How to End a Note Stating I Reviewed What the Medical Scribe Typed

• Journal List
• J Gen Intern Med
• v.31(nine); 2016 Sep
• PMC4978677

J Gen Intern Med. 2016 Sep; 31(9): 990–995.

Physician, Scribe, and Patient Perspectives on Clinical Scribes in Primary Care

Chen Yan, BS,¹ Susannah Rose, PhD,^{one, 2} Michael B. Rothberg, Physician, MPH,³ Mary Beth Mercer, MPH,² Kenneth Goodman, Doc,⁴ and Anita D. Misra-Hebert, Md, MPH ³

Chen Yan

^aneCleveland Clinic Lerner Higher of Medicine of Case Western Reserve University, 9500 Euclid Avenue/NA21, Cleveland, OH 44195 USA

Susannah Rose

¹Cleveland Clinic Lerner Higher of Medicine of Case Western Reserve University, 9500 Euclid Avenue/NA21, Cleveland, OH 44195 USA

²Department of Bioethics, Center for Ideals Humanities and Spiritual Care, Cleveland Clinic, 9500 Euclid Avenue, JJ60, Cleveland, OH 44195 USA

Michael B. Rothberg

³Center for Value-Based Intendance Research, Medicine Plant, Cleveland Clinic, 9500 Euclid Artery, G10, Cleveland, OH 44195 U.s.

Mary Beth Mercer

²Department of Bioethics, Center for Ethics Humanities and Spiritual Care, Cleveland Clinic, 9500 Euclid Artery, JJ60, Cleveland, OH 44195 United states

Kenneth Goodman

^fourDepartment of Family unit Medicine, Cleveland Clinic, BD10, 26900 Cedar Road, Beachwood, OH 44122 USA

Anita D. Misra-Hebert

³Center for Value-Based Care Enquiry, Medicine Found, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH 44195 USA

Received 2015 Dec 14; Revised 2016 Mar 29; Accepted 2016 Apr nineteen.

Abstruse

BACKGROUND

Extending medical assistants and nursing roles to include in-visit documentation is a recent innovation in the age of electronic health records. Despite the utilise of these clinical scribes, niggling is known regarding interactions among and perspectives of the involved parties: physicians, clinical scribes, and patients.

OBJECTIVE

The purpose of this project is to describe perspectives of physicians, clinical scribes, and patients regarding clinical scribes in chief care.

Pattern

Nosotros used qualitative content analysis, using Interpretive Description of semi-structured audio-recorded in-person and telephone interviews.

PARTICIPANTS

Participants included eighteen physicians and 17 clinical scribes from six healthcare systems, and 36 patients from 1 healthcare system.

Key RESULTS

Despite physician concerns regarding terminology within notes, physicians, clinical scribes, and patients perceived more detailed notes because of real-time documentation by scribes. Well-nigh patients were comfy with the scribe's presence and perceived increased attention from their physicians. Clinical scribes also performed more agile roles during a patient visit, leading to formation of positive scribe–patient relationships. The resulting shift in workflow, however, led to stress. Our theoretical model for successful doctor-scribe teams emphasizes the importance of interpersonal aspects such as communication, mutual respect, and adaptability, also as arrangement level back up such as training and staffing.

CONCLUSIONS

Both interpersonal fit between medico and scribe, and arrangement level support including acceptable preparation, transition fourth dimension, and staffing support are necessary for successful use of clinical scribes. Time to come directions for research regarding clinical scribes include report of intendance continuity, scribe medical knowledge, and scribe burnout.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-016-3719-10) contains supplementary fabric, which is available to authorized users.

