Effects of medical scribes on patients, physicians, and safety: A scoping review

A scoping review was conducted to investigate the effects of medical scribes on physician and patient satisfaction, physician burnout, the educational experience of medical students and residents, risk, and safety. The databases PubMed, EMBASE, and CINAHL were searched for the years 2000-2020. Relevant studies were analyzed qualitatively. Literature analysis found that medical scribes increase physician satisfaction and decrease physician burnout, while having minimal impact on patient satisfaction. Patient impressions of scribes tend to be neutral to positive. The effects of scribes on medical student and resident education appear positive in preliminary results. Scribe-generated notes seem to be of equal or greater quality compared to physician-generated notes, though few studies have examined this issue. The impact of scribes on risk and safety has not been fully studied. Few studies of medical scribes have been conducted in Canada, and only one has been published in a peer-reviewed journal. Medical scribes are a promising solution to the growing challenge of physician documentation-related burden fueled by electronic health records and electronic medical records. Studies on the impact of scribes in countries other than the United States are needed. Administrative hurdles to the implementation of scribes in Canadian hospitals could be a barrier to pilot studies in Canada.


Introduction
With the implementation of electronic health records (EHRs) and electronic medical records (EMRs) in the past few decades, healthcare has become more "data driven", with increased clerical workload for physicians (Bossen et al., 2019). Many physicians now spend more time on documentation and other "desktop medicine" than on direct patient care (Sinsky et al., 2016;Tai-Seale et al., 2017). The medical scribe industry developed in response to this new data-centric workload in healthcare, in an effort to off-load some of the clerical tasks from physicians. Medical scribes document the words of the practitioner who is assessing the patient, and do not have any patient care responsibilities. There are no formal training or background requirements for scribes (American College of Emergency Physicians, 2018). Medical scribes have been in existence since the 1970s, but their numbers did not increase dramatically until after the implementation of EHRs and EMRs (Bossen et al., 2019). Scribes were first employed to chart in paper medical records in emergency departments, due to the rapid pace of work faced by emergency physicians. As EHR and EMR implementations increased, so too did the number of medical scribes (Bossen et al., 2019). As medical scribes are not a regulated profession, it is difficult to quantify their current numbers in the healthcare workforce.
Medical scribes are described as "personnel specifically hired to chart patientclinician encounters in real time, from the beginning of the encounter to its end" (Shultz & Holmstrom, 2015, p. 372). As these authors clarify, "the identification of a person as a scribe is not dependent on their training per se, but the person's predefined role" (Shultz & Holmstrom, 2015, p. 372). Though there are no formal training or licensing requirement for medical scribes, they are often considered EHR experts by those who work with them Hafer et al., 2018). Medical scribes chart patientphysician encounters in real time, and physicians must sign scribed notes to authenticate them (Shultz & Holmstrom, 2015). The goal of adding scribes to healthcare teams is to decrease the clerical work of physicians and allow them to focus on clinical work. The scope of duties for a medical scribe can vary, depending on the practice environment, as well as the wishes of the physician.
Appendices A, B, and C include the Joint Commission definition of a medical scribe, the American Academy of Emergency Medicine position statement on scribes, and the details of the organizations in the United States offering scribe certification exams. There are several different organizations in the United States which offer their own scribe certification exams, but these are not regulated by any accreditation body. Woodcock et al. (2017) noted that there are not any national, state, or local regulations governing scribe scope of practice in the United States (p. 383). This is also the case in Canada.
Accurate medical documentation is vital in communicating between health care providers. Adding an additional person into the documentation process has the potential to affect patient safety, particularly without any regulatory oversight of the medical scribe role. Concern about scribe role expansion or unintentional functional creep exists.
The adoption of health information systems in Canada has exploded over the past fifteen years, with EMR use among primary care physicians increasing from 24% in 2006to 85% in 2017(Canada Health Infoway, 2018. Widespread EHR/EMR implementation has increased documentation time, especially for primary care physicians (Zallman et al., 2018). Documentation-related burden, exacerbated by poor EHR usability, is known to decrease physician professional satisfaction (DiSanto & Prasad, 2017;C. Lowry et al., 2017). Quality of care may be decreasing due to physicians being burdened by excess administrative duties (Olson et al., 2019;Rao et al., 2017). Physician burnout has been described as a public health crisis, with primary care physicians experiencing the highest rates (Mishra et al., 2018;Olson et al., 2019).
A Canadian Medical Association (CMA) survey conducted in 2017 found that 30% of Canadian physicians reported burnout (Canadian Medical Association, 2018). Despite this statistic, medical scribes have not been widely implemented in Canada as they have in the United States. This review aims to determine what is currently known about medical scribe effects on patients and physicians, and what barriers might be preventing Canadian physicians from obtaining the documentation assistance of scribes.

