Scribe support may help alleviate documentation, trim physician burnout

The COVID-19 crisis has put a spotlight on the mental and physical stresses that frontline healthcare workers face, and how that may impact patient care. Recog­nized as a growing crisis of its own, physician burnout has pushed physician suicide rates to the highest of any profession, now more than twice that of the gen­eral population.1 According to the American Medical Association’s 2020 Environmental Scan, the annual cost of physician burnout on a national scale is $4.6 billion, taking into account physician turnover and reduced clinical hours.

Amplified by the COVID-19 care delivery pressures, experts agree that efforts to comply with the bur­densome document creation processes inherent to electronic health records (EHR) are at the root of the problem. Study after study confirm physicians now spend more time facing computer screens than their patients, causing serious concern for physicians and patients alike. Technology should not divert physi­cian focus away from their patients, yet that is exactly what federally mandated EHR data generation does.

 Physicians are expected to be infallible in their care for patients, yet as an industry we have turned a blind eye to caring for physicians and how their wellness im­pacts patient care. If COVID-19 has taught us anything, it is the importance of caring for individual healthcare workers and their struggles to do their jobs efficiently with the tools they have available.

A recent American Medical Association survey of over 15,000 medical professionals in 29 specialties revealed what physicians feel contribute most to their feelings of burnout. Unsurprisingly, the top four most prominent concerns all trace back to document cre­ation responsibilities, including:

• The burden of bureaucratic tasks
• Long hours at work
• Lack of respect for their role as caregivers
• Increased computerization of their practice, spe­cifically EHR

What’s Being Done

Due to the inevitable impact of physician burnout on patients, the US Department of Health and Hu­man Services (HHS) and the Office of the National Coordinator for Health IT (ONC) helped drive the 21st Century Cures Act to find ways to improve the qual­ity of patient care by addressing the growing problem of physician documentation overload.5 In response to that legislation, the AMA launched a three-year multi-million-dollar Practice Transformation Initiative to identify actionable solutions that specifically address the root causes of physician burnout.

“The Practice Transformation Initiative includes inno­vative research and bold advocacy aimed at removing obstacles and burdens that contribute to symptoms of burnout in 44 percent of physicians,” said AMA Board Chair Jesse M. Ehrenfeld, MD, MPH. “To make physi­cian burnout a thing of the past, the initiative will sup­port research and advance evidence-based solutions by collaborating with organizations who are commit­ted to the practice transformation journey.”

That ongoing research has already revealed substan­tial insights, most notably being that you cannot cure physician technology burnout with more technology.

The Technology Approach

Technology vendors suggest the inevitable cure to burnout will be reached through incremental software upgrades and/or additional applications, especially speech recognition–driven artificial intelligence (AI) di­rectly integrated with EHRs in the form of virtual phy­sician assistants (VPA). The content technology will, in the not-too-distant future, completely eliminate the problem, possibly documenting a complete encounter with a single command from the attending provider.

What those expectations fail to address however, is that although we all can imagine such an artificial intelligence (AI)–driven future, today’s physician burn­out problems are caused by the inherent limits of to­day’s technology. Given the immediate significance of burnout, as an industry we cannot afford to wait and pay for incremental steps. We need practical solutions for the here and now. Preferably ones without a huge upfront cost that can be deployed in a limited-scope, proof-of-concept mode to ensure effective outcomes, then easily scaled as results justify.

Fortunately, such pragmatic burnout remedies have already been validated by the AMA program targeting the top four root causes of burnout. Ongoing research and advanced evidence-based solutions from grant-sponsored Practice Transformation Initiative studies have identified a cost-effective, scalable solution that delivers measurable results within today’s technology limitations.

Relief of Bureaucratic Tasks—Charting and Paperwork

One of the Practice Transformation Initiative’s con­trolled studies looked at the effectiveness of medical scribes in concert with the implementation of a new EHR. In findings published in JAMA Dermatology, the authors wrote: “Our scribe pilot program achieved sig­nificant documentation time savings and reduction of physician burnout factors. Dermatologists’ willingness to see additional patients with scribe support reflect­ed enhanced physician efficiency, improved patient access, and increased clinical revenue.”

The net increase in efficiency was striking, cutting phy­sicians’ average time spent on EHR work in half. Across 690 pre-scribe time-audited encounters, dermatolo­gists averaged 6.1 minutes of clinical documentation per patient, the study reports. Across 695 post-scribe visits, physician documentation time significantly de­creased, averaging three minutes per patient.

Also notable were the financial results, with the study confirming the scribe service paid for itself. Compar­ing two three-month periods, there was a 7.7 per­cent increase in revenue comparing each physician’s scribe-supported sessions to unsupported sessions, researchers found. That efficiency more than offset the cost of the scribes.

Relief of Hours at Work

Time spent after normal working hours on EHR-related documentation issues was the second most common cause of frustrations for physicians. A recent study by the University of Arizona College of Medi­cine in Phoenix found that family medicine practice providers can spend upwards of 33 hours per month working on EHR tasks during after-hours, resulting in burnout.

Another study about scribes published in JAMA Inter­nal Medicine noted that medical scribes were associ­ated with decreased physician EHR documentation burden, improved work efficiency, and improved visit interactions, resulting in physicians spending less than one hour documenting during after-hours 95 percent of the time.

Relief of Overall Stress/Lack of Respect

Countless news stories during the COVID-19 crisis highlight the overall stress experienced by health­care workers. As a nation, we have seen that these frontline heroes are clearly physically and emotionally drained.

Burnout and its impact on patient care was the impe­tus of Section 4001 of the 21st Century Cures Act and it’s also what prompted the Practice Transformation Initiative. The positive impact scribes have in reducing burnout was specifically addressed in a recent ONC study titled “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHR.” That research found that scribe-supported physicians reported meaningful gains in multiple categories, including “joy of practice,” charting quality and accuracy, improved patient experience, and qual­ity care for patients.

Relief of EHR Struggles

Digging deeper into healthy EHR use strategies identi­fied in this ONC study, a recent article that summa­rized comments from Andrew Gettinger, MD, chief clinical officer at ONC and Thomas Mason, MD, chief medical officer at ONC noted that “Feedback from more than 200 provider organizations has shown that helping clinicians use the EHR more effectively, per­sonalizing the EHR, and created a shared ownership model are key factors in successful implementations—and satisfied users.”

KLAS has been conducting ongoing Arch Collaborative research for several years as a provider-led effort to unlock the potential of EHRs in revolutionizing patient care. Their 100,000 frontline clinician respondents help identify verified best practices based on evolv­ing market technology and services. Although there certainly is not a single magic pill that works for all providers in all settings, one finding is clear. There are dramatically different satisfaction scores from sepa­rate physician groups using the same EHR, so technol­ogy alone is not the answer.

KLAS research did indicate, however, that virtual scribes can make a notable difference. “Scribes can be an effective tool in helping providers be more effi­cient,” said Connor Brice, director of operations, Arch Collaborative at KLAS, in an email communication. “The Arch Collaborative longitudinal data demon­strates that scribe supported providers see increases in EHR satisfaction scores and chart closure rates.”

Driving Business Traction

A notable portion of the Practice Transformation Ini­tiative includes research on how scribes impact physi­cian burnout and business outcomes. All such studies, including those published in JAMA Internal Medicine, JAMA Dermatology, and other periodicals confirm scribes increase physician job satisfaction, productiv­ity, patient volumes, and overall practice revenue. One specifically notes that the improved productivity directly attributed to scribes resulted in 3,029 more relative-value units (RVUs) of work from 507 more patient visits, translating into almost $1.4 million of added revenue for a cost of about $99,000.

The COVID-19 crisis elevated physician wellness and overall healthcare industry business metrics into the national consciousness more acutely than ever before. The call to arms launched by the 21st Century Cures Act and the following array of AMA Practice Transfor­mation Initiative studies validate virtual scribes as a cost-effective tool to move from physician burnout to business traction. Connecting the dots from these numerous studies show virtual scribes relieve burn­out, support improved patient care, and deliver better financial outcomes. No other AMA-studied service or technology approach has been found to deliver paral­lel issue scope or cost-benefit results.

Notes

1. Anderson, Pauline. “Doctor’s Suicide Rate Highest of Any Profession.” WebMD, May 8, 2018.
2. American Hospital Association. 2020 Environmental Scan. November 2019. aha.org/environmentalscan.
3. Cohen, Jessica Kim. “Primary care physicians spend more time on EHR than face-to-face care, study sug­gests.” Becker’s Health IT, October 16, 2018. https://www.beckershospitalreview.com/ehrs/primary-care-physicians-spend-more-time-on-ehr-than-face-to-face-care-study-suggests.html.
4. “Could A.I. Turn the Tables on the Physician Burnout Epidemic?” The Medical Futurist, January 31, 2019. https://medicalfuturist.com/physician-burnout/.
5. US Congress, House, 21st Century Cures Act, HR 34, 114th Congress, https://www.congress.gov/bill/114th-congress/house-bill/34.
6. American Medical Association. “AMA Fights burnout with new Practice Transformation Initiative.” Press Release, September 5, 2019. https://www.ama-assn.org/press-center/press-releases/ama-fights-burnout-new-practice-transformation-initiative.
7. CBS News. “Epic: How a company you never heard of handles your medical records.” February 23, 2020. cbsnews.com/video/epic-how-a-company-you-never-heard-of-handles-your-medical-records.
8. Nambudiri, Vinod E. et al. “Medical Scribes in a Dermatology Practice.” JAMA Dermatology 154(1), 2018: 101-103. https://jamanetwork.com/journals/jamadermatology/fullarticle/2660011.
9. “EHR scribes cut physician documentation time in half, study says.” AMA website. December 21, 2017. ama-assn.org/practice-management/digital/ehr-scribes-cut-physician-documentation-time-half-study-says.
10. Anderson, Jacob, Jason Leubner, and Steven R. Brown. “EHR Overtime: An Analysis of Time Spent After Hours by Family Physicians.” Family Medicine 52(2), 2020: 135-137. stfm.org/familymedicine/2020/febru­ary/anderson-2019-0169.
11. Mishra, Pranita, Jacqueline C. Kiang, and Richard W. Grant. “Association of Medical Scribes in Primary Care with Physician Workflow and Patient Experience.” JAMA Internal Medicine 178(11), November 1, 2018: 1467-1472. ncbi.nlm.nih.gov/pubmed/30242380.
12. Office of the National Coordinator for Health IT. “Strategy on Reducing Regulatory and Administrative Bur­den Relating to the Use of Health IT and EHR: Final Report.” February 2020. healthit.gov/sites/default/files/page/2020-02/BurdenReport_0.pdf.
13. Gamble, Kate. “‘We See a lot of Opportunity’: Breaking Down HHS’ Report on Clinical Burden.” com, Febru­ary 26, 2020. https://healthsystemcio.com/2020/02/26/we-see-a-lot-of-opportunity-breaking-down-hhs-report-on-clinical-burden.
14. Robeznieks, Andis. “The Overlooked Benefits of Medical Scribes.” AMA website, October 26, 2018. ama-assn.org/practice-management/sustainability/overlooked-benefits-medical-scribes.