Date: March 20th, 2019
Guest Skeptic: Dr.Katie Walker is an emergency physician in Melbourne, Australia. She is a clinical researcher at Cabrini Hospital and an Adjunct Clinical Associate Professor at Monash University.
Case: The emergency department is backing up. You have ambulances ramping and patients queuing at triage. Your medical team is great, but you notice that the busier you all become, the more you see your docs at their computers, rather than at patient bedsides. You are frustrated that whilst you frantically fill in data in the Electronic Medical Record (EMR) from your last consultation, your neighbor is in your waiting room with a dislocated shoulder and you haven’t been able to get to her yet. Is there a better way of working than this way?
Background: One in ten health high-income country consultations are now in Emergency Medicine. Most emergency physicians use some form of electronic medical records (EMRs) when seeing patients.
The EMR tasks we undertake are expanding rapidly, far beyond simply documenting history and physical examination and every implementation slows us down.
Research by Hill et al (1) demonstrated that an ED shift can have 4,000 clicks. Physicians are spending more time on EMRs (40%) than any other activity including direct patient care (30%). SGEM#159 looked at the implementation of an EMR in a tertiary care ED. Median wait times, length of stay, left without being seen, and length of stay for admitted patients all got worse with adding computerized physician order entry (CPOE) as part of their EMR (2).
The implementation of the EMR into clinical practice represents a very large, global, medical productivity loss. It could also have a negative impact on patient care.
There are studies showing that EMRs are one of the biggest causes, if not the number one cause of physician burnout (3). Physicians suffering from burnout provide a lower quality and safety of care (4). This means there is an association between EMRs and worse patient care.
If we have to use EMRs, how can we improve our productivity? There haven’t been any large, independent, multi-centre, randomised evaluations of scribe effectiveness and safety, until now.
Scribes are individuals who help physicians by doing the clerical tasks. There is a long list of things that they do including documentation of the clinical encounter, information retrieval, and discharge preparation.
Most physicians (85%) prefer working with scribes (5) and most patients tolerate scribes being involved in the clinical encounter (6). They have been used in US departments for years, but are only now beginning to be used in Canada and Australia.
Clinical Question: What is the impact of scribes on emergency medicine physicians’ productivity and patient throughput.
Reference: Impact of scribes on emergency medicine doctors’ productivity and patient throughput: multicentre randomised trial, BMJ January 2019
- Population: Five emergency departments in Australia
- Intervention: Scribes rostered to a physician for a shift
- Comparison: Same physicians working shifts without scribes
- Primary: Total patients/physician/hour (including medical triage and handovers, where another doctor undertakes the primary/main consultation)
- Secondary: Primary patients/physician/hour, door-to-doctor time, door-to-discharge time, regions of emergency department patients/physician/hour, patient safety events (scribe group only, no comparator) and retrospective cost-benefit analysis
Authors’ Conclusions: “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.”
Quality Checklist for Randomized Clinical Trials:
- The study population included or focused on those in the emergency department. Yes
- The patients were adequately randomized. Yes
- The randomization process was concealed. Yes
- The patients were analyzed in the groups to which they were randomized. Yes
- The study patients were recruited consecutively (i.e. no selection bias). No
- The patients in both groups were similar with respect to prognostic factors. Yes
- All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
- All groups were treated equally except for the intervention. Yes
- Follow-up was complete (i.e. at least 80% for both groups). Yes
- All patient-important outcomes were considered. Yes
- The treatment/economic effect was large enough and precise enough to be clinically/economically significant. Unsure
Key Results: There were 12 scribes and 88 physicians working at five sites.They compared 589 scribed shifts to 3,296 non-scribed shifts. This included 5,098 scribed consultations and 23,838 non-scribed consultations.
Total patients seen per hour increased with scribes.
- Primary Outcome: Patients seen per hour
- Without a Scribe: 1.13 (95% CI; 1.11 to 1.17)
- With a Scribe: 1.31 (95% CI; 1.25 to 1.38)
- Absolute increase of 0.18 more patients per hour
- Relative increase of 15.9%
- Secondary Outcomes:
- Primary consultations per hour increased from 0.83 to 1.04 (25.6% gain)
- Door-to-doctor times were unchanged
- Door-to-discharge times reduced from 192 to 173 minutes (19 minutes shorter)
- Within ED productivity changes:
- Medical triage increased by 0.53 patients per hour
- Acute areas increased by 0.10 patients per hour
- Sub-acute/Short stay showed no gains
- Pediatrics increased by 0.17 patients per hour
- There was a minor patient safety event reported for 1:300 consultations. Events mainly related to wrong patient selection in EMRs, half the events reported involved the scribe identifying a problem in someone else’s patient and intervening to prevent harm.