KEYWORDS: primary intendance, main intendance redesign, md–patient relationships, patient centered care, qualitative research

INTRODUCTION

Though implementation of electronic wellness records (EHRs) has been shown to have positive effects in quality and cost of intendance,^{one , 2} concerns have arisen regarding the impact of EHR use on patient–physician relationships,^{3 – 5} particularly the computer's negative influence on overall patient centeredness.^{3 , 6 , 7} Combined with a national shortage of primary care physicians^{viii – x} and increasing physician exhaustion,¹¹ these concerns take sparked efforts to redistribute responsibilities in an expanded primary intendance team.^{12 , thirteen} In item, the function of medical administration (MAs) and nurses have been expanded to include clinical scribing, too known as team documentation.^{xiv – 16}

As clinical scribes, MAs and nurses are hired individually and retain usual duties of gathering information during patient intake, assisting with physician in-baskets, fielding patient telephone calls, and performing clinical tasks such as in-office testing and immunizations. To perform the boosted documentation duty, they remain in the examination room during the physician–patient encounter and utilise EHR templates to update history, physical exam findings, prescriptions, and necessary orders in real fourth dimension. In consideration of the heterogeneity of training and work experience among clinical scribes,¹⁴ clinics applying team documentation carry onsite preparation that include EHR navigation, clinical shadowing, and connected projection management follow-up. Existing studies of clinical scribes are few with data restricted to efficiency¹⁶ and patient–physician face time.¹⁷ They offer little insight into the dynamic interactions and relationships among physician, clinical scribes, and patients. This project thus seeks to fill these gaps through eliciting and describing the perspectives of physicians, clinical scribes, and patients regarding clinical scribes in the primary intendance setting.

METHODS

In consideration of the exploratory nature of the study and the limited number of physicians and clinical scribes participating in team documentation, qualitative research methods were chosen to generate broad descriptions and new hypotheses. Semi-structured sound recorded individual interviews were conducted with physicians, clinical scribes, and patients. Interview guides appear in Online Appendix^one, ², and ³. Recruitment using individual emails included eight health systems that utilize clinical scribes based on a previously published article describing innovations in master care.⁸ At Cleveland Clinic sites, all eligible physicians identified from a project management-provided list were contacted. Snowball sampling was used for scribe recruitment, with invitations sent based on referral by physicians and scribes. At other sites, invitations were made based on referral past site liaisons. Invitations grouped past clinical site were sent out on a rolling basis to accommodate concurrent thematic analysis until data saturation was reached. Patients were recruited and interviewed during a dispensary day with the physicians' permission. No incentives were offered for participation. All interviews were conducted individually. Because of geographic constraint, in-person interviews were conducted at Cleveland Clinic sites while telephone interviews were conducted elsewhere. The interview guides did not differ for in-person versus telephone interviews. Patient interviews were conducted only at Cleveland Clinic sites. Interview questions were written to be open up-ended with both positive and negative prompts included in an attempt to remain objective and to avoid leading questions. Probing questions were scripted based on a broad framework of the interactions of the key players (Fig.i). A single interviewer (C.Y.) obtained informed consent, then conducted and transcribed the audio-recorded interviews verbatim. Thematic analysis using Interpretive Description, involving inductive analytic methods such equally data immersion, coding, memoing and constant comparison,¹⁸ was iterative and cyclical. By design, no themes were prospectively identified. Rather, using Interpretive Description, themes were extracted in a bottom-up manner. This methodology generates do-relevant findings in context of previously known data and discipline-specific biases. Using NVivo10, the principal coder (C.Y.) reviewed each transcript and coded primal quotations. New coding was constantly compared with codes from previous transcripts within an interview grouping to generate descriptive summary codes. Upon review with a collaborator with extensive feel in qualitative methodologies (1000.B.Yard.), summary codes were discussed and coalesced into broader themes for each study population. When both C.Y. and One thousand.B.K. agreed that no new themes could be generated, data saturation was deemed to be reached. Tables of generated group themes and related quotations for physicians, clinical scribes, and patients were further presented to three physicians (A.Thou.H., M.R., and K.Grand.) and ane doctorate level health services researcher (S.R.) every three months. These reviewers aided in interpretation of the descriptive themes to generate overarching umbrella themes reflecting overlaps of carve up grouping themes. This research study was approved by the Cleveland Clinic Institutional Review Board.

Considerations of interactions in scribing model for questionnaire design

RESULTS

Of eight contacted health systems, physicians and clinical scribes at half dozen systems agreed to participate (Table ​ one). Interviews were conducted from September 2014 to August 2015. Physician interviews ranged 15–36 minutes, scribe interviews 6–18 minutes, and patient interviews 3–eight minutes. Information saturation was reached at 18 physicians, 17 scribes, and 36 patients. Scribe documentation experience ranged from 0.v to 8 years (boilerplate 2.iii years). Scribes had clinical experience ranging iii to 30 years (average 12 years). Well-nigh patients were established patients (31/36) presenting for follow-up (23/36). Length of patient–physician human relationship ranged from 0 to 27 years (average 7.12 years). Qualitative assay generated three core themes: documentation, patient intendance, and teamwork.

