A Time-Driven Activity-Based Costing Analysis of Emergency Department Scribes

Effect of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act Scribes Trial on Emergency Department Provider Productivity and Patient Throughput Times

BACKGROUND

To help improve access to care, section 507 of the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act of 2018 mandated a 2-year trial of medical scribes in the Veterans Health Administration (VHA).

OBJECTIVE

The impact of scribes on provider productivity and patient throughput time in VHA emergency departments (EDs) was evaluated.

METHODS

A clustered randomized trial was designed using intent-to-treat difference-in-differences analysis. The intervention period was from June 30, 2020 to July 1, 2022. The trial included six intervention and six comparison ED clinics. Two ED providers who volunteered to participate in the trial were assigned two scribes each. Scribes assisted providers with documentation and visit-related activities. The outcomes were provider productivity and patient throughput time per clinic-pay period.

RESULTS

Randomization to intervention resulted in decreased provider productivity and increased patient throughput time. In adjusted regression models, randomization to scribes was associated with a decrease of 8.4 visits per full-time equivalent (95% confidence interval [CI] 12.4-4.3; p < 0.001) and 0.5 patients per day per provider (95% CI 0.8-0.3; p < 0.001). Intervention was associated with increases in length of stay of 29.1 min (95% CI 21.2-36.9 min; p < 0.001), 6.3 min in door to doctor (95% CI 2.9-9.6 min; p < 0.001), 19.5 min in door to disposition (95% CI 13.2-25.9 min; p < 0.001), and 13.7 min in doctor to disposition (95% CI 8.8-18.6 min; p < 0.001).

CONCLUSIONS

Scribes were associated with decreased provider productivity and increased patient throughput time in VHA EDs. Although scribes may have contributed to improvements in other dimensions of quality, further examination of the ways in which scribes were used is advisable before widespread adoption in VHA EDs.

A Computational Framework to Evaluate Emergency Department Clinician Task Switching in the Electronic Health Record Using Event Logs

Workflow fragmentation, defined as task switching, may be one proxy to quantify electronic health record (EHR) documentation burden in the emergency department (ED). Few measures have been operationalized to evaluate task switching at scale. Theoretically grounded in the time-based resource-sharing model (TBRSM) which conceives task switching as proportional to the cognitive load experienced, we describe the functional relationship between cognitive load and the time and effort constructs previously applied for measuring documentation burden. We present a computational framework, COMBINE, to evaluate multilevel task switching in the ED using EHR event logs. Based on this framework, we conducted a descriptive analysis on task switching among 63 full-time ED physicians from one ED site using EHR event logs extracted between April-June 2021 (n=2,068,605 events) which were matched to scheduled shifts (n=952). On average, we found a high volume of event-level (185.8±75.3/hr) and within-(6.6±1.7/chart) and between-patient chart (27.5±23.6/hr) switching per shift worked.

Micro-costing analysis of suspected lower respiratory tract infection care in a French emergency department

Introduction

In the context of budgetary constraints faced by healthcare systems, the medical-economic evaluation of care strategies becomes essential. In particular, valuing consumed resources in the overcrowded emergency departments (EDs) has become a priority to adopt more efficient approaches in treating the growing number of patients. However, precisely measuring the cost of care is challenging. While bottom-up micro-costing is considered the gold standard, its practical application remains limited.

Objective

The objective was to accurately estimate the ED care cost for patients consulting in a French ED for suspected lower respiratory tract infection.

Methods

The authors conducted a cost analysis using a bottom-up micro-costing method. Patients were prospectively included between January 1, and March 31, 2023. The primary endpoint was the mean cost of ED care. Resources consumed were collected using direct observation method and cost data were obtained from information available at Strasbourg University Hospital.

Results

The mean cost of ED care was €411.68 (SD = 174.49). The cost elements that made the greatest contribution to the total cost were laboratory tests, labor, latency time, imaging and consumables. Considering this cost and the current epidemiological data on respiratory infections in France, the absence of valuation for outpatient care represents an annual loss of over 17 million euros for healthcare facilities.

Conclusion

Micro-costing is a key element in valuing healthcare costs. The importance of accurately measuring costs, along with measuring the health outcomes of a defined care pathway, is to enhance the relevance of health economic evaluations and thus ensure efficient care.

Scribes with PGY-1 Residents on Inpatient Medicine Teams: Effect on Time Spent in Meaningful Work

Background

The high documentation demands and limited time in direct patient care in the first year of internal medicine residency represent concerns for burnout and low job satisfaction in this important year of training.

Objective

To assess the effect of scribes on the time PGY-1 residents spent on various work tasks.

