The Growing Profession of Medical Scribes

THE AMERICAN RECOVERY and Reinvestment Act’s “meaningful use” incentives for outcomes and value in healthcare have fully kicked in and so, too, have the penalties for lack of compliance with use of electronic health records (EHRs). While EHRs have been widely touted as an opportunity to improve health record accuracy and patient satisfaction, some medical professionals are not entirely convinced. Complaints about the challenge of learning new software, the potential for distractions caused by data entry at the point of care and, worse, the potential for misremembering patient information should data be entered later are, for some, hindrances.

Enter the fairly new profession of medical scribe that helps bridge the barriers between EHR requirements and physician efforts to provide optimal patient care. Medical scribes, unlicensed clerical assistants, enter patient exam data into EHRs under supervision and typically during a patient’s exam. From the first noted reference to scribes in 1974, to the “birth of the industry” in 2004, scribes have been used for decades in emergency rooms, and their numbers are increasing exponentially. The American College of Medical Scribe Specialists (ACMSS) estimated 15,000 scribes in the workplace in 2014, and expect more than 100,000 by 2020.¹ And, Kaiser Healthcare suggests that one in five physicians is now using a scribe.²

Scribes work in hospitals, doctor offices, emergency rooms and long-term care facilities, and they may be employed by the provider directly or the healthcare organization, or they may work as contractors. Scribe services are used not only by physicians but, state law permitting, by other licensed healthcare providers. “The greatest innovation for scribes is their use in the outpatient setting,” says Kristin Hagen, executive director of ACMSS. “This is where we are working to improve health most proactively using a team-based approach.”

Education Requirements

As one would expect, scribes are not authorized to make any independent determinations or enter any orders. Rather, they are clerical assistants, capturing data of patient visits as authorized by providers. They may also be requested by the provider to pull up previous notes or tests for review, assist in navigating through the EHR or simply input current information. Though the minimum education level generally is a high school degree or some college, in many cases, medical scribes are aspiring medical and nursing students who are working to gain experience before attending professional school. Tushar Kapoor, MD, FACEP, executive vice president of staff development and founder of CityMD, a practice that has used medical scribes since its inception, agrees, saying the majority of its applicants are prehealthcare specialists who want to go on to obtain other degrees. In speaking with other scribe companies, he explains, it is fairly standard across the U.S. for medical scribes to be seeking higher education.

While it is an unlicensed field, about one-third of medical scribes opt to obtain a voluntary certification.² ACMSS offers three paths to certification: education-based (through schools certified by the Commission on Accreditation of Allied Health Education Programs); work experience-based (a minimum of 200 hours of clinical instruction required or 50 hours for individuals who currently hold a license or certification); and via physician practice administrator, whereby a provider or hospital may refer a trusted staff member for certification testing. As EHRs have become commonplace, so too have the personnel requirements to meet the needs of that investment.

Increased Productivity, But at What Cost?

Should the volume and complexity of patients and the number of providers warrant, medical scribes can provide a valuable service while increasing efficiency. Proponents of scribes say their assistance leads to greater productivity, which leads to increased revenue. And, increased accuracy in the recording of EHR entries leads to greater accuracy in coding and billing. Scribes also enable more face-to-face time since providers are no longer typing notes during visits, which can lead to improved patient satisfaction.

Examples of scribes making positive contributions in the field are many. A John F. Kennedy Medical Center report states that the use of scribes contributed to an increase in revenue of 15 percent and improved patient satisfaction scores.³ An article published in Family Practice Management Journal discusses a boost in productivity of 40 percent and a 23 percent increase in revenue when using assistants who provide transcription services.⁴ And, a study published by the National Library of Medicine showed both large increases in productivity (59 percent more patients seen in a relative hour) and additional downstream revenue with the assistance. Overall quality improvements in patient visits was also seen.⁵

Patient satisfaction can potentially be improved when patients feel their providers are listening closely and not distracted by technology. A study by researchers at the University of California, San Francisco found patients were less likely to rate their care as “excellent” when doctors spent more time on computers entering notes. It also found that doctors may miss nonverbal cues when not looking directly at patients,⁶ which could change the course of patient conversation and care.

Providers using medical scribes say they have greater job satisfaction with fewer clerical tasks, and some report scribes provide more accurate notes, both in granularity and specificity, in a shorter amount of time due to greater familiarity with EHR software and its various screens and toggles. These improvements can be used to argue “meaningful use” for the EHR incentive program;⁷ as ACMSS’s Hagen explains, scribes must be certified to meet the definition of “meaningful use.”

“Scribes have been an integral part of what we do since day one,” says Dr. Kapoor. “There was never a question of scribe use in our company. From the patient perspective, they want my individualized attention with no distractions and to have all of their questions answered. As a physician, I want to provide the best quality care, and scribes eliminate me having to focus on charts and screens. Because of scribes, I am able to treat my patients physically and emotionally and educate them on issues that are current. Without scribes, half of my attention would go to the [EHR].”