- The cost analysis was in favour of employing scribes, given the productivity and throughput gains
- 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. This could have introduced selection bias. Scribes were also not present on nights and public holidays. This also could have introduced selection bias and could limit the validity to those shifts.
- Lack of Blinding: Scribe research, like most complex intervention evaluations, is hard. It is not practical to blind physicians/patients/scribes to the intervention. This lack of blinding could have introduced a Hawthorne effect. There are issues with measuring the intervention that don’t get properly incorporated into studies. Examples include physicians staying late to complete medical notes after their shift ends (unrostered / unpaid / unrecorded overtime) when unassisted but going home on time with a scribe. When scribes were used in our observation wards / short stay, the intern had no role and went and picked up new patients (again unmeasured by the study). A rigorous study protocol can also be upset by simple day-to-day ED operations glitches like last minute sick leave. No scribe study will be academically perfect, but hopefully pragmatic studies will better resemble the real-life working environments in our EDs.
- Payment Models: Some jurisdictions may (or may not) find that per-patient billing/revenues increase when a scribe is present. This wasn’t measured in the study but may (or may not) provide a stronger economic argument for scribes in some settings. It will all depend. A lower volume community ED not using CPOE a scribe would make little sense. However, in a high volume setting that is using CPOE and paid on productivity it might make great sense to have scribes on shift.
- External Validity: More work should be undertaken in several areas. Similar studies should be considered in settings outside Australia such as the USA, Canada, the UK and European countries. As clinicians, we should advocate for ourselves/our patients and partner with information technology (IT) designers to make EMRs that work for us. We should also rigorously explore the scribe role in alternate settings such as clinics, offices and in-patient wards.
- Band-Aid: While we would all like our IT systems to be better designed/integrated, able to reduce duplication or give us improved functionality, the scribe role could provide an immediate (even if temporary) fix. Until IT research is able to demonstrate productivity gains with a similar cost profile, we should offload our clerical tasks in a safe way and return to our core medical roles – information synthesis and communication.
Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.
SGEM Bottom Line: Scribes could have a positive impact of productivity and patient throughput depending on your practice environment.
Case Resolution: You decide to implement a scribe program at your hospital. The IT and processes still remain tedious but you have offloaded many of them. You rediscover what it is like to be a physician who is enabled to walk from one room to another, seeing patients, providing high-quality/evidence-based care and moving rapidly to where you are needed. You go home less tired despite a bigger patient load.
Clinical Application: When working with a scribe, enjoy your work and get used to being enabled to see more patients, whilst feeling like you have done less.
Enable your scribe to speak up if they see anything untoward happening in the department, they may be the only one to notice it. Check every time you open the EMR that you have selected the correct patient.
What Do I Tell the Patient? This is John, he what is called a scribe. His job is to organize everything you need today and write down all my instructions for the emergency team. This will help me focus on being your physician.
Keener Kontest: There was no winner last week. The correct answer was that the earliest article published describing ultrasound confirmation of endotracheal tube placement was by Raphael and Conard, Ultrasound confirmation of endotracheal tube placement, Journal of Clinical Ultrasound, 1987 Sep; 15(7) 459-62.
Listen to the podcast to hear this weeks’ trivia question. If you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.
- ZDoggMD – EHR State of Mind
- REBEL EM – Hate Using Electronic Hospital Records? An Evaluation of Medical Scribes in Emergency Departments.
- St. Emlyn’s – Do we need scribes in the ED?
- St. Emlyn’s – Scribes in the ED?
Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.
- Hill et al. 4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED. AJEM 2013
- Gray et al. The impact of computerized provider order entry on emergency department flow. CJEM 2016
- Shanafelt et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clinic Proc 2016
- Salyers et al. The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. JGIM 2017
- Cowan 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
- Yan et al. Physician, Scribe, and Patient Perspectives on Clinical Scribes in Primary Care. J Gen Intern Med 2016