SGEM#250: Scribes – I Want to Break Free (from the EMR)

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 Outcomes: 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