Table one.

Interview sites

Site	Location	Recruited	Interviews
Cleveland Clinic	Beachwood, OH Brunswick, OH Cleveland (principal) Solon, OH Twinsburg, OH Strongsville, OH Willoughby, OH Wooster, OH	iii physicians, 4 scribes 2 physicians, 0 scribes 1 md, one scribe 3 physicians, 4 scribes 1 physician, ii scribes 7 physicians, 4 scribes 1 doc, 1 scribe 4 physicians, 4 scribes	3 physicians, 2 scribes 0 physicians, 0 scribes 0 physicians, 0 scribes two physicians, 2 scribes 1 doctor, ii scribes 3 physicians, 3 scribes 0 physicians, 0 scribes 2 physicians, two scribes
Bellin Wellness	Light-green Bay, WI	1 md, 1 scribe	1 dr., 1 scribe
Dekalb Medical Health Group	Auborn, IN	2 physicians, 1 scribe	i doctor, 0 scribes
Martin's Signal Healthcare	Bangor, ME	2 physicians, 2 scribes	two physicians, 2 scribes
Quincy Family unit Exercise	Quincy, IL	ii physicians, ii scribes	1 physician, ane scribes
Academy of Utah	South Jordan, UT	2 physicians, ii scribes	2 physicians, two scribes

DOCUMENTATION

Physicians, scribes, and patients agreed that physicians should not be the ones to document. Ane physician commented that "having doctors scribe is a waste of doctor fourth dimension. I don't think it meets the concept of everybody working to the top of their license." Equally another physician explained, "the main thing that physicians should do is make medical decisions and do assessments…we would really like to take physicians primarily doing that instead of busy work." Scribes echoed these sentiments. 1 noted, "the scribing and doing all this typing…it'southward really not provider-level." Patients also separated documentation from the function of a medico. As one patient observed, with the scribe, the physician was "not and then doing administrative type things, he's being the doctor."

Perceptions of the resulting quality of documentation were mixed. Real-time documentation led to the perception of improved record details. 1 scribe noted that without a scribe, physicians were "but making quick little notes, And so, like, at the end of the 24-hour interval, or even 2 days later, they're going in and doing their notation! And so a lot of things would get missed and the notes aren't very good." Patients besides remarked on the delay in documentation. As one patient observed, "the dr.'s really decorated and then by the time he goes back, probably not equally much item in there as with the nurse in that location typing it in." Some physicians admitted that without a scribe, their notes consisted of just "loftier points," "brief phrases," or "partial sentences." With the scribe, as one physician summarized, "key components…are recorded in real-time…so I feel like I'yard not missing out on whatsoever of those details." Both physicians and scribes, however, raised concerns regarding annotation structure and linguistic communication. To facilitate documentation, many scribes used pre-designed templates. One doctor noticed, however, that "at that place can exist patient scenarios where we don't quite accept a template that fits." Another physician added, "you tin can't really template a human existence." Consequently, the scribe may need to go off template. Unfortunately, 1 doc observed, some scribes are "not so skilful at free-texting." Scribes admitted to these challenges. "My biggest struggle," one scribe stated, was "I don't know what to type in here, what non to type in hither; what'south important, what's non important." Another claiming was medical terminology. Every bit 1 scribe described, "we don't know all the medical terms…that'southward a large learning bend." A physician shared the following example: "when I say 'swollen glands,' they type 'swollen glands' instead of 'adenopathy'." Consequently, "information technology does not look similar a physician wrote the note unless I right information technology." For some physicians, the lack of medical terminology presents a concern because, as one lamented, "the notes are non always exactly what I would want them to exist." For others, the difference in the scribes' terminology is more acceptable. I physician asked, "does it really affair if it says that this was erythematous? Is it ok if information technology says information technology'southward reddish? Yeah. Admittedly. Fine. Same thing." For this physician, "letting go of a little of that helps some of that challenge."