Methods

Participants were 24 PGY-1 internal medicine residents on two inpatient medicine teams at one site for 6 months (September 2019-February 2020). Residents were assigned a scribe during the first or second 2 weeks of a 4-week rotation and had no scribe for the other 2 weeks. Time study observers documented resident work activities. Residents ranked the meaningfulness of work activities via survey at the end of each 2-week period.

Results

Of 24 residents, 18 (75%) completed the survey at both time points. Residents ranked patient care as the most meaningful and EHR work as the least meaningful work activity. EHR work claimed the largest percentage of time, with or without a scribe (mean, 33.2% and 39%, respectively). With a scribe, residents spent significantly less time (-5.8%, P < 0.0001) in EHR work and significantly more time (1.3%, P = 0.0267) in direct patient care and coordinating patient care (3.0%, P < 0.0001).

Conclusions

The presence of a scribe with PGY-1 internal medicine residents on inpatient teams resulted in a significantly greater percentage of total work time spent in work they considered most meaningful and a significantly lower percentage of total work time in work they considered least meaningful.

Adaptation of time‐driven activity‐based costing to the evaluation of the efficiency of ambulatory care provided in the emergency department

Objectives

The aim of this study was: (1) to adapt the time‐driven activity‐based costing (TDABC) method to emergency department (ED) ambulatory care; (2) to estimate the cost of care associated with frequently encountered ambulatory conditions; and (3) to compare costs calculated using estimated time and objectively measured time.

Methods

TDABC was applied to a retrospective cohort of patients with upper respiratory tract infections, urinary tract infections, unspecified abdominal pain, lower back pain and limb lacerations who visited an ED in Québec City (Canada) during fiscal year 2015–2016. The calculated cost of care was the product of the time required to complete each care procedure and the cost per minute of each human resource or equipment involved. Costing based on durations estimated by care professionals were compared to those based on objective measurements in the field.

Results

Overall, 220 care episodes were included and 3080 time measurements of 75 different processes were collected. Differences between costs calculated using estimated and measured times were statistically significant for all conditions except lower back pain and ranged from $4.30 to $55.20 (US) per episode. Differences were larger for conditions requiring more advanced procedures, such as imaging or the attention of ED professionals.

Conclusions

The greater the use of advanced procedures or the involvement of ED professionals in the care, the greater is the discrepancy between estimated‐time‐based and measured‐time‐based costing. TDABC should be applied using objective measurement of the time per procedure.

Process, resource and success factors associated with chimeric antigen receptor T-cell therapy for multiple myeloma

Background: Chimeric antigen receptor T-cell (CAR-T) therapy represents a new frontier in multiple myeloma. It is important to understand critical success factors (CSFs) that may optimize its use in this therapeutic area. Methods: We estimated the CAR-T process using time-driven activity-based costing. Information was obtained through interviews at four US oncology centers and with payer representatives, and through publicly available data. Results: The CAR-T process comprises 13 steps which take 177 days; it was estimated to include 46 professionals and ten care settings. CSFs included proactive collaboration, streamlined reimbursement and CAR-T administration in alternative settings when possible. Implementing CSFs may reduce episode time and costs by 14.4 and 13.2%, respectively. Conclusion: Our research provides a blueprint for improving efficiencies in CAR-T therapy, thereby increasing its sustainability for multiple myeloma.

A Mobile App for the Precise Measurement of Healthcare Provider Activity Times to Support Time-Driven Activity Based Costing Studies

The duration of activities performed by healthcare providers are pivotal to Time-Driven Activity-Based Costing (TDABC) models. This study examines the use of a smartphone mobile application technology to record activity times. This study validates the accuracy of activity times recorded on a smartphone mobile application, dTool, compared to observed length of time recordings in the operating room. For analysis, we performed two one-sided tests for the measurements "Case Start" and "Case End". Equivalence bounds were specified in terms of raw mean difference of 1 min (upper) and -1 min (lower). The total number of comparisons in the observer protocol was 72 (32 "case start" patient comparisons and 40 "case end" patient comparisons measured over 45 individual OR cases). Given equivalence bounds of -1.000 and 1.000 (on a raw scale) and an alpha of 0.05, both equivalence tests were significant: provider and third-party observer protocol presented t(40) = 3.228 and p = < 0.001; observer timing protocol presented t(68.68) = 56.762, p = < 0.001. Conclusions: With this novel smartphone technology, a healthcare provider can reliably self-record activity LoT using dTool while providing patient care. Future TDABC studies incorporating this technology will reduce the potential operational barriers to implementation.