Yet, despite the advantages, critics of scribes in the healthcare setting worry that they will potentially make patients uncomfortable and less forthcoming with information (although, patients always have the right to refuse the presence of additional staff in the exam room). However, as evidenced in an article published in the American Association of Family Physicians, when the role of an assistant is explained, patients are generally accepting of his or her presence. Patients also feel greater satisfaction since they view the assistant as an additional advocate who will allow more quality time for provider-patient interaction.⁸

Others worry that EHR software developers will have fewer incentives to continue making improvements to make their products easier to use. They argue the acceptance of an “inferior product” is one of the primary reasons practitioners hire scribes, and if EHRs were more user-friendly, the need for scribes would be lessened. In addition, critics claim providers who rely on scribes will have difficulty navigating the software in the event a scribe is unavailable.⁹ Yet, an opposing argument suggests providers should always remain conversant in EHR software, even when using scribe services, because they maintain final responsibility for the medical chart and its content. Without an understanding of the system, their ownership of that content would be difficult at best. In any case, it would also be unwise to assume a scribe will always be available.

Critics also raise concerns that the defined lines between providers and scribes could become blurred in a busy practice. For instance, patient load and the requirement for provider authentication may actually slow down the process it is intended to speed up. Should providers not take the time to thoroughly review a scribe’s work, errors could occur, and the time it takes to review the work could negate any initial time savings.

How Do Scribes Work?

In a busy practice with a high volume of patients, scribes can improve workflow. Medical scribes work alongside providers as they attend to patients. Working at a computer terminal, scribes enter data using their own security rights into the EHR. As alerts pop up, scribes share them with providers, and providers give the appropriate response. At the conclusion of the office visit, or as soon as possible thereafter, providers review and authenticate the scribes’ entries.

Dr. Kapoor shares that, in his practice, scribes are an integral part of the medical team. So, in addition to performing traditional scribe duties, they also assist in bringing patients in, informing them of the status of their stay (for example, how many minutes until they can be seen in X-ray) and conducting similar duties. Scribes’ close proximity to both patients and providers makes it imperative that they be flexible and adaptable to the workflow and a variety of personalities. “We are looking for scribes who are team players, enjoy healthcare and helping others,” explains Dr. Kapoor. “They must also be well conversant in the [EHR], document quickly and efficiently, and grasp new concepts quickly.” CityMD both sources and trains their scribes internally.

Since physicians are ultimately the responsible parties, and scribes assist in nonclinical duties, there is no liability insurance requirement for medical scribes, nor do third-party payers reimburse for scribe services.

The CPOE Debate

In 2011, the Health Information Technology for Economic and Clinical Health Act mandated that unlicensed workers may not enter orders such as those for prescriptions and X-rays, meaning that these must be initiated by providers rather than scribes. However, in 2012, the Centers for Medicare and Medicaid Services (CMS) issued a ruling that in addition to licensed medical staff, only “credentialed medical assistants” may enter a computerized provider order entry (CPOE) to meet “meaningful use” under the EHR incentive program criteria. Assistants, according to CMS, must be credentialed outside the organization in which they work.

So, when providers have orders via CPOE, scribes may initially enter the data, but orders will not be placed until providers have authenticated and signed off on them, making providers ultimately responsible for the records.

The Scribe/Provider Electronic Record

In 2011, the American Health Information Management Association Joint Commission issued a guideline7 on appropriate use of scribes that dictates the types of information they may input into an EHR:

• History of the patient’s present illness
• Review of systems and physical examination
• Vital signs and lab values
• Results of imaging studies
• Progress notes
• Continued care plan and medication lists

The guideline also describes how scribes should notate their involvement in the EHR:

• Name of the provider providing the service
• Date and time the service was provided
• Name of the patient for whom the service was provided
• Authentication, including date and time

And, it provides authentication guidance for providers:

• Affirmation of the provider’s presence during the time the encounter was recorded
• Verification that the provider reviewed the information
• Verification of the accuracy of the information
• Any additional information needed
• Authentication, including date and time

According to the guideline, scribes’ and providers’ signatures should be separate and clearly distinguishable.

It should be noted that security rights for scribes and providers are similar, which is not the case for clinical assistants. Those utilizing clinical assistants and/or scribes should clearly differentiate the duties of each job description to avoid any confusion in policy and workload. Also, third-party payers have various requirements for authentication of electronic signatures. As such, organizations using scribes should check to determine the specifics.

Putting the Patient Back in Focus

Medical scribes provide a valued service and an often-needed reprieve from the newer technology requirements of medical care, enabling providers to tend more closely to patients’ needs, while knowing office visits are being appropriately and thoroughly documented. For many, this addition to the care team is an enhancement and provides the opportunity to meet federal requirements and bring medicine’s focus fully back to the patient. “Our goal is to provide excellent patient care, and we wanted to bring back for physicians what we were trained to do,” says Dr. Kapoor. “For us, the only logical way to do that was to take away the IT component, and the next logical step was using scribes.” Hagen echoes that sentiment: “Scribes give providers the ability to do what they got into medicine to do in the first place.”