Methods
Medical scribes are an emerging phenomenon in Canada and other countries outside of the United States, with few published research studies. The objectives of this scoping review are to assess the current state of research on the effects of scribes on patients, physicians, medical learners, medical record quality, risk, and safety. Scoping reviews are more appropriate than systematic reviews for topics with emerging evidence, such as medical scribes (Levac et al., 2010). As this is a scoping review, broad questions were defined: 1. What are the effects of medical scribes on physician burnout, physician wellbeing, and physician professional satisfaction? 2. What are the effects of medical scribes on patient satisfaction? 3. What are the effects of medical scribes on medical student and resident education? 4. What is known about the effects of medical scribes in Canada? 5. How does the quality of scribed notes compare to notes written by physicians?
The methodological framework for conducting a scoping review developed by Arksey and O'Malley was followed (Arskey & O'Malley, 2005;Levac et al., 2010;Younge et al., 2015). Peer-reviewed published studies and the grey literature were examined. Themes were identified to create a thematic analytic framework, and gaps in current knowledge sought. The methodological quality of individual studies was not assessed in depth, but sample sizes and methods were noted to identify current gaps in research (Pham et al., 2014).

Search strategy
Preliminary searches were done to pilot the search strategy using the following terms: "scribe*", "medical scribe*", and "physician scribe*". Studies were identified that referred to medical scribes simply as "scribes", or as "clinical scribes". Therefore, a determination was made that the term "scribe*" should be used on its own for the searches, to maintain breadth of coverage (Arskey & O'Malley, 2005). The databases PubMed, EMBASE and CINAHL were searched using the term "scribe*". Un updated search was done in February 2021 to include records published in 2020. Records published electronically in 2020 were included, even if the print publication date was in 2021. The results of those searches are summarized in Table 1. Note. Search query used: "scribe*"; Filters: English language, from Jan. 1, 2000 to Dec. 31, 2020

Study selection
The process for study selection was iterative and was refined as abstracts and articles were reviewed (Joseph et al., 2020;Levac et al., 2010). The database search results were imported into EndNote, combined into one group, and the EndNote de-duplication procedure was used. Authors L.S. and J.S. completed a rapid title screen, followed by an abstract review. Articles that seemed to meet the inclusion criteria based on the information in the abstract were read in full. Articles for which an abstract was not available were included in the final stage of full article review to determine if they met the inclusion criteria. See Table 2 for inclusion and exclusion criteria. Fig. 1 shows the Prisma diagram that was generated to demonstrate the process used for article selection (Crampton et al., 2016;Tricco et al., 2018).

Table 2
Inclusion and exclusion criteria Inclusion Criteria • Peer-reviewed articles regarding medical scribes and their effects on physician professional satisfaction or burnout • Peer-reviewed articles regarding medical scribes and their effects on patient satisfaction • Peer-reviewed articles regarding medical scribes and their effects on medical student or resident physician educational experience • Peer-reviewed articles regarding the quality of medical scribe-generated documentation • Grey literature from professional associations, dissertations, and conference abstracts, due to the lack of published Canadian studies on the topic of medical scribes Exclusion Criteria • Articles published in a non-English language • Opinion pieces and letters to the editor • Articles and dissertations without full text available (if attempts to locate these articles through inter-library loans and the relevant university's website were unsuccessful) • Articles focusing only on the financial impact of medical scribes • Articles focusing only on the effect of medical scribes on emergency department throughput metrics • Conference abstracts that went on to publication as full articles based on the same datathe article reporting the most complete data set was used, as per Pham et al. (2014)

Charting the data
Articles meeting the inclusion criteria were read and their contents summarized as per the Tables D. 19, D.20, D.21, and D.22 in Appendix D. These tables were developed to systematically capture data from the included studies (Villumsen & Nøhr, 2017). Data on publication year, country, setting (hospital vs. outpatient), medical or surgical specialty, study methods, and results were summarized.

Collating, summarizing, and reporting the results
A thematic analysis approach was used to collate and summarize the data from the included studies (Crampton et al., 2016). All the articles eligible for inclusion were read and broad themes were identified. More themes were added as new topics emerged. Articles could be mapped to multiple themes, if applicable (Crampton et al., 2016). After themes were identified from all articles, they were analyzed, and sub-themes were developed and categorized (see Table 3).