Reduced Cognitive Burden and Increased Focus: A Mixed-methods Study Exploring How Implementing Scribes Impacted Physicians

BACKGROUND

Understanding how medical scribes impact care delivery can inform decision-makers who must balance the cost of hiring scribes with their contribution to alleviating clinician burden.

OBJECTIVE

The objective of this study was to understand how scribes impacted provider efficiency and satisfaction.

DESIGN

This was mixed-methods study.

PARTICIPANTS

Internal and family medicine clinicians were included.

MEASURES

We administered structured surveys and conducted unstructured interviews with clinicians who adopted scribes. We collected average days to close charts and quantity of after-hours clinical work in the 6 months before and after implementation using electronic health record data. We conducted a difference in difference (DID) analysis using a multilevel Poisson regression.

RESULTS

Three themes emerged from the interviews: (1) charting time is less after training; (2) clinicians wanted to continue working with scribes; and (3) scribes did not reduce the overall inbox burden. In the 6-month survey, 76% of clinicians endorsed that working with a scribe improved work satisfaction versus 50% at 1 month. After implementation, days to chart closure decreased [DID=0.38 fewer days; 95% confidence interval (CI): -0.61, -0.15] the average minutes worked after hours on clinic days decreased (DID=-11.5 min/d; 95% CI: -13.1, -9.9) as did minutes worked on nonclinical days (DID=-24.9 min/d; 95% CI: -28.1, -21.7).

CONCLUSIONS

Working with scribes was associated with reduced time to close charts and reduced time using the electronic health record, markers of efficiency. Increased satisfaction accrued once scribes had experience.

Clinical Documentation During Scribed and Non-scribed Ophthalmology Office Visits

PURPOSE

Observe the impact of employing scribes on documentation efficiency in ophthalmology clinics.

DESIGN

Single-center retrospective cohort study.

PARTICIPANTS

A total of 29,997 outpatient visits conducted by seven attending ophthalmologists between 1/1/2018 and 12/31/2019 were included in the study; 18,483 with a scribe present during the encounter and 11,514 without a scribe present.

INTERVENTION

Use of a scribe.

MAIN OUTCOME MEASURES

Total physician documentation time, physician documentation time during and after the visit, visit length, time to chart closure, note length, and percent of note text edited by physician.

RESULTS

Total physician documentation time was significantly less when working with a scribe (mean ± SD, 4.7 ± 2.9 vs. 7.6 ± 3.8 minutes/note, P<.001), as was documentation time during the visit (2.8 ± 2.2 vs. 5.9 ± 3.1 minutes/note, P<.001). Physicians also edited scribed notes less, deleting 1.9 ± 4.4% of scribes' draft note text and adding 14.8 ± 11.4% of the final note text, compared to deleting 6.0 ± 9.1%(P<.001) of draft note text and adding 21.2 ± 15.3%(P<.001) of final note text when not working with a scribe. However, physician after-visit documentation time was significantly higher with a scribe for 3 of 7 physicians (P<.001). Scribe use was also associated with an office visit length increase of 2.9 minutes (P<.001) per patient and time to chart closure of 3.0 hours (P<.001), according to mixed-effects linear models.

CONCLUSIONS

Scribe use was associated with increased documentation efficiency through lower total documentation time and less note editing by physicians. However, the use of a scribe was also associated with longer office visit lengths and time to chart closure. The variability in the impact of scribe use on different measures of documentation efficiency leaves unanswered questions about best practices for the implementation of scribes, and warrants further study of effective scribe use.

Emergency medicine residents spend over 7.5 months of their 3-year residency on the electronic health record

BACKGROUND

Use of the electronic health record (EHR) is a standard component of modern patient care. Although EHRs have improved since inception, cumbersome workflows decrease the time for residents to spend on clinical and educational activities. This study aims to quantify the time spent interacting with the EHR during a 3-year emergency medicine (EM) residency.

METHODS

System records of time spent actively engaged in EHR use were analyzed for 98 unique EM residents over a period of 5 years from July 2015 to June 2020. Time spent on the EHR was totaled to give a career time, with a "work month" defined as a 4-week period of 70.5 h per week, based on Accreditation Council for Graduate Medical Education work hour restrictions for EM residents. Engagement in specific activities such as chart review, documentation preparation, and order entry were separately analyzed.

RESULTS

Over their 3-year training, a resident interacted with the EHR for 2,171 continuous hours. This amounts to 30.8 work weeks or 7.7 work months. Chart review was the most time-intensive activity at 11.42 weeks. Documentation accounted for 9.91 weeks, with an average career total of 7,280 notes created. Additionally, each resident spent 4.57 weeks on order entry, with 46,347 orders entered during training. While the number of charts opened increased after first year of residency, average time spent on each activity per patient decreased.

