Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study
The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR funct...
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Published in | JMIR medical informatics Vol. 5; no. 3; p. e30 |
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Main Authors | , , , , , , , |
Format | Journal Article |
Language | English |
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JMIR Publications
20.09.2017
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Abstract | The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges. This highlights the need for new assessment tools for medical scribes.
The objective of this study was to develop a virtual video-based simulation to demonstrate and quantify the variability and accuracy of scribes' transcribed notes in the EHR.
From a pool of 8 scribes in one department, a total of 5 female scribes, intent on pursuing careers in health care, with at least 6 months of experience were recruited for our simulation study. We created three simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video-recorded a standardized patient-provider encounter. Five scribes with at least 6 months of experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated EHR environment. Transcribed notes were evaluated for interscribe variability and compared with a gold standard for accuracy.
All scribes completed all simulated cases. There was significant interscribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%.
We created a high-fidelity, video-based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency. |
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AbstractList | Background: The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges. This highlights the need for new assessment tools for medical scribes. Objective: The objective of this study was to develop a virtual video-based simulation to demonstrate and quantify the variability and accuracy of scribes’ transcribed notes in the EHR. Methods: From a pool of 8 scribes in one department, a total of 5 female scribes, intent on pursuing careers in health care, with at least 6 months of experience were recruited for our simulation study. We created three simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video-recorded a standardized patient-provider encounter. Five scribes with at least 6 months of experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated EHR environment. Transcribed notes were evaluated for interscribe variability and compared with a gold standard for accuracy. Results: All scribes completed all simulated cases. There was significant interscribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%. Conclusions: We created a high-fidelity, video-based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency. The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges. This highlights the need for new assessment tools for medical scribes. The objective of this study was to develop a virtual video-based simulation to demonstrate and quantify the variability and accuracy of scribes' transcribed notes in the EHR. From a pool of 8 scribes in one department, a total of 5 female scribes, intent on pursuing careers in health care, with at least 6 months of experience were recruited for our simulation study. We created three simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video-recorded a standardized patient-provider encounter. Five scribes with at least 6 months of experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated EHR environment. Transcribed notes were evaluated for interscribe variability and compared with a gold standard for accuracy. All scribes completed all simulated cases. There was significant interscribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%. We created a high-fidelity, video-based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency. BACKGROUNDThe increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges. This highlights the need for new assessment tools for medical scribes. OBJECTIVEThe objective of this study was to develop a virtual video-based simulation to demonstrate and quantify the variability and accuracy of scribes' transcribed notes in the EHR. METHODSFrom a pool of 8 scribes in one department, a total of 5 female scribes, intent on pursuing careers in health care, with at least 6 months of experience were recruited for our simulation study. We created three simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video-recorded a standardized patient-provider encounter. Five scribes with at least 6 months of experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated EHR environment. Transcribed notes were evaluated for interscribe variability and compared with a gold standard for accuracy. RESULTSAll scribes completed all simulated cases. There was significant interscribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%. CONCLUSIONSWe created a high-fidelity, video-based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency. |
Author | O'Reilly, Megan Gold, Jeffrey A McGrath, Karess Hirsh, Maxwell Pranaat, Robert Mohan, Vishnu Scholl, Gretchen Woodcock, Deborah |
AuthorAffiliation | 4 Pulmonary Critical Care Oregon Health & Sciences University Portland, OR United States 2 Obstetrics and Gynecology Oregon Health & Sciences University Portland, OR United States 1 Medical Informatics Oregon Health & Sciences University Portland, OR United States 3 School of Medicine Oregon Health & Sciences University Portland, OR United States |
AuthorAffiliation_xml | – name: 3 School of Medicine Oregon Health & Sciences University Portland, OR United States – name: 1 Medical Informatics Oregon Health & Sciences University Portland, OR United States – name: 4 Pulmonary Critical Care Oregon Health & Sciences University Portland, OR United States – name: 2 Obstetrics and Gynecology Oregon Health & Sciences University Portland, OR United States |
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BackLink | https://www.ncbi.nlm.nih.gov/pubmed/28931497$$D View this record in MEDLINE/PubMed |
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Cites_doi | 10.1093/jamia/ocv103 10.3122/jabfm.2011.06.100255 10.1186/1472-6920-14-224 10.3109/13561820.2015.1063482 10.1016/S1553-7250(12)38024-0 10.1016/j.socscimed.2013.05.001 10.1136/bmjopen-2013-002549 10.1136/qhc.13.suppl_1.i85 10.1016/S0196-0644(83)80559-9 10.1016/j.ijmedinf.2016.02.011 10.1001/jama.2014.17128 10.1080/13561820.2016.1193479 10.1097/00132981-200402000-00001 10.4300/JGME-D-15-00201.1 10.1136/amiajnl-2013-002627 |
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Copyright | Robert Pranaat, Vishnu Mohan, Megan O'Reilly, Maxwell Hirsh, Karess McGrath, Gretchen Scholl, Deborah Woodcock, Jeffrey A Gold. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 20.09.2017. 2017. This work is licensed under https://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. Robert Pranaat, Vishnu Mohan, Megan O'Reilly, Maxwell Hirsh, Karess McGrath, Gretchen Scholl, Deborah Woodcock, Jeffrey A Gold. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 20.09.2017. 2017 |
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Snippet | The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and... Background: The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider... BACKGROUNDThe increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider... |
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SubjectTerms | Accuracy Documentation Electronic health records Original Paper Patient safety Pharmacists Physicians Plagiarism Simulation Usability Workloads |
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Title | Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study |
URI | https://www.ncbi.nlm.nih.gov/pubmed/28931497 https://www.proquest.com/docview/2516918474/abstract/ https://search.proquest.com/docview/1941367034 https://pubmed.ncbi.nlm.nih.gov/PMC5628287 |
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