The clerical work involved in managing the electronic health record (EHR) is clearly not at the top of the skill set for physicians, yet many office-based clinicians find themselves bogged down in this work with no easy way out.
However, practices that are adopting team-based care—where each team member works at the top of his or her skill set—are finding a solution in the form of scribing or team documentation. This approach can ease that burden and perhaps even help to curb physician burnout in the process. But many questions still surround this approach, notably: What do we know about the quality of this documentation?
A recent study published by Misra-Hebert and colleagues reported on this issue.1 It provides some insight—and reason for optimism, especially because the study authors found that outpatient notes from trained staff stack up quite well when compared to those of physicians. Having worked myself with this approach to documentation, I can attest to its benefits, as well.
Team documented notes compare well
There are 2 different ways that physicians can get help with documentation. One involves the use of trained scribes, who come from a variety of backgrounds and are charged with writing down, or scribing, what the physician says. The other involves training staff, usually certified medical assistants (CMAs) or licensed practical nurses (LPNs), to take on a wide variety of additional duties including refill management, care gap closure, and most of the duties concerning the EHR—including documentation.
Misra-Hebert and colleagues studied the second approach in a retrospective chart review of ambulatory progress notes written before and after 8 practice sites transitioned to using medical assistants as scribes. Comparing notes relating to diabetes encounters and same-day appointments, the study authors found important evidence that using staff in this way does not adversely affect—and may even enhance—documentation previously done entirely by physicians. For diabetes encounters, scribed notes were rated higher in overall quality, as well as more up to date, thorough, useful, and comprehensible, than unscribed notes.1
Scribing versus team documentation: terminology can be important
A person who is serving in a medical scribe role is a "personal assistant to the physician; performing documentation in the [electronic health record], gathering information for the patient's visit, and partnering with the physician to deliver the pinnacle of efficient patient care," according to Scribe America, the largest US company that employs scribes, providing their services to hospitals, emergency departments, and outpatient care and urgent care facilities, etc.1
Scribes versus team-based care
Scribe America mainly employs medical students, offering students a way to become exposed to physicians, mentors, and medical care. In fact, they note on their website that "a background in medical scribing is quickly becoming the standard for premedical experience, and is suggested by medical school acceptance committees across the country."2
Bellin Health, and many practices transitioning to team-based care, do not use medical students as scribes but rather "train up" employed certified medical assistants and licensed practical nurses to perform what they call "team documentation." This is the model described by Misra-Hebert and colleagues.3 The advantage is that these licensed health care workers can perform many other aspects of patient care, such as agenda setting and basic health coaching, and can perform additional work in the electronic health record, such as order entry and pending refills.
- What is a medical scribe? ScribeAmerica website. http://www.scribeamerica.com/what_is_medical_scribe.html. Accessed June 20, 2016. .
- Why be a medical scribe? ScribeAmerica website. http://www.scribeamerica.com/why_be_a_medical_scribe.html. Accessed June 20, 2016.
- Misra-Hebert AD, Amah L, Rabovsky A, et al. Medical scribes: how do their notes stack up? J Fam Pract. 2016;65(3):155−159.
In my experience
This change in the way we approach EHRs involves commitment, as I have seen first hand. There needs to be significant training to make this work and there needs to be more staff, since physicians require 2 of these valuable team members to function effectively. (At least that has been our experience.)
How has the physician’s role changed? Prior to team-based care, I would try to enter information into the EHR in the room while seeing the patient. After the visit, I would go to the computer at my station and use voice recognition software to add information. Now, the CMA/LPN does the initial documentation and other EHR work, while I am able to focus on the patient without the distraction of the computer. When I leave the room, the CMA/LPN stays with the patient, arranging necessary tests or consults, scheduling future labs and appointments, and reviewing the chart, all before seeing the next patient.
We are in the process of implementing team-based care throughout our 32-location health care system and have found that using CMAs and LPNs to assist with documentation is a “win” for everyone. And since the problems with burnout and all of the other reasons for making this transformation to team-based care applies to all office-based specialties, we plan to have our entire system adopt this model.