Getting the Predoc Back Into Documentation: Students as Scribes During Their Clerkship

The introduction of the electronic health record (EHR) has transformed clinical practice over the past few decades, impacting physician workflow in both positive and negative ways.1

EHR use is tied to reimbursement, which pushed adoption rates to 67% by March 2016.3 EHR implementation has proved challenging for physicians, and contributed to physician burnout.4-6 The increased time required for documentation has not been offset by the efficiencies promised with EHR use.7-9 Preceptors comment that this has made it harder to find time to teach. Medical schools are challenged to find physicians willing to be medical student preceptors, and the time required for EHR work further reduces their available teaching time. The use of students as scribes to assist with documentation provides dual benefits. Physician satisfaction with teaching increases and students receive early experience with patient documentation. In practices where providers have scribes, job satisfaction, productivity, and reimbursement all increase.2,4,11,12

The Association of American Medical Colleges (AAMC) recommends that all medical school students gain some EHR competency prior to residency. The Alliance for Clinical Education (ACE) and the Society of Teachers of Family Medicine (STFM) state that learning to document and use the EHR is an essential skill for students.15,16 Physicians comment that they understand the need to have students document in the EHR. Gaining access to the EHR for students has been a challenge medical schools must overcome. The American Medical Association (AMA) and AAMC advocate for increased student access.13,14

The Centers for Medicaid and Medicare Services (CMS) have also changed their stance on student documentation in the EHR.17 EHR access is still limited by some health systems for security or compliance reasons.18 This study investigated a novel method that allows students to document in the EHR. The study looked at students in the scribe role to determine benefits to faculty in the areas of increased productivity and provider satisfaction.2,12,19 Allowing students to act in the scribe role should improve EHR skills and increase engagement. For preceptors, it has the potential to reduce their documentation burden and increase teaching satisfaction.

The Institutional Review Boards of the University of North Dakota and Sanford Health exempted this research proposal. We recruited students from the University of North Dakota School of Medicine and Health Sciences (UND SMHS) from May 2016 to July 2017. When a student was scheduled with a provider and system that allowed scribes, they were asked if they wished to participate. Volunteer students were then trained in the role of scribe. An extra 4 to 6 hours of training was designed to increase EHR skills in the EPIC EHR. First, Sanford Health led training in advanced EPIC use, and proper scribe documentation. Then the students practiced in the EPIC training environment, under the lead physician. They documented clinical visits using case videos for seven different common visits. If the scribed notes met requirements for completeness and accuracy, the students were given a certificate of completion and were scribe-capable. We developed compliant attestation statements indicating the students’ role as scribe. Although the students’ primary role was to learn, they also functioned as documentation scribe on a few patients daily. The learning sequence was as follows: the student entered the room to interview the patient and take an appropriate history and physical; (2) they then presented the patient to the preceptor and discussed the case; (3) they entered the room together; and (4) while the preceptor interviewed and examined the patient, the student entered the visit information into the EHR as scribe. Students, faculty preceptors, and staff (registered nurses, licensed practical nurses, or certified medical assistants who worked with the student) completed surveys at the conclusion of the study to ascertain the impact on the student, the preceptor, and the practice. The survey elicited comments from students, faculty, and staff.

Tables 1-3 summarize item responses by group. Among clinical faculty, 18 returned surveys; among clinical staff; 11 returned surveys; among students, 20 returned surveys. Overall, 49 of 53 participants completed surveys.

All participants reported that documenting would be useful. The faculty and clinical staff reported that documenting was beneficial for teaching and should be learned in the third year of medical school. The students did not think documenting detracted from their student role. Learning to document was beneficial for training, and should be learned in the third year.

Qualitative feedback explained variability. The students’ comments included statements such as “it was a great experience,” “I would recommend for everyone,” and “I learned a lot of things in the EMR, not just note writing but how to navigate it to find information.” The preceptor and staff indicated that the students appeared more engaged. They also clarified answers that fell below 3, such as “Harder at the time since the record gets tied up/hard to flip through the record.”

The EHR is a tool providers use daily. By residency, students need skills to navigate the EHR to appropriately document care. CMS rule changes open the door for students to document in the EHR. Faculty noted students with increased documentation responsibilities are more engaged overall. In addition, decreases in the documentation burden provided by student scribes appeared to make it easier for physicians to teach in their practice. Some clinical staff did not feel it helped with time, and when the findings were discussed with staff, not all teaching time lost in clinic was made up for by documenting. This study included only the Epic EHR, although skills of documenting and using an electronic health record should transfer to other settings and other EHRs. With new CMS rules, this study should serve as an early indicator that students can have a positive impact while acquiring skills to use EHRs. Further research into how the new CMS rules have affected the opportunity for students to learn to document in the EHR would increase knowledge of the rule’s impact.