PATIENT Intendance

Physicians, scribes, and patients described improved in-visit dr. attention to patients. Many patients considered the computer a competitor for the medico'due south attention. One patient described, "with computers, the concentration is on the calculator screen and not on the reactions of the patients." The scribe'due south presence helped remove the calculator as a distraction. One patient alleged, "I felt like I was existence attended to by a person…I felt more cared for today, than I have [in the past]…I recall it matters, when somebody is talking to me and non to a calculator." Physicians besides noticed a change. 1 physician noted, "I look at naught only the patient." Some other doctor stated, "I'one thousand able to talk directly to the patient, which improves my listening ability, which improves my diagnostic ability, 'cause I'm listening to the story, I'k not looking at a computer." A patient added "there's a lot to be told in an assessment by being able to look at the person," such equally "body language." Improved heart contact also allowed physicians to take more meaningful discussions with patients. Every bit ane dr. shared, "the majority of the time should really be on the cess and program and I really feel like we're having…very effective conversations near that."

Both physician and patients also noted that the clinical scribes performed roles beyond documentation. Through collecting preliminary information gathering during patient intake, for example, scribes also developed relationships with patients. As one scribe revealed "[the patients] know me, they telephone call me by name, they feel like they know more well-nigh me, I remember." Patients also appreciated that the scribe'due south consistent presence allowed them to serve as a reminder. I patient gave the following example, "I was asking about…some medicine I was taking…Well, [the scribe] was there, [the scribe] wrote information technology downwards, so we didn't forget to ask! I didn't forget to ask!" Another patient added that "sometimes when the doctors come in…y'all freeze and forget everything," the scribe helped the patient remember. A few patients, withal, did limited more hesitation near the scribe'southward presence. One patient commented that "more invasive checkup…that might be an issue." A male person patient noted that because the scribe was female, "maybe sexual, that sort of thing" would be more uncomfortable to talk over. During the encounter, scribes also frequently looked up relevant exam results on behalf of the physician. For most patients, this interaction was not disruptive. As one patient described, "[the physician] was able to asking, from [the scribe], past history stuff and [the scribe] was able to get it for her… it ran smoothly." Physicians note, however, that the scribes' ability with this chore tin vary, equally one physician described, "some of them are more familiar with how to observe things in the chart. I'm sometimes request for the last thyroid…their concluding stress test…some of them are simply more facile, through experience or training in finding those rapidly." Less capable scribes or those just starting out in their role might need to ask the physician for help. Equally one scribe noted, "[the doctor] might have to help me pull up an X-ray or something like that."

Scribes too played an active office at the end of a visit. As one scribe noted, "patients are not leaving equally bewildered as they may have beforehand…they're able to inquire those questions at the cease of their visits that they didn't understand or, there was and so much to blot, they didn't go everything." A patient echoed this sentiment, "in example the doctor says something and I don't pay attending, considering, you know, it'south too much going on… [the scribe] explains it to me." One patient noted the combined work of the doctor and scribe reinforced that "someone's looking afterwards my health." Some other patient alleged, "I accept a lot of conviction in both of them." Physicians noted an opportunity to decrease errors in communication regarding in-visit tests. As one physician explained, the scribe "was there, they heard me do all that and they can just have over from in that location. Whereas before I used to have to notice a medical assistant and explicate everything that I had washed…in that location'south a chance I might have forgotten one of the labs I had ordered or didn't tell them every trivial thing." This flow of data was especially valuable in clinics where the scribe besides collected blood work because, as one scribe shared, "you're in the room with them and you already know what needs to be washed."

The time demands of scribe in-visit documentation, however, often interfered with tasks outside of visits, leading to concerns regarding follow-upwards advice and scribe exhaustion. One scribe shared, "being in the office setting, we are still responsible for all the other things that are required in the office. And considering we spend so much of our time in the room, with the patient and the dr., at that place's just less time to practice everything else." Another scribe described, "the paperwork doesn't stop, the telephones don't stop." A doc echoed this concern: "they're so busy doing, working with me full time, that they don't accept time to get to the phone calls." Another md described the state of affairs equally more continuity with patients "in the room" but "less continuity outside the room." This potential gap in intendance presented an important trouble considering, every bit i doc realized, "here was this recognition that, for me, every bit the main care person, at least one-half of what I exercise is not in the visit."

