Keywords
scribes - efficiency - electronic health record
Electronic health records (EHR) have been associated with advantages in clinical practice
such as increased patient safety, enhanced retrieval and maintenance of patients'
record, decreased medication errors, and better communication between providers,[1]
[2]
[3]
[4] all of which improve clinical care. However, the EHR has posed certain challenges
such as high implementation cost, initial training requirement, reduction in clinical
volume,[3]
[5] concerns of negative patient–physician relationship, and increased physician's documentation.[1]
[2]
[4] The latter is associated with increased work burden, physician dissatisfaction,
and burnout.[6] Sinsky et al reported that for every hour a physician has direct contact with patients,
an additional 2 hours are spent on EHRs and administrative tasks in clinic. Another
1 to 2 hours each night outside office hours were spent for clerical work.[7]
In ophthalmology, the addition of the EHR has generated a variety of opinions, but
it is widely known that utilizing EHRs in practice requires a significant amount of
time for physicians.[5]
[8] One study reports that the EHR accounted for 27% of ophthalmologist's time during
patient encounters, using 10.8 minutes on average per encounter and 1.9 hours per
half-day clinic session.[9] The burden of the EHR on ophthalmologists specifically has been shown in several
studies to have a negative impact on productivity, with an increase in documentation
time but little to no increase or even reduction in clinical volume.[5]
[10]
Scribes have been shown to alleviate this clerical burden and reduce physician burnout.
Gidwani et al demonstrated that scribes improved charting efficiency and physician
satisfaction with no detrimental effect on patient satisfaction in a family medicine
clinic in an academic center.[2] In addition, productivity, revenue, and patient–physician interaction were shown
to improve with the use of scribes.[4]
[11]
[12]
[13] However, there have been no published studies to date evaluating the effect of incorporating
scribes into ophthalmology practice. The aim of this study is to determine what effect
scribes have on efficiency in an academic ophthalmology clinic.
Methods
This is a quality improvement study conducted by two attending ophthalmologists at
UT Health San Antonio from January 2018 to April 2018. Implementation of medical scribes
was the primary intervention. The main objectives of the scribes were to record exam
findings as dictated by the physician, provide in-room support to the physician, and
facilitate patient flow through clinic. In-room support varied with the type of patient
encounter but would consist of reviewing medication regimens, cleaning equipment,
or retrieving additional supplies. This study assigned scribe duties to individuals
who were previously trained as ophthalmic technicians, thus having knowledge of the
field and terminology. Clinic session time, patient encounter time, number of patients
seen per session, and template time adherence were recorded before and after intervention.
Session time was defined as start time of physician with the first patient until the
last patient encounter was completed. Clinic sessions typically represented a half-day
morning or afternoon, excluding extended break periods. These data points were recorded
by the scribe on a data sheet during each encounter, which prevented masking them
to the study. Template time was measured as the time allotted in a physician's schedule
for a particular encounter type such as preoperative follow-up, procedure, or new
patient evaluation. Unpaired two-tailed Student t-test and statistical process control charts were used for statistical analysis.
A second component of our analysis included a retrospective study of session time
and number of patients seen per session 12 to 18 months after implementation of scribes
into practice to evaluate whether this intervention allowed the provider to increase
patient load. Clinic sessions 12 to 18 months after the intervention were chosen at
random for evaluation. Session time was again defined as start time of physician with
first patient until last patient in clinic session and determined based on time stamps
in EHR. All statistical analyses were completed using QI Macros and Microsoft Excel.
Discussion
To our knowledge, this is the first study evaluating the use of medical scribes in
an ophthalmology practice and their effect on efficiency. Our study found that using
scribes in an ophthalmology practice improved clinical efficiency, demonstrated by
a reduction in mean clinic session time and mean patient encounter time. For our practice,
this created additional time to increase patient volume in future clinic sessions,
demonstrated by the increase in patients seen per session 12 to 18 months post-intervention.
The key findings in our report are consistent with studies from multiple other specialties
utilizing scribes in practice.[2]
[11]
[12]
[13]
[14] Our study also identifies specific actions for scribes to carry out that can increase
physician and practice efficiency. These actions include facilitating patient flow
through clinic and providing in-room support to physicians, in addition to helping
with the electronic medical record. These steps increased efficiency in each patient
encounter and allowed for comprehensive, personalized care in shorter amount of time.
Our study also emphasizes the long-term effect of scribes in practice over a 12- to
18-month period post-intervention. While the mean session time increased overall during
this period, the total patient volume also increased. These data suggest that scribes
allowed for increased efficiency in clinic, creating more time for additional patients
and a subsequent increase in patient volume.
In addition, the decrease in clinic session time allows for a variety of options for
utilization of that time in practice based on individual needs or requirements. We
chose to increase the amount of patients seen per half-day session, in an effort to
increase access to care based on the need in our population. In general, as the population
begins to age, the gap between eye care providers and patients is increasing.[15] Because of this finding, time and efficiency in ophthalmology has become increasingly
valuable. Implementing scribes into practice could have an additive effect on improving
access to care for the aging population. Other institutions and practices may utilize
the time in different ways including dedicated research, quality improvement projects,
or resident education.
Further, financial considerations were taken into account with regards to incorporating
a scribe into practice. Given that our own ophthalmic technicians were trained as
scribes, that meant an additional ophthalmic technician would need to be hired to
account for the patient screenings that the scribe was no longer doing. Thus, a return
on investment was calculated. Hiring a new technician costs approximately $50,000
annually. The average reimbursement for an office visit is approximately $148 (internal
departmental data). We took into account approximately 247 days spent in clinic each
year when subtracting weekends and holidays. Thus, adding two patients each day would
equate to $73,112 additional per year. This would result in an approximate return
on investment of $23,112 per year to the provider. Thus, adding a scribe seems makes
financial sense as well as improving efficiency and access to care.
Some limitations to the study should be noted. This study was limited to only two
physicians in the same geographic region and practice type, and thus findings might
not be generalizable to different areas or specialties. Our implementation of scribe
duties was performed by previously trained ophthalmic technicians. Traditional implementation
of newly-hired scribes might require additional time for training, familiarization
with space, and the EHR and could affect the speed of noticeable change in practice.
Our practice also utilizes residents working in conjunction with physicians which
could have affected overall timing in some clinic sessions and should be considered
as a possible confounding factor. In addition, patient and physician satisfaction
were not evaluated in our study. However, many studies in other fields have noted
favorable increases in physician satisfaction without changes in patient satisfaction.[1]
[2]
[11]
[12]
[13] Also, this study did not address what effect scribes may have on patient wait times.
The aforementioned limitations warrant future investigation and study.
Conclusion
Overall, our findings support increased efficiency with implementation of scribes
into ophthalmology practice. Specifically, scribes reduce the mean clinic session
time and mean patient encounter time. These effects allow for additional time within
a workday to increase patient volume or focus on quality improvement projects, research,
and resident education in an academic setting.
