participation in their care, and most physicians prefer working with scribes.^4,5

Clinical Question

Can scribes improve physicians’ productivity and improve patient throughput?

Reference

Walker K, Ben-Meir M, Dunlop W, et al. Impact of scribes on emergency medicine doctors’ productivity and patient throughput: multicentre randomised trial. BMJ. 2019;364:l121.

• Population: Five Australian emergency departments
• Intervention: Physicians working shifts with scribes
• Comparison: Physicians working shifts without scribes
• Outcomes:
  • Primary Outcome: Patients seen per hour
  • Secondary Outcome: Primary patients/physician/hour, door-to-doctor time, door-to-discharge time, patients/physician/hour in different regions of emergency department, patient safety events (scribe group only, no comparator), and retrospective cost-benefit analysis

Authors’ Conclusions

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“Scribes 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.”

Key Results: Investigators studied five sites. Twelve scribes and 88 physicians were included in the trial. There were 589 shifts with scribes capturing 5,098 patient encounters. Findings were compared to 3,296 shifts without scribes capturing 23,838 patient encounters.

The total number of patients seen per hour increased with scribes, and the cost analysis favored employing scribes.

• Primary Outcome: Patients seen per hour was 1.13 without a scribe and 1.31 with a scribe. This is an absolute increase of 0.18 more patients per hour (relative increase of 15.9 percent).
• Secondary Outcomes: Primary consultations per hour increased from 0.83 to 1.04, an absolute increase of 0.21 (relative increase of 25.6 percent). The door-to-doctor times were unchanged, while door-to-discharge times were reduced from 192 to 173 minutes. Within ED productivity changes, medical triage throughput increased by 0.53 patients per hour, acute area throughput increased by 0.10 patients per hour, sub-acute/short-stay throughput showed no changes, and pediatric throughput increased by 0.17 patients per hour. There was a minor patient safety event reported for one out of every 300 consultations.

Evidence-Based Medicine Commentary

1. Selection Bias: Scribes were not used at the discretion of the physician or if the patient declined. The number of times patients declined a scribe was not recorded. Scribes were also not present on nights and holidays. This could have introduced selection bias.
2. Lack of Blinding: It was not possible to blind the patients, physicians, and scribes. The lack of blinding could have introduced a Hawthorne effect, where individuals modify their behavior when they know they are being observed. This could bias the results, making the efficacy of scribes appear greater.
3. External Validity: This study was done in five Australian emergency departments. Their health care system is different than ours, as evidenced by a baseline throughput of 1.1 patient per hour. This is typically lower than what would be expected in an American emergency department.

Bottom Line

Scribes were cost-effective and had a positive impact on productivity in these Australian emergency departments.

Case Resolution

Your democratic group decides to conduct a trial period of using scribes. Their impact on physician satisfaction, cost-effectiveness, and throughput will be assessed after a few months. Whether scribe use decreases burnout has not been assessed.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References

1. Hill RG Jr, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31(11):1591-1594.
2. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clinic Proc. 2016;91(7):836-848.
3. Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. J Gen Intern Med. 2017;32(4):475-482.
4. Yan C, Rose S, Rothberg MB, et al. Physician, scribe, and patient perspectives on clinical scribes in primary care. J Gen Intern Med. 2016;31(9):990-995.
5. Cowan TL, Dunlop WA, Ben-Meir M, et al. Emergency consultants value medical scribes and most prefer to work with them, a few would rather not: a qualitative Australian study. Emerg Med J. 2018;35(1):12-17.