Results
Database searches of PubMed, EMBASE, and CINAHL retrieved 1888 results. Duplicates were removed using the EndNote de-duplication procedure and manual scanning, leaving 1399 unique records. Fig. 1 describes the process for article selection. Final article count included in the scoping review was 55 peer-reviewed studies and 40 grey literature articles. Table 4 lists studies by country of origin and type, excluding systematic reviews and studies that did not state the location.
Themes emerged regarding the effects of scribes on patients, physicians, and medical learners. Other themes involved the interaction between scribes and physicians, and the organizational impacts of scribes. Finally, the lack of validated measures for assessing the impact of scribes was a major theme.

. Patient satisfaction
Most of the studies reviewed found that patient satisfaction with the medical visit was high in the pre-scribe period and did not change very much post-scribe. Pre-scribe refers to the period before scribe implementation, and post-scribe to the period after scribe implementation. Patient attitudes towards scribes tended to be neutral to positive. A recent systematic review found that 7 of 18 studies reported a favorable patient satisfaction with scribes, and no studies reported a negative patient satisfaction (Gottlieb et al., 2021). See Tables D.1 and D.2 in Appendix D for details of studies of scribes which included patient satisfaction surveys or qualitative interviews.
A large study of patient attitudes towards scribes found that among patients who had concerns regarding having a scribe present, some were simply unsure of who exactly the scribe was (Addesso et al., 2019). This study concluded that healthcare providers may need education on how to introduce scribes to patients. Martel et al. (2018) found a slight decrease in patient satisfaction, from 100% to > 90%. Taylor et al. (2019) also reported a slight decrease in patient experience when a scribe was present, however "overall patient experience and satisfaction were not negatively impacted when using scribes" (p. 4).

Willingness of patient to discuss sensitive topics with a scribe present
A concern that has repeatedly been raised in the literature is that patients may not feel comfortable discussing sensitive topics with their physician if a scribe is present (Taylor et al, 2019;Wangenheim, 2018). Issues such as sexual function, mental health, domestic violence, and substance abuse are topics that some patients may rather discuss with their physician alone. The recurrent theme of studies which examined this topic was that most patients were comfortable having a scribe present during their medical visit, even during the discussion of sensitive issues. Dunlop et al. (2018) recommended that physicians be trained to subtly ask the scribe to leave if they sense that the scribe's presence is affecting a patient's comfort level or disclosure of sensitive information. See Table D.3 in Appendix D for a summary of studies that examined this topic.

Physician professional satisfaction
Physicians were overwhelmingly positive about the impact of working with a medical scribe. Quotes frequently mentioned the huge improvement in workload and work hours, along with increased joy of practice, that physicians experienced when working with the assistance of a scribe. Scribe assistance beyond just documentation was valuable to physicians, as they were also able to help with paperwork and forms (Gao et al., 2020;Sattler et al., 2018). A recent systematic review found that 14 of 16 studies reported favorable provider satisfaction with scribes (Gottlieb et al., 2021).
Occasionally physicians provided negative feedback about working with a scribe. Inexperienced scribes may be less effective, and some physicians are frustrated by overlap in areas of the record documented by scribes (Hudson et al., 2020;Martel et al., 2018). Out of approximately 100 physicians in the study by Martel et al. (2018), three later requested not to work with scribes because they preferred to maintain their personal documentation style. See Tables D.4 and D.5 in Appendix D for details of the effects of scribes on physician satisfaction.

Physician burnout
Very few studies directly measured the impact of scribes on physician burnout. Morawski et al. (2017) found that physicians working with scribes showed improvement on all Maslach Burnout Inventory (MBI) sub scores. This was the only study that used the MBI to measure the effects of scribes on physician burnout, though it was categorized as an opinion paper and thus was classified as grey literature in this review (Morawski et al., 2017).
Although they did not directly measure physician burnout, many studies reported that physicians had decreased stress levels when working with a scribe. Physician time spent documenting in the EHR after hours has been shown to be associated with physician burnout (Gardner et al., 2019;Tran et al., 2019). Olson et al. (2019) found that insufficient documentation time increased the odds ratio of physician burnout to 5.63. Approximately 70% of physicians surveyed in Rhode Island reported health information technology-related stress and insufficient time for documentation, and this predicted burnout symptoms (Gardner et al., 2019). Therefore, studies which assessed the effects of scribes on physician documentation-related burden and EHR use after hours may be indicative of the effects of scribes on physician burnout. Studies consistently found that scribes decreased documentation-related burden for physicians during work hours, and decreased physician after-hours work in the EHR. Therefore, it may be inferred that scribes can provide a systems-level approach to decreasing physician burnout, though this issue requires further study (Gao et al., 2020). See Tables D.6 and D.7 in Appendix D for details on this topic.

