While the adoption of EHRs has aimed to improve patient care, it has had unintended consequences for clinician well-being—clinician burnout at the hands of EHR documentation.
In a 2022 athenahealth survey, 57 percent of providers reported that excessive EHR documentation requirements are driving clinician burnout.
Some healthcare organizations have invested in EHR scribing services to alleviate rising rates of clinician burnout. A medical scribe is typically an unlicensed paraprofessional whose purpose is to document patient encounters in real-time in the EHR.
For Open Door Family Medical Center, a federally qualified health center (FQHC) in New York, medical scribes were a saving grace when they brought them into the practice eight years ago.
"It is widely reported that time spent by clinicians on documentation has risen substantially over the last couple of decades with the adoption of EHR and meaningful use criteria," Daren Wu, MD, Open Door Family Medical Center’s chief medical officer, told EHRIntelligence in an interview.
As an FQHC, Open Door has taken extra consideration to support physician well-being. A 2021 survey also from athenahealth found that FQHC physicians are 11 percent more likely to experience clinician burnout than physicians employed at independent practices.
"We are a busy practice," Wu said. "If we spend a lot of time documenting during workday hours, that means we eat into potential access visit time for patients, and if we expect clinicians to document after hours, it becomes an imposition on their personal and family time."
Leveraging on-site scribes helped Open Door clinicians focus more on direct patient care. The scribes not only documented patient encounters in the EHR but also helped clinicians complete administrative tasks like printing out patient education materials and booking patient appointments.
However, when the COVID-19 pandemic began, Open Door's scribing vendor had to eliminate on-site scribes due to social distancing restrictions.
After several months of lapse in scribing support, the vendor began offering off-site scribing services to Open Door clinicians.
Off-site virtual scribes are human scribes who communicate with clinicians via a laptop, smartphone, tablet, or another two-way communication device. Scribes enter clinical notes, update charts, clarify information, and make suggestions to physicians.
While Open Door clinicians found some value in the virtual scribing service, the offering did not bring the same perks as the on-site human scribes. That’s not to mention, virtual scribes come at a higher price tag.
"The benefits of having a human colleague on-site scribing for you were obviously not transferable to someone who's off-site," Wu said.
For instance, off-site scribes cannot help clinicians with office-based administrative tasks as on-site scribes could.
"Off-site remote dictation services were beneficial in helping to complete the notes, but it was no longer as great a value for what we were paying the scribing company," Wu noted. "Looking at what we were getting for that price relative to what we were getting in remote off-site scribing support, we just felt like we needed to look at other options."
Prompted by advances in speech technology, artificial intelligence (AI)-based EHR scribing services have come to market in recent years.
Open Door assessed various AI dictation services and selected a tool from its EHR vendor, eClinicalWorks, for its value and scalability.
"We realized that eCW had its own scribe product, and we felt that it met our needs, especially with regard to the value proposition," Wu said. "It is an affordable solution that's very effective in reducing the amount of time our clinicians spend documenting in the EHR, and therefore very scalable."
Wu explained that clinicians had to see almost two additional patients per day to offset the cost of the off-site human scribes they used to have. With the AI scribing service, providers only have to see two extra patients per month.
After an initial pilot with a few providers, more than half of the FQHC's clinicians now use the tool. Providers use their smartphones as voice input devices for the application. Once the recording is complete, the clinician says, "scribe it," which then produces the dictation into the EHR progress note on the clinician's laptop or desktop computer.
"Relative to the cost, it's a very good return on investment, given the support it provides our clinicians," Wu said. "The feedback, on the whole, has been this tool has been tremendous in cutting down after-hours time, home time, and weekend time on finishing notes."
Notably, he said that two clinicians who have used human scribes over the years have told him that they prefer the AI-based tool because of its quick transcription turnaround.
"Having a human scribe, you can ask them to populate this area of the EMR or clarify this error in the medical history," Wu emphasized. "eCW Scribe doesn't allow you to do that. However, you control the timing of the note. When you finish it, it's done."
"eCW Scribe allows our clinicians to lock their notes faster because they're not waiting for a human scribe to lay out the note," he continued. "A lot of the human scribes are in college or med school, and they're very busy. Often the notes that you are waiting for a human scribe to finish won't be done until late in the evening or even the next morning."
Wu noted that while the technology has been relatively intuitive for most Open Door clinicians, some more seasoned clinicians have struggled to adopt the tool.
"Not every clinician in Open Door is as facile as most of our others when it comes to using eCW Scribe," Wu explained. "You need to feel comfortable using an app on a smartphone. From a generational perspective, some clinicians are just not very comfortable using something other than a keyboard and mouse, but the great majority of our clinicians have felt this has not been an issue."
Open Door has also had to work through some technical hurdles with the implementation.
"There are a few issues when it comes to names and most notably specialist names that you have to train the app AI to spell out correctly," Wu said. "That's not too hard, but it's an area where we have to sometimes pause because we work with so many specialists."
"Otherwise, when it comes to medical terminology, which frequently stumped a lot of our human scribes in accurately spelling the medical phrase or word, the AI product is excellent at capturing complex medical terminology and displaying it correctly in the note," he said.
Wu said that Open Door strongly recommends that clinicians complete patient notes as they go, which may mean dictating in front of the patient, which he said can help reinforce care plans.
"Some of it is personal preference and organizational skills as far as if an individual clinician is going to dictate in front of the patient," he noted. "I've done that plenty of times. I think patients are curious about what happens and seem interested in hearing what I say in a neutral fashion.
"When dictating right in front of a patient, you tend to use more colloquial terms that the patient may understand, which reinforces the conversations and treatment plans," Wu said. "I think that's very helpful."