TEAMWORK

For physician and scribes, the working relationship was a partnership requiring contributions from both parties (Fig.2). Every bit one scribe summarized, "adaptability is huge…adjustability and trust are two for the biggest things for the doctor and for the [scribe]." One physician described the working relationship alike to "existence on the trip the light fantastic toe floor with someone who doesn't know the steps." The dr. takes on the leading function. A scribe reflected, the md "led the path and I just kind of like followed in the footsteps." For example, though scribes had templates bachelor, many physicians had their own preferences for physical examination. As one scribe observed, "every provider is just a footling different." Consequently, as a physician noted, the scribe had to larn "how you lot like to organize things and the…progression of the concrete exam elements that…you're gonna follow. If they know what's coming up and they're not scrolling up and downwardly looking for places to put data, they're just moving along at the same rate y'all are." As they led, physicians likewise learned to adapt their behavior. One doc learned to "call out my findings" on physical exam. A scribe appreciated that the physician was "actually good at repeating, if I need something to be repeated," and "spells stuff out." Underlying the partnership was open advice. One scribe reflected, "yous accept to be open up to constructive criticism or feedback from the providers…just existence willing to accept that feedback and acquire from it." Likewise, physicians learned to arm-twist questions from their scribes. One md shared, "I tell them up front end, 'I want you to tell me if y'all don't understand something I'm saying or if yous don't sympathise what, what nosotros need to document'…I would much rather accept my staff say, 'I take no idea what you merely said' rather than effort to document something and not know." Some other medico shared, "y'all have to exist willing to heed to your team members. I remember that'due south really key." For physicians and scribes, the ability to depend on each other as well derived from combined reflection. As one scribe described, "the biggest thing was probably having [the md] say, 'this isn't working.' Or even us saying, 'this isn't working, we demand to figure something else out' and we'll come up with some sort of solution." A physician farther emphasized the importance of mutual feedback, "we've got to work equally a team and permit's figure out what works best together. Let's work out what'southward best for patient care."

Edifice a successful squad

Physicians and scribes also described other challenges of implementing and sustaining clinical scribes. One physician described initial frustration that "despite over 3 years of expressed interest even from changing leadership, no one seems willing to really pull the trigger." Some other dr. noted that a philosophical change may play a role, "part of it is only that doctors don't like change. It's really tough. And really, more doctors have trouble giving up some control." Specifically, one physician described initial hesitations, "do I trust them in the room? Are they going to put it in properly? I'm kinda OCD in terms of getting things washed. I call up about doctors are." A scribe echoed these sentiments, "the hardest part for them is… the providers really letting go of that command of what and how everything is being entered into the office visit…trust…that nosotros're gonna do the right thing, and type the right matter, and get everything the way they need information technology to exist." Physician-scribe interactions as well shifted to ane of teacher-educatee. As one scribe described, "[the doctor]'s as well teaching us…also educating us also equally…on why this patient could take gotten this." Some other shared that she was "learning most the diseases and what to do for them, and all the medications, and things like that…" One dr. reflected, "our clinical back up kind of go our, our, uh, medical students with which we can train them about eye failure and diabetes and this way we're answering a lot more than questions and didactics." These interactions, withal, did not occur overnight. Thus, every bit one physician noted, institutions had to "brand sure that they're giving the trial a sufficient amount of time and support." Fifty-fifty after teams were established, maintaining adequate staffing could be a claiming. One clinic had trouble considering "we seem to be chronically short of medical assistants." This inconsistency was detrimental because, as i dr. described, the scribing is "not that comfortable if you don't practise it every fourth dimension." At some other clinic, successful scribes "don't stick around very long. Normally they go along to nursing school, become PAs, or even sometimes go to medical schoolhouse."

