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Impact of scribes on emergency medicine doctors’ productivity and patient throughput: multicentre randomised trial

BMJ 2019; 364 doi: (Published 30 January 2019) Cite this as: BMJ 2019;364:l121


It’s time to think hard about how clinicians work in a digital age

Throwing good money after the bad: patch job of a solution is not addressing the real problem

Dear Editors

I call for caution in accepting the conclusions made by the authors in which they stated "scribes improved emergency physicians’ productivity, particularly during primary consultations, and decreased patients’ length of stay".

They acknowledge:

" A medical scribe helps the physician by doing clerical tasks. The scribe stands with the physician at patients’ bedsides, documenting consultations, arranging tests and appointments, completing electronic medical record tasks, finding information and people, booking beds, printing discharge paperwork, and doing clerical tasks. They do this via a computer-on-wheels connected to the hospital’s electronic medical record system. The aim of the role is for scribes to do clerical tasks otherwise done by the physician, enabling the physician to manage more patients in the same amount of time."

In other words, the scribe assists by reducing the time spent by clinicians (trying) to interface with the electronic medical record system.

It is of no surprise to most readers that the rollout of electronic medical record system (EMRS) in Australian hospitals is associated with clinician dissatisfaction and costs overrunning (ref 1-3), given the varied experiences in UK.

More importantly it is known that the introduction of the EMRS is also associated with deterimental effects on producitivty in Emergency Departments (EDs). In NSW the "implementation of the FirstNet electronic medical record system was associated with deterioration in ED KPIs" (ref 4) which aggravates the difficulties in meeting the 4 hour target.

Hence despite the large sum of monies invested in the hardware and software to implement EMRS, researchers struggle to find immediate outcome improvement, which was the basis of EMRS uptake; some found that "over time, maturation of the baseline functions was associated with a 0.09-percentage-point reduction in mortality rate per year per function. Each new function adopted in the study period was associated with a 0.21-percentage-point reduction in mortality rate per year per function. We observed effect modification based on size and teaching status, with small and nonteaching hospitals realizing greater gains" thus concluding that "national investment in hospital EHRs should yield improvements in mortality rates, but achieving them will take time." (ref 5)

When a multimillion/billion project involving EMRS reduces hospital productivity, and yet is unable to offer reassuring returns of better patient outcome including mortality rates, the last thing we should consider is throwing more good money after the bad by hiring medical scribes to improve productivity. We ought to really re-examine how EMRS are procured and designed and if they really offer any better result at the current level of technology.

4. Mohan MK, Bishop RO, Mallows JL. Effect of an electronic medical record information system on emergency department performance. Med J Aust 2013; 198 (4): 201-204. || doi: 10.5694/mja12.10499
5. Lin SC, Jha AK, Adler-Milstein J. Electronic Health Records Associated With Lower Hospital Mortality After Systems Have Time To Mature. Health Aff (Millwood). 2018 Jul;37(7):1128-1135. doi: 10.1377/hlthaff.2017.1658.

Competing interests: No competing interests

11 February 2019
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia