Medical Scribes Have a Variable Impact on Documentation Workflows

Adam Rule, Michael Chiang, Michelle R. Hribar

Research output: Chapter in Book/Report/Conference proceedingConference contribution

Abstract

Physicians can reduce their documentation time by working with a scribe. However, what scribes document and how their actions affect existing documentation workflows is unclear. This study leverages electronic health record (EHR) audit logs to observe how scribes affected the documentation workflows of seven physicians and their staff across 13,000 outpatient ophthalmology visits. In addition to editing progress notes, scribes routinely edited exam findings and diagnoses. Scribes with clinical training also edited items such as vital signs that a scribe without clinical training did not. Every physician edited patient records later in the day when working with a scribe and those who deferred their editing the most had some of the largest reductions in EHR time. These results suggest that what scribes document, how physicians work with scribes, and scribe impact on documentation time are all highly variable, highlighting the need for evidence-based best practices.

Original languageEnglish (US)
Title of host publicationMEDINFO 2021
Subtitle of host publicationOne World, One Health - Global Partnership for Digital Innovation - Proceedings of the 18th World Congress on Medical and Health Informatics
EditorsPaula Otero, Philip Scott, Susan Z. Martin, Elaine Huesing
PublisherIOS Press BV
Pages892-896
Number of pages5
ISBN (Electronic)9781643682648
DOIs
StatePublished - Jun 6 2022
Event18th World Congress on Medical and Health Informatics: One World, One Health - Global Partnership for Digital Innovation, MEDINFO 2021 - Virtual, Online
Duration: Oct 2 2021Oct 4 2021

Publication series

NameStudies in Health Technology and Informatics
Volume290
ISSN (Print)0926-9630
ISSN (Electronic)1879-8365

Conference

Conference18th World Congress on Medical and Health Informatics: One World, One Health - Global Partnership for Digital Innovation, MEDINFO 2021
CityVirtual, Online
Period10/2/2110/4/21

Keywords

  • Documentation
  • Electronic Health Records

ASJC Scopus subject areas

  • Biomedical Engineering
  • Health Informatics
  • Health Information Management

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