CONCLUSIONS

This unique study quantifies the total time an EM resident spends on the EHR during a 3-year residency. Use of the EHR accounted for over 7.5 work months or nearly 21% of their training. Residents spend a substantial portion of their training interacting with the EHR and workflow improvements to reduce EHR time are critical for maximizing training time.

The Effect of Medical Scribes in Emergency Departments: A Systematic Review

BACKGROUND

Integrating medical scribes with clinicians has been suggested to improve access, quality of care, enhance patient/clinician satisfaction, and increase productivity revenue.

OBJECTIVE

Conduct a systematic review to evaluate the effects of medical scribes in emergency departments.

METHODS

Electronic databases from 2010 through December 2019. Two individuals independently reviewed study eligibility, rated risk of bias, and determined overall certainty of evidence. Data abstracted included study and population characteristics, outcomes (efficiency, patient or clinician satisfaction, financial productivity, documentation quality, cost, and training time), and the effect of compensation structure, qualifications, duties, and setting on outcomes.

RESULTS

Twenty studies (18 observational) were included; 12 from two institutions. All utilized in-person rather than virtual scribes. Fifteen were rated as serious or critical risk of bias; five were rated moderate. Findings indicate that scribes may increase patients seen per day and decrease length of stay; however, effects were small and may vary by setting and outcome measured (low certainty). Scribes may increase financial productivity; however, costs associated with developing, implementing, and maintaining scribe programs were not adequately reported. Results were mixed for door-to-room or door-to-provider time, patients left without being seen, and patient/clinician satisfaction. No studies examined the effects of scribes based on compensation structure, qualifications or duties.

CONCLUSIONS

Although information quality, quantity, and applicability are limited, in-person medical scribes may improve emergency department efficiency and financial productivity. There was no information on virtual scribes. There was little information on patient or clinician satisfaction, scribe documentation quality, or whether results vary by in-house vs. contracted hiring and training.

Five Years' Experience With a Medical Scribe Fellowship: Shaping Future Health Professions Students While Addressing Provider Burnout

Professional burnout has reached epidemic levels among U.S. medical providers. One key driver is the burden of clinical documentation in the electronic health record, which has given rise to medical scribes. Despite the demonstrated benefits of scribes, many providers-especially those in academic health systems-have been unable to make an economic case for them. With the aim of creating a cost-effective scribe program in which premedical students gain skills that better position them for professional schooling, while providers at risk of burnout obtain documentation support, the authors launched the Clinical Observation and Medical Transcription (COMET) Program in June 2015 at Stanford University School of Medicine. COMET is a new type of postbaccalaureate premedical program that combines an apprenticeship-like scribing experience and a package of teaching, advising, application support, and mentored scholarship that is supported by student tuition. Driven by strong demand from both participants and faculty, the program grew rapidly during its first 5 years (2015-2020). Program evaluations indicated high levels of satisfaction among participants and faculty with their mentors and mentees, respectively; that participants felt the experience better positioned them for professional schooling; and that faculty reported improved joy of practice. In summary, tuition-supported medical scribe programs, like COMET, appear to be feasible and cost-effective. The COMET model may have the potential to help shape future health professions students, while simultaneously combating provider burnout. While scalability and generalizability remain uncertain, this model may be worth exploring at other institutions.

Methods for Large-Scale Quantitative Analysis of Scribe Impacts on Clinical Documentation

Many medical providers employ scribes to manage electronic health record (EHR) documentation. Prior studies have shown the benefits of scribes, but no large-scale study has quantitively assessed scribe impact on documentation workflows. We propose methods that leverage EHR data for identifying scribe presence during an office visit, measuring provider documentation time, and determining how notes are edited and composed. In a case study, we found scribe use was associated with less provider documentation time overall (averaging 2.4 minutes or 39% less time, p < 0.001), fewer note edits by providers (8.4% less added and 4.2% less deleted text, p < 0.001), but significantly more documentation time after the visit for four out of seven providers (p < 0.001) and no change in the amount of copied and imported note text. Our methods could validate prior study results, identify variability for determining best practices, and determine that scribes do not improve all aspects of documentation.

Process Mapping and Activity-Based Costing of the Intravitreal Injection Procedure

PURPOSE/AIM OF THE STUDY

To quantify the cost of performing an intravitreal injection (IVI) utilizing activity-based costing (ABC), which allocates a cost to each resource involved in a manufacturing process.