Physician efficiency
Dramatic reductions in documentation time, both during and after clinic hours, were a recurrent theme. See Tables D.8 and D.9 in Appendix D for details of the effects of scribes on physician efficiency. Some pilot quality improvement studies required that physicians be willing to add extra patients to their clinic sessions in order to work with a scribe, due to management mandated return on investment guidelines (Earls et al., 2017). Other programs that did not have this requirement reported that physicians offered to see extra patients to cover the cost and continue working with a scribe. Morawski et al. (2017) noted that physicians were more likely to add on urgent patients to their schedules on short notice when working with a scribe.

Physician-patient relationship
Physician distraction by the EHR/EMR has been assumed to negatively affect the amount of face-to-face time during medical encounters. Several studies identified in this scoping review included observation of physicians by research assistants. The amount of time that physicians spent staring at the computer decreased when they were working with a scribe, while the amount of time spent facing the patient increased. Physicians felt that working with a scribe improved the quality of their interactions with patients. Face-to-face interaction between physicians and patients increased and medical visits were more patient-centered when a scribe was present. See Tables D.10 and D.11 in Appendix D for details of the effects of scribes on the physician-patient relationship.

Scribe-physician team
Interpersonal fit within the scribe-physician team is important, and the working relationship can take time to develop (Danila et al., 2018;Yan et al., 2016). To foster a positive scribe-physician interaction, scribes need to communicate their needs and be able to handle constructive feedback, while physicians need to verbalize what findings they want in the chart note (Corby et al., 2019). Some studies reported that physicians were repeatedly paired with the same scribe, when possible, to facilitate the development of this interprofessional connection. Numerous studies noted the negative effect of rapid scribe turnover on the development and maintenance of this team approach to documentation. See Table D.12 in Appendix D for information on studies which examined the concept of a scribe-physician team.

Concern about the number of people in the room
Several studies raised the concern of too many people in the room if a scribe is present (Keefe et al., 2020;Pozdnyakova et al., 2018b). Some medical offices are very small, and thus may not be large enough to hold the patient, family member(s), translators, medical learners, the scribe, and the physician. Ash et al. (2020) found that many exam rooms are too small to accommodate scribes well. Academic medical centres where medical trainees are common reported that the high level of patient acceptance of scribes at their centres could be due to patients being accustomed to having additional people present during their medical visits (Koshy et al., 2010;C. Lowry et al., 2017;Rohlfing et al., 2019). Zallman et al. (2018) found that the proportion of patients who felt very comfortable with the number of people in the room decreased from 93% to 66% when a scribe was present. DeWitt and Harrison (2018) raised the concern that the presence of a scribe may lead to the exclusion of medical learners if there is not enough space in exam rooms for them.

Different need for scribes in academic versus non-academic settings
The difference between the documentation-related burden faced by academic versus nonacademic physicians was raised by numerous authors. At academic hospitals affiliated with medical schools, attending physicians often have the assistance of medical students and resident physicians when completing documentation. Several studies noted that scribes are even more valuable in community-based emergency departments, as community hospitals do not have residents and medical students to help attending physicians with documentation (Bastani et al., 2014;Shuaib et al., 2019).

Tasks and model of documentation for scribes need to be clearly defined
As scribes are not a regulated profession and their tasks can vary, the model of documentation assistance provided by scribes needs to be clearly articulated. The Joint Commission recognizes the evolving roles that scribes may take on (The Joint Commission, 2021a). A signed agreement between the physician and the scribe outlining responsibilities and expectations is recommended. Table D.13 in Appendix D outlines the details of possible scribe roles and the need for clarity.

Quality of scribe-generated documentation
Only a few peer-reviewed studies have directly examined the quality of scribed notes. These studies found that scribed notes are of equal or greater quality compared to physician-generated notes. There is widespread agreement that future studies of scribed note accuracy and completeness are needed (Yan et al., 2016). A recent qualitative study that focused on safe use of the EHR by scribes found that scribes, physicians, and managers all felt that scribe documentation was more complete and more accurate than physician documentation, and that standard documentation templates help ensure this high quality . See Tables D.14 and D.15 in Appendix D for more information on the effect of scribes on documentation quality.

Safety and risks associated with medical scribes
Some concerns about the risks of scribes exist. Campbell et al. (2012) cautioned that documentation errors can occur due to inexperienced scribes who lack adequate knowledge of medical terminology. There is a risk that physicians may not thoroughly review scribed notes for accuracy before note authentication. A study which included numerous specialties and primary care found that once physicians are comfortable with their scribe, they may become complacent and not adequately review scribed notes before signing off on them (Corby et al., 2019). There is not currently a standardized method for evaluating scribe performance and ensuring that their notes are of high quality.
Physicians who rely on scribes may become overly dependent on them, and not be able to navigate an EHR or EMR system when a scribe is not available (Campbell et al., 2012;Corby et al., 2019). Physicians may miss computer prompts and clinical decision support generated by the EHR if a scribe does not alert them to these. Campbell et al. (2012) recommended that physicians direct scribes on the correct response to any alerts that arise during documentation in the EHR/EMR. Some physicians worry that working with a scribe could have a negative cognitive impact, as the act of writing down a medical note can help them to process the medical encounter and remember details better (Corby et al., 2019). A lack of clear boundaries around scribe duties could lead providers to ask scribes to complete tasks beyond their scope, and the power dynamic can exacerbate this risk (Corby et al., 2019). A multicentre randomised trial that encouraged reporting of safety incidents involving scribes did not find evidence of patient harm (Walker et al., 2019).
It is important to avoid inappropriate role expansion of scribes to avoid legal liability . Conversely, scribes can provide legal protection for physicians by acting as witnesses and/or helping physicians to obtain security assistance in the rare instance of a violent patient .

Cost
The biggest barrier to implementation of scribes in private practice physician offices may be the cost. This scoping review did not include articles focused only on the economic issues related to scribes, however many of the studies which met inclusion criteria mentioned cost. A recently published study from the United States stated that total costs for scribes are around $25 per hour (Miksanek et al., 2021). The only Canadian peerreviewed published study stated that scribes were paid $27/hour (Graves et al., 2018). Table D.16 in Appendix D details scribe salaries noted by the articles in this review. The cost required to purchase computers for scribes also must be factored in.
Although beyond the scope of this review, some studies mentioned that the increased efficiency of physicians when working with scribes may partially or completely cover their cost (Golob et al., 2018;Graves et al., 2018;Martel et al., 2018). 3.4.6. Training scribes in-house vs. scribes contracted from a scribe company Many of the studies described hiring scribes from professional scribe companies. Comments were made that the cost was higher with the scribe company employees, but that training support was available. Other authors stated that they preferred to train their own scribes (Martel et al., 2018). These tended to be hospital-based programs with more financial resources. One study used volunteer scribes, which the authors described as a mentoring environment for future medical professionals (C. Lowry et al., 2017). They recommended recruiting university students during semesters and training them during academic breaks.

Problem of rapid scribe turnover
Many of the studies included in this scoping review mentioned the problem of rapid scribe turnover (C. Lowry et al., 2017;Yan et al., 2016). Scribes are most often recruited from local universities, and tend to be students interested in healthcare careers, or already enrolled in medical or nursing programs (Martel et al., 2018;J.E. Lowry, 2017). Because they tend to move on to other careers, most only work as scribes for approximately one year (Martel et al., 2018;Miller et al., 2016;Danak et al., 2019). Ash et al. (2020) found that it takes around six months for scribes to become skilled at their jobs. Due to the labour-intensive nature of scribe training, and the importance of developing a physicianscribe working relationship, rapid scribe turnover is a major problem. The importance of repeated pairing of the same physician and scribe to allow team building and scribe learning of physician documentation preferences was emphasized by several authors (Danila et al., 2018;Morawski et al., 2017). The formation of sustainable partnerships cannot take place if scribe turnover is too rapid (Yan et al., 2016). One study mentioned the possibility of medical office assistants taking on the role of scribes to help reduce turnover, though the authors acknowledged that this cross-over role type would be complicated and require further investigation (Danak et al., 2019).

Effects of scribes on medical students and resident physicians
Scribe presence as part of the healthcare team seems to have a positive effect on medical education. Attending physicians and resident physicians working with scribes reported more time for teaching and patient care. Medical students noted these improvements to their educational experience as well. See Tables D.17 and D.18 in Appendix D for more details of the effects of scribes on medical learners.
A subtheme emerged around the common practice of university students in the United States working as scribes, partly to improve their resumes before applying to medical school (DiSanto & Prasad, 2017;Martel et al., 2018). Some authors have expressed concern that prior experience working as a medical scribe may become an unofficial pre-requisite for applying to medical school (DeWitt & Harrison, 2018). This may create inequity for medical school applicants who do not have the opportunity to work as scribes. Stanford University School of Medicine launched a medical scribe fellowship program in 2015. This program trains postbaccalaureate premedical students in scribing while also providing them with scholarly mentorship, with the goal of helping students increase their chance of admission to health professional schools (Lin et al., 2020).
A recent phenomenon involves medical students being trained to work as scribes during their time in medical school. A Canadian conference abstract reported that medical students trained as scribes felt that scribing provided them with unique benefits and should be added to the medical school curriculum (Abelev et al., 2020). In the United States, medical students also felt that being trained as scribes improved their education (Delage et al., 2020).

