Creation and validation of a training toolkit to ensure safe and proficient use of EHR by medical scribes

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With the widespread adoption of Electronic Health Records (EHRs) there has been a growing appreciation of the unintended consequences associated with their adoption and specifically the negative impacts on productivity and workflow. Consequently, there has been dramatic growth in the use of medical scribes to aid providers by, in essence, “untethering the provider from the EHR”. In spite of this rapid growth, and the purported benefits on improving physician efficiency and improved billing, there is little to no regulation on standardization of scribe training, nor any assessment of their ability to safely interface with the EHR. To better understand the role and functionality of scribes, we undertook a national survey of health care providers. We found that scribes comprise a wide range of personnel from college students to Medical Assistants. There is wide variability in their training, with the majority of scribes receiving job specific training by the hiring practice. In terms of scribe function, again there was wide variability in scribe activities with relation to the EHR, from simple encounter note creation, to finding information in the EHR for the physicians to entering orders and responding to patient messages. We directly assessed scribe function at OHSU in a novel video based virtual simulation. We found that there is tremendous intra-scribe variability in note creation and structure. This corresponds to significant errors of omission and commission (incorrect information entered into the system). Specifically, the average scribe captured only 40% of the diagnoses or plans mentioned in the simulation with less than 40% overlap in documentation between scribes. Further, every scribe documented a number of incorrect plan and diagnosis items. Combined, these data suggest a new and potentially significant safety issue with scribe use of the EHR. Therefore the goal of this proposal is to fully assess the scope of scribe use with respect to the EHR and use this information in conjunction with national experts in EHR safety and medical documentation to establish a series Entrustable Professional Activities (EPAs) for medical scribes. We will use these as basis to create and validate a toolkit to allow for organizations to assess the ability of scribe to complete these EPAs. In Aim #1, we will use a combination of surveys and site visits to assess the landscape of scribe functionality. This information will then serve as the basis for a consensus conference to define scribe Entrustable Professional Activities (EPAs) with respect to the EHR. In Aim #2 we will map these EPAs to a set of competencies and create a curriculum to assess these competencies. This curriculum will contain a series on online EHR didactics and video based simulation exercises with corresponding simulated EHR records to asses real world performance of scribes. In Aim #3, we will calibrate and validate this curriculum across a variety of specialties and EHR use expectations with current scribes. In Aim #4, we will hold another consensus conference to review the curricular elements and use the results to create an online toolkit to allow providers and health care organization to assess scribe competency. Thus by the end of the study period we will have a web based, comprehensive toolkit to allow for real-world assessment of safe and accurate use of EHR by medical scribes across a range of EHR functional levels and a variety of specialties and environments.