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|Issue 179||October 2020|
The report is a product of the VA/HSR&D Evidence Synthesis Program.
The Effect of Medical Scribes in Cardiology, Orthopedic, and Emergency Departments: A Systematic Review
The use of medical scribes has increased markedly in the past 10 years, in part, due to implementation of electronic medical records required by legislation. In 2009 the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted and required the meaningful use of health information technology. Moreover, Section 507 of the MISSION Act mandates a two-year pilot of in-clinic medical scribes in VA specialty clinics and emergency departments to evaluate clinician efficiency, patient volume, and patient satisfaction.
With insight from Operational Partners and Technical Expert Panel members, investigators with VA’s Evidence Synthesis Program (ESP) Center in Minneapolis, MN conducted a systematic review of medical scribes focused on outpatient emergency, cardiology, and orthopedic departments. ESP investigators searched the literature, including searched MEDLINE, EMBASE, and CINAHL from 2010 through December 2019. After reviewing 621 citations (45 articles received full text review), they included 22 articles (20 from emergency departments). Two observational studies were from cardiology departments, both conducted by the same group at a Minneapolis, MN healthcare system. No eligible articles were identified from orthopedic departments, and no studies were conducted within the VA healthcare system.
Summary of Findings
Despite information that there currently may be as many as 100,000 medical scribes in the U.S., there is a paucity of data on the effectiveness, harms, costs, and quality of scribes—or on best methods for implementation and evaluation. Overall, current findings have limited applicability and raise important questions about implementation, research gaps, and future research. No studies were conducted within VA, and the effectiveness and financial productivity for widespread implementation across a national healthcare system are unknown.
Medical scribes may improve efficiency (low certainty of evidence) and financial productivity (low certainty of evidence). The magnitude of effect on efficiency is likely small to moderate. Efficiency varies based on the setting, outcomes assessed, and methods for evaluating financial productivity. The effect on costs is difficult to ascertain as complete cost reporting was not provided. The resources required to identify, hire, train, staff, maintain, and monitor a scribe program are expected to be substantial and are rarely reported in the literature. There are no direct comparative data on the quality of documentation, medical errors, or scribe training (i.e., time to train, turnover), and there are no data comparing these outcomes among contracted scribes versus scribes (i.e., vendor supplied) trained “in-house” or using “virtual scribes.”
The efficiency, financial productivity, and effect on patient and provider satisfaction of scribe programs is uncertain, with findings based on only one serious risk of bias study from a cardiology group in the United States that evaluated medical scribes provided by a vendor.
There are no data on medical scribes in orthopedic clinics.
Implications for VA
The Section 507 Committee will use the findings of this review to inform the use of medical scribes within the VA healthcare system. Findings suggest that prior to widespread implementation of medical scribes, more information is needed on the effectiveness, harms, and costs of scribe programs. If information is deemed sufficient for programmatic rollout, then the clear identification and evaluation of programmatic goals, resources, models, and personnel required, as well as implementation barriers and facilitators, will be needed.
Research Gaps/Future Research
The principal finding of this review is that there are large gaps in evidence that require future research. Despite the marked increase in the use of medical scribes in the U.S., there is no high-quality information evaluating their effects on clinic efficiency, access to healthcare, patient or clinician satisfaction, or financial investment and productivity in cardiology, orthopedic, and emergency departments. There also are no data on the use of virtual scribes. Additionally, there are limited data on other important aspects of a medical scribe program, including the quality of documentation, the comparative effects of in-house versus contracted hiring, and large-scale implementation of medical scribes. Further, data from other clinical settings (primary care and other specialty clinics) are of limited applicability, quality, and quantity.
Ullman K, McKenzie L, Bart B, Park G, MacDonald R, Linskens E, Wilt TJ. The effect of medical scribes in cardiology, orthopedic, and emergency departments: a systematic review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2020.
To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/medical-scribes.cfm
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.
This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.
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