Lack of standardized/validated measures for assessing satisfaction with scribes
A recurrent issue that was raised as a limitation in studies of scribes was the lack of validated survey instruments to measure the impact of scribes on physician and patient satisfaction (Gottlieb et al., 2021;Koshy et al., 2010;Ou et al., 2017;Platt & Altman, 2019;Taylor et al., 2019;Zallman et al., 2018). This issue prevented meta-analysis by Heaton et al. (2016). Shultz and Holmstrom (2015) conducted a systematic review of scribes and concluded that the lack of validated survey instruments was a major weakness of the identified studies. The lack of validated measurement tools of scribe effects was also noted in the recent systematic review by Gottlieb et al. (2021).
Many of the studies identified in this scoping review that assessed patient and physician satisfaction developed their own survey instruments (see Table E.1 in Appendix E). Most of these used Likert-type scales, while some studies used Press Ganey surveys to measure patient satisfaction.

Discussion
In industries where safety is critical, such as the airline industry, the cognitive workloads of employees are carefully monitored (Sinsky & Privitera, 2018). Physicians have not been afforded such consideration. The physician workspace "now consists of a cacophony of warning alerts, pop-up messages, mandatory tick boxes, a Sisyphean inbox, and maddening documentation" (Sinsky & Privitera, 2018, p. 741). Industrial engineers can shadow physicians to determine the tasks they are currently completing that do not require medical expertise (Birznieks & Zane, 2017). Some of these tasks can be handed over to scribes. Scribes can save physicians "cognitive time", by relieving them of documentation and administrative burdens (Gao et al., 2020).
Safety is paramount in healthcare, and medical scribes have the potential to either improve or adversely affect the quality of documentation in the EMR/EHR. Few studies have examined the impact of scribes on safety. A recent qualitative study of scribes conducted using a sociotechnical framework found that healthcare providers, scribes, and managers all considered scribes to be EHR super users . Medical trainees may consider scribes to be a resource for EHR help (Hafer et al., 2018). Scribes are generally able to learn the documentation style of healthcare providers, and EHR template customization can help to ensure that providers are comfortable with the documentation completeness of scribed chart notes . Although outside of the scope of this literature review given its publication date, the Joint Commission recently reviewed the literature and updated its statement on medical scribes (The Joint Commission, 2021a). The Joint Commission identified potential quality and safety issues related to medical scribes, which they also refer to as documentation assistants. These included unclear roles and responsibilities, scribes using practitioner logins rather than independently logging in to the EMR, failure of practitioners to verify scribed notes, and unqualified staff performing documentation assistance (The Joint Commission, 2021a). The Joint Commission provides guidelines to avoid these problems and increase safety, including training scribes in medical terminology, EMR navigation, and proper login procedures, as well as more advanced EMR functionalities, when scribes have a broader scope of tasks (The Joint Commission, 2021a). Healthcare data quality assurance policies should be put in place to ensure the continuous evaluation of data quality in health information systems, and when scribes are involved in documentation their note quality should be included in these policies (Borycki, 2015).
The potential for scribe role expansion under different scribing models can be a potential source of risk, if scribes are asked to take on tasks they are not trained for. Conversely, scribes can help to ensure the safety of both physicians and patients, by helping physicians remember what a patient said or helping to get assistance in a rare adversarial interaction .
While it is clear that scribes benefit time-stressed physicians, ethical concerns exist. Woodcock et al. (2017) and Wangenheim (2018) raised concerns about the impact of scribes on how patients interact with physicians. Woodcock et al. (2017) stated that "the scribe becomes an actor in the patient encounter and may affect how the patient interacts with the provider" (p. 383). Wangenheim (2018) had the opinion that "scribes improve physicians' difficulties with EHRs, but at the expense of patients' confidentiality" (p. 242). Wangenheim (2018) stated that more studies are needed on the issue of patients' comfort with scribe presence. The studies identified during this scoping review reported that most patients were comfortable having a scribe present during the discussion of sensitive issues. Every effort must be made to explain the purpose of the scribe to patients and to ask for their permission that the scribe be present during the visit. Physicians can ask patients if they feel comfortable with scribe presence when discussing sensitive topics, or if they would prefer if the scribe left the room. Cases often arise where physicians or patients request that a third person be present. Medical students, residents, translators, and family members are often present during medical encounters. A systematic review found that the rate of friend or family member companions attending outpatient medical consultations with older patients is 36-57% (Troy et al., 2019, p. 746). The addition of a medical scribe is thus not necessarily a major change in terms of the presence of an additional person during the medical encounter. Patients already interact with many allied medical professionals during their medical encounters.
Administrative barriers could slow the implementation of scribes in Canadian hospitals. There is only one published peer-reviewed study of scribes in Canada, thus the literature has not yet addressed the issue of how scribes might face administrative barriers in Canada. Medical scribes do not currently require any formal qualifications. Thus, introducing this new role into a hospital could be seen as taking away existing jobs from health professionals or even custodial staff, since any hospital employee could theoretically fill the scribe role. Paradoxically, current hospital employees may not want to work as scribes for a variety of reasons. Transcription staff may not want to switch roles from a job that can be done remotely, to an in-person job that can be physically demanding (Tegen & O'Connell, 2012). For scribes who are hired to round with physicians on hospital wards, "the rounding process is intense. Scribes stand for the entire process, which averages four to five hours in length. There are no breaks." (Tegen & O'Connell, 2012, p. 35).
In Canada it is likely that some type of government assistance would be required to make the cost of scribes feasible for primary care providers. Team-based medical care initiatives are increasing in British Columbia. At these clinics, government funding helps to cover the cost of healthcare professionals to assist family physicians in caring for their patients (Harnett & Kines, 2019). Such a model would lend itself to the addition of scribes to the healthcare team. If government funded multi-disciplinary health clinics included scribes to assist physicians with documentation, it could be a valuable incentive in attracting physicians to under-served rural areas. Scribes have been shown to be a valuable addition to team-based primary care clinics, increasing the benefit from complementary professional roles and a patient-centered approach to care (Sinsky, 2014;Van Tiem et al., 2019).
It is possible that scribes may be a temporary strategy to help physicians cope with EHRs that have poor human factors ratings. Synchronous or asynchronous virtual scribes are an alternative to in-person scribes, as they remove the extra person from the exam room (Bates & Landman, 2018;Benko et al., 2020). However, virtual scribes introduce the risk of remote data transmission because audio recordings of the medical visit are transmitted electronically to remote virtual scribes. The COVID-19 pandemic has increased the uptake of remote scribing, with many in-person scribes having to transition to remote scribing . Speech recognition technology is another alternative to scribes. It generally necessitates the physician dictating the note after the medical encounter has ended, rather than in real-time as when working with a scribe. Coiera et al. (2018) described a new option of digital scribes. These are documentation support systems that use speech recognition, natural language processing and artificial intelligence to automate documentation (Coiera et al., 2018). These authors acknowledged that digital scribes are still in their infancy and may introduce new patient safety risks. Quiroz et al. (2020) determined that less than 20% of what is said during a general practice patient consultation is required for a summary of the consultation, and that machine learning algorithms to guide the development of digital scribes will need to identify this 20%.