MATERIALS AND METHODS

A prospective, observational cohort study was performed at an urban, multi-specialty ophthalmology practice affiliated with an academic institution. Fourteen patients scheduled for an IVI-only visit with a retina ophthalmologist were observed from clinic entry to exit to create a process map of time and resource utilization. Indirect costs were allocated with ABC and direct costs were estimated based on process map observations, internal accounting records, employee interviews, and nationally-reported metrics. The primary outcome measure was the cost of an IVI procedure in United States dollars. Secondary outcomes included operating income (cost subtracted from revenue) of an IVI and patient-centric time utilization for an IVI.

RESULTS

The total cost of performing an IVI was $128.28; average direct material, direct labor, and overhead costs were $2.14, $97.88, and $28.26, respectively. Compared to the $104.40 reimbursement set by the Centers for Medicare and Medicaid Services for Current Procedural Terminology code 67028, this results in a negative operating income of -$23.88 (-22.87%). The median clinic resource-utilizing time to complete an IVI was 32:58 minutes (range [19:24-1:28:37]); the greatest bottleneck was physician-driven electronic health record documentation.

CONCLUSIONS

Our study provides an objective and accurate cost estimate of the IVI procedure and illustrates how ABC may be applied in a clinical context. Our findings suggest that IVIs may currently be undervalued by payors.

Economic Evaluation of a Telemedicine Service to expand Primary Health Care in Rio Grande do Sul: TeleOftalmo's microcosting analysis

This study evaluated the cost of public telediagnostic service in ophthalmology. The time-driven activity-based costing method (TDABC) was adopted to examine the cost components related to teleophthalmology. This method allowed us to establish the standard unit cost of telediagnosis, given the installed capacity and utilization of professionals. We considered data from one year of telediagnoses and evaluated the cost per telediagnosis change throughout technology adaptation in the system. The standard cost calculated by distance ophthalmic diagnosis was approximately R$ 119, considering the issuance of 1,080 monthly ophthalmic telediagnostic reports. We identified an imbalance between activities, which suggests the TDABC method's ability to guide management actions and improve resource allocation. The actual unit cost fell from R$ 783 to R$ 283 over one year - with room to approach the estimated standard cost. Partial economic evaluations contribute significantly to support the incorporation of new technologies. The TDABC method deserves prominence, as it enables us to retrieve more accurate information on the cost of technology, improving the scalability and management capacity of the healthcare system.

Ambient virtual scribes: Mutuo Health's AutoScribe as a case study of artificial intelligence-based technology

Studies show that clinicians are increasingly burning out in large part from the clerical burden associated with using Electronic Medical Record (EMR) systems. At the same time, recently developed health data analytic algorithms struggle with poor quality free-text entered data in these systems. We developed AutoScribe using artificial intelligence-based natural language processing tools to automate these clerical tasks and to output high-quality EMR data. In this article, we describe the benefits and drawbacks of our technology. Furthermore, we describe how we are positioning our company's culture within the existing healthcare system and suggest steps leaders of the system should consider in order to ensure that potentially transformative artificial intelligence-based technologies like ours are optimally adopted.

Effect of Medical Scribes on Outpatient Oncology Visits at a Multidisciplinary Cancer Center

PURPOSE

The use of medical scribes has emerged as a strategy to increase clinic workflow efficiency and reduce physician burnout. While oncology clinics may be ideally suited to scribe integration because of the high burden of documentation, oncology-specific scribe research has been limited. The objective of this study was to determine the effect of scribe integration on clinic workflow efficiency and physician satisfaction and quality of life in outpatient oncology clinics.

METHODS

We conducted a retrospective, concurrent qualitative and quantitative analysis of patient visit durations and survey data for 129 attending physicians affiliated with an academic hospital's cancer center between January 2017 and January 2019. Thirty-three physicians were paired with scribes in each physician's individual clinic or clinics.

RESULTS

In terms of clinic efficiency, physicians with scribes had a 12.1% decrease in their overall average patient visit duration compared with their own time before receiving a scribe (P < .0001) and spent significantly less time completing charts at the end of the day (P = .04). Compared with their peers, oncologists with scribes showed a 10%-20% decrease in the duration of all patient visits. Scribes also contributed to patient care, as shown by 90% of physicians surveyed who strongly agreed that they spent less time at the computer and more time with patients; 100% of physicians surveyed strongly agreed that scribes improved their quality of life.

CONCLUSION

The integration of medical scribes into oncology clinics across several oncologic disciplines has the potential to reduce burnout through increasing physician satisfaction and quality of life, improving patient care, and streamlining clinic workflow.