Objective Medical scribes are increasingly employed to improve physician efficiency with regard to the electronic medical record (EMR). The impact of scribes on the quality of outpatient visit notes is not known. To assess the effect, we conducted a retrospective review of ambulatory progress notes written before and after 8 practice sites transitioned to the use of medical assistants as scribes.
Methods The Physician Documentation Quality Instrument 9 (PDQI-9) was used to compare the quality of outpatient progress notes written by medical assistant scribes with the quality of notes written by 18 primary care physicians working without a scribe. The notes pertained to diabetes encounters and same-day appointments and were written during the 3 to 6 months preceding the use of scribes (pre-scribe period) and the 3 to 6 months after scribes were employed (scribe period).
Results One hundred eight notes from the pre-scribe period and 109 from the scribe period were reviewed. Scribed notes were rated higher in overall quality than unscribed notes (mean total PDQI-9 score 30.3 for scribed notes vs 28.9 for nonscribed notes; P=.01) and more up-to-date, thorough, useful, and comprehensible. The differences were limited to diabetes encounters. For same-day appointments, scribed and nonscribed notes did not differ in quality. The total word count of all scribed and nonscribed notes was similar (mean words 618, standard deviation (SD) 273 for scribed notes vs 558 words, SD 289 for nonscribed notes; P=.12).
Conclusions In this retrospective review, ambulatory notes were of higher quality when medical assistants acted as scribes than when physicians wrote them alone, at least for diabetes visits. Our findings may not apply to professional scribes who are not part of the clinical care team. As the use of medical scribes expands, additional studies should examine the impact of scribes on other aspects of care quality.
Team-based models of primary care delivery may incorporate medical scribes to improve efficiency of electronic documentation.1-4 The employment of medical scribes has grown rapidly, and it is estimated that within several years there may be one scribe for every 9 physicians.3
Accurate documentation is important to providing high-quality patient care but can take a significant amount of time. Attending physicians have been estimated to spend as long as 52 minutes per day authoring notes.5 Medical scribes can help physicians improve the efficiency of electronic documentation6 and save time.2 Using scribes can also improve physician productivity7-10 and thereby potentially increase access to care. The impact of scribes on the quality of outpatient visit notes, however, is unknown.
A team-based care delivery model in our health system’s primary care clinics uses medical assistants to scribe notes during the outpatient encounter. We hypothesized that outpatient notes written by medical assistant scribes would be of similar quality to notes written by the same group of physicians without a scribe.
Study design and sample
We conducted a retrospective review of ambulatory notes from 18 primary care physicians at 8 practice sites in our health system who had adopted a care model in which medical assistants act as scribes. Each physician works with 2 medical assistants. To train for the new model, the physician and medical assistants participated in 2 training sessions of 2 hours each and a half day of clinic observation and evaluation with a project manager.
Of the 18 primary care physicians included in this study, none had less than one year of experience in our health system. Tenure ranged from one to 24 years with a mean of 11.3 years.
For each participating provider, we requested all available outpatient progress notes with either an International Classification of Diseases, 9th revision (ICD-9) code for diabetes or a designation of “same day” for the 3 to 6 months preceding the use of scribes (pre-scribe period) and the 3 to 6 months after employing scribes (scribe period). We chose diabetes encounters as examples of notes addressing chronic disease management and same-day encounters as examples of problem-focused notes because these 2 types of encounters are common in outpatient primary care practice.
Note quality was evaluated using the Physician Documentation Quality Instrument 9 (PDQI-9), a validated instrument designed for this purpose, comprising 9 items rated subjectively on a 5-point Likert scale (1= not at all, 5= extremely). The items assess whether notes are up-to-date, accurate, thorough, useful, organized, comprehensible, succinct, synthesized, and internally consistent.11,12 The PDQI-9 has been applied previously in inpatient12 and outpatient settings.13
While the PDQI-9 is a validated tool, it relies on subjective ratings of note quality by the reviewer. To control for the subjective nature of the ratings, an experienced internist and an internal medicine resident coded 10 progress notes separately using the PDQI-9 and discussed the results. The process was repeated for a total of 20 notes, after which consensus was reached with >70% agreement on each attribute of the PDQI-9, suggesting that the resident’s ratings were reliable when compared with those of an experienced practicing physician.