Limitations
Interpretation of the included articles could be subject to reviewer bias (Pham et al., 2014). The search term "scribe*" was used to maintain breadth of coverage, but it is possible that other terms exist to describe scribes which may have been missed in this search. This review was limited to articles published in English, which may have led to the exclusion of articles from non-English speaking countries. No peer-reviewed articles published in English were identified originating from any countries other than the United States, Australia, and Canada.
The majority of studies identified in this scoping review were from the United States. Clinical notes in the United States were found to be nearly four times longer on average than clinical notes in other countries (Downing et al., 2018). It is possible that the effects of scribes found in the United States may not be generalizable to other countries where clinical notes are briefer.

Need for future study
Validated survey instruments are needed to standardize the assessment of scribe impact upon physicians and patients. Standardized methods of assessing physician burnout and the possible impact of scribes on this problem are also required. Studies are needed that address the issue of gender differences and language differences among the three parties of patient, scribe, and physician, and the impact of these differences on patient comfort with the presence of a scribe. The effect of scribe presence during emotionally charged patient disclosure on such sensitive topics as sexual health, mental health, and domestic violence has not been adequately studied (Schiff & Zucker, 2016). The comparison of patient discomfort due to the presence of a scribe versus the physician staring at a computer during the medical visit warrants investigation (Platt & Altman, 2019).
Different types of scribe-provider relationships exist but have not been adequately studied. Documented scribe management styles include pooled, dedicated one-to-one scribe to physician, or hybrid with one scribe working for several providers (Woodcock et al., 2017, p. 383). Additional studies are needed on scribed note quality and accuracy, preferably with blinded observers using a validated instrument (Gidwani et al., 2017;Yan et al., 2016). Another issue that warrants further study is the additional responsibilities that scribes can take on. In an advanced team-based care strategy, medical office assistants act as scribes and also have additional duties (Basu et al., 2018). Scribe role expansion creates the possibility of new safety risks, and requires future study . A multicentre randomised trial concluded that scribes prevented medical errors, but self-reporting likely led to an underestimate of harms (Walker et al., 2019). No studies have objectively quantified scribe-related safety issues.