Give-and-take

To our knowledge, this is the first study to examine in parallel the perspectives of physicians, clinical scribes, and patients regarding clinical scribes in primary care. We found that clinical scribes played a more agile office non simply in documentation, but likewise patient intendance. Perception of improved note completeness agreed with an existing report demonstrating that clinical scribe notes were more than up-to-date, thorough, useful, and comprehensible.^xix Within a patient visit, clinical scribes likewise helped remove distraction of the computer and led to a perception of improved md–patient interactions from all three groups. These findings claiming concerns of disruptive furnishings of scribes.²⁰ Scribes also directly interfaced with patients, leading patients to use scribes not only for in-visit reminders, but also mail service-visit explanations. While the scribe's presence during the visit led to perceived improvements in communication of visit-related procedures, the patient–scribe human relationship meant that physicians not only had to trust scribes to certificate correctly, but also provide medically right information. Though both physicians and scribes mentioned physician pedagogy of medical knowledge, an important surface area for future research is thus the level of clinical cognition necessary for clinical scribes. The scribes' more active role during visits likewise shifted fourth dimension away from managing patient phone calls or messages. This shift raises questions regarding mail-visit continuity of care. Scribes also admitted that this workflow modify represented a source of stress. While previous enquiry demonstrated that a collaborative surround correlates with improved staff exhaustion,²¹ information technology may not exist enough to offset the stress from increased duties. The bodily effect on scribe burnout is thus some other area for further investigation.

Our report also demonstrates the importance of fit and sustained pairing between physician and scribe. Teamwork is a rise tendency in principal care,^{22 – 24} and our study revealed important details of interpersonal interactions. While scribes nevertheless expected physicians to lead, they also appreciated having opinions heard and considered. Likewise, physicians expected their scribes actively to limited their opinions. This atmosphere of mutual respect and open up communication not only depends on private willingness, but besides took time to build. Staff turnover presented an obstacle for the building of such relationships. Not only must individuals retrain to fit together, systems must consider their capability to rehire and restrain new scribes.

Limitations

Our study used rigorous qualitative methods. All the same, as with any methodological approaches, there are inherent limitations. In this study, though nosotros reached data saturation and included different national sites, the sample remained minor, thus affecting its generalizability. The perspectives described may also be skewed equally all written report participants were volunteers and all physicians and scribes interviewed have likewise chosen to continue using team documentation. While some physicians and scribes worked together, non all were part of the same team, which may limit exploration of squad dynamics. Most patients had established relationships with their physician and may accept acclimated to the clinical scribe. The short length of feel of the clinical teams also offered a more than curt-term look at the clinical scribe model. Given that our study does not focus on quantitative assay of bodily notation completeness, note accuracy, patient outcome measures, or practise efficiency, future studies are needed to address such limitations.

CONCLUSION

This study presents the first simultaneous descriptions of the perspectives of physicians, clinical scribes, and patients regarding clinical scribes in principal care. It revealed a more active role of clinical scribes during in-visit patient intendance that led to perceived improved documentation quality, just also possible encroachment on follow-upwardly care. The right personal and skills-based fit between physician and scribe and staff continuity are both necessary for sustainable partnerships. Awarding of clinical scribes should thus exist based on careful consideration of provider-specific and clinic-specific needs and capabilities, as well equally patient preferences. Future directions for research regarding clinical scribes include written report of care continuity, scribe medical knowledge, and scribe burnout.

Electronic supplementary material

Beneath is the link to the electronic supplementary textile.

Acknowledgements

Special cheers to Dr. Christine A. Sinsky for her aid in identifying and recruiting at national sites.

Author Contributions

Ms. Chen Yan, Drs. Anita D. Misra-Hebert, Susannah Rose, Kenneth Goodman, and Michael B. Rothberg made substantial contributions to the conception and design of the project, data estimation oversight, drafting and critically revising the work for intellectual content, and have approved the final version.

Ms. Chen Yan, Drs. Anita D. Misra-Hebert and Michael B. Rothberg made substantial contributions to logistical planning and recruitment.

Ms. Chen Yan and Ms. Mary Beth Mercer had full access to all of the data in the written report and take responsibleness for the integrity of the data and the accuracy of the information analysis.

Compliance with Upstanding Standards

Disharmonize of Interest

The authors declare that they do non have a conflict of interest.

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Articles from Journal of General Internal Medicine are provided here courtesy of Gild of General Internal Medicine

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978677/

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