Conclusion
As health care documentation has digitized, the documentation workload of many physicians has become unmanageable and contributes to burnout. Possible solutions to this documentation-related burden include the use of scribes, EHR/EMR optimization to improve usability, and clinician education on improving EHR/EMR workflow (Gesner et al., 2019(Gesner et al., , p. 1196. Natural language processing and artificial intelligence are not yet able to relieve physician documentation-related burden, as digital scribes are still in their infancy (Coiera et al., 2018;Gesner et al., 2019). Scribes are viewed as a safe addition to the healthcare team, with best practices implementation providing an opportunity to enhance patient safety .
While the medical community waits for digital scribes to become a reality and for EHR/EMR vendors to optimize usability, scribes remain a possible salvation for physicians pushed to the brink by documentation demands. EHR redesign is difficult and time consuming, while scribes are potentially a proximate solution. The ability of a physician to provide undivided attention to the patient is a benefit of scribes that would remain even with excellent EHR usability (Martel et al., 2018). With the current staggering EHR/EMR documentation-related burden faced by physicians, scribes are an option that can be considered in Canada. There is not currently any evidence in the literature, other than one pilot proof-of concept study, on whether scribes will fit within the structure of the Canadian healthcare system (Graves et al., 2018). The implementation of scribes in Canadian hospitals may face administrative hurdles, whereas physicians have more autonomy to begin working with scribes in their private offices.

Author Statement
The authors declare that there is no conflict of interest.

Joint Commission definition of a medical scribe
The Joint Commission is an independent, not-for-profit organization that "accredits and certifies more than 22,000 health care organizations and programs in the United States" (The Joint Commission, 2021b).
As per the Joint Commission (retrieved Feb. 21, 2021): The Joint Commission has previously defined scribes as unlicensed personnel and prohibited them from entering orders. However, due to the emergence of models including both licensed and unlicensed personnel of varying levels of skill and clinical knowledge, that previous definition is no longer valid or appropriate. There are individuals with the official title of "scribe" for whom documentation assistance is their only role, and there are individuals who perform dual roles that include clinical responsibilities as well as documentation assistance (The Joint Commission, 2021a).

Appendix B
Position statement of the American Academy of Emergency Medicine on medical scribes American Academy of Emergency Medicine Position Statement on Medical Scribes (American Academy of Emergency Medicine, 2014): Medical scribes should be considered ancillary staff members employed to assist the emergency physician with data entry and documentation requirements. Their function should be to free the emergency physician to focus on clinical duties. All information entered or generated in a health care record by a medical scribe should be reviewed for accuracy by the treating emergency medicine physician. The documentation generated by a medical scribe is by necessity an accurate reflection of the encounter between the emergency medicine physician and the patient. Medical scribes should be prohibited from taking liberties with documenting from their own perspective. The medical scribe duties should not include independent interaction with a patient, order entry or selection of discharge plans or documents.    • In family medicine (Gidwani et al., 2017) • In internal medicine, despite medical appointments being shortened by 25% when scribes were present (Heckman et al., 2020) • In otolaryngology (Keefe et al., 2020) • In primary care (C. Lowry et al., 2017) • In urology (McCormick et al., 2018) • In otolaryngology (Rohlfing et al., 2019) • In emergency medicine (Shuaib et al., 2019) Patient attitudes towards scribes neutral to positive • In cardiology (Bank et al., 2013) • In primary care (Mishra et al., 2018) • In family medicine (Platt & Altman, 2019) • In internal medicine (Pozdnyakova et al., 2018b) • In otolaryngology (Rohlfing et al., (Hudson et al., 2020) • Some physicians may struggle with relinquishing total control of their documentation, and they must learn to call out their physical exam findings for the scribe to document (        Idea raised of combining medical assistant & scribe role to decrease turnover of scribes Physicians did not report any patient concern with scribe gender, but some reported that they asked the scribe to leave the room during sensitive exams Scribe turnover was common concern of physicians Scribes were contracted through a Patient satisfactionslight decrease (from 100% to 90 % satisfied) Physician satisfactionincreased Physician efficiencyincreased Documentation time at the office improved: 75% of providers rated it as poor pre-scribe, 24% rated it as poor post-scribe Time spent on EHR at home decreased: 64% excessive or moderately high pre-scribe, 32% post-scribe Qualitative reports from providers on scribes were overwhelmingly positive Negative qualitative feedback from providers mainly on 2 topics: inexperienced scribes & overlap of sections of the record documented by scribes Out of approximately 100 physicians, 3 later requested not to work with scribes because they preferred to maintain their personal documentation style "Scribes allow physicians to provide undivided attention to the patient, which would be valuable even with exceptional EHR usability" (p. 247) For many providers "the addition of scribes was one of the most substantive changes they had ever experienced in their practice" (p. 244) Some physicians in this study felt that scribes had saved their careers These authors found nearly uniform acceptance of scribes by patients, as they want the provider's focused attention