Integration of Medical Scribes

This article discusses reasons to employ medical scribes and why scribes play a critical role in both hospitals and independent practices. Scribes are able help physicians with documentation and increase productivity. Physicians are able to fully engage with patients while the scribe documents the encounter in real-time. Although scribes are unlicensed, they still need to be recruited and trained in the same manner as any other medical professional.

Electronic health records (EHRs) are becoming more prevalent in hospitals and private practices and are recognized as a tool to help increase productivity, quality, and safety. Although EHRs are promoted as being more effective than paper-based systems, many physicians describe challenges with the current state of the technology: they find that EHRs can be difficult to use, time consuming, inefficient, disruptive to face-to-face encounters with patients, and a hindrance to the clinical documentation process. These challenges can become more troublesome among those who lack support to help manage documentation. Scribes have become a link between physicians and complex EHR systems, creating a more engaging experience for patients.

Since the 1990s, medical scribes have been found alongside physicians mostly in the emergency department. Today, the number of scribes working in healthcare is on the rise, and so is the variation in the settings in which you will find them. What is a medical scribe? Why are scribes used? And why is their employment on the rise? The Joint Commission describes a medical scribe as “an unlicensed individual hired to enter information into the electronic medical record (EHR) or chart at the direction of a physician or licensed independent practitioner.”1 According to the American College of Emergency Physicians (ACEP), “a scribe works side by side with the practitioner as a documentation assistant. The scribe accompanies the physician into the examination room and documents the encounter as it is verbalized by the physician and patient.”2 A scribe cannot act independently but documents the physician’s dictation and activities during the visit. An ACEP study reported a 100% return on investment when scribes are employed in the emergency department. Physicians in the emergency department setting spend approximately half of their time on indirect patient care activities such as charting and recordkeeping. The use of a scribe frees the physician from spending too much time on indirect activities, allowing that physician to see more patients. Scribes make sense in the fast-paced and critical emergency department setting. Why are scribes now being employed in new specialties and clinical settings? This movement has been fueled by federal payments and incentives under the American Recovery and Reinvestment Act, which led to the implementation of EHR systems for more than 4000 hospitals and 300,000 physician practices. The push for hospitals and practices to switch to EMRs, and the monetary reward that follows, has created an unexpected and growing need to employ medical scribes in such facilities. Physicians find the implementation of the new EHRs to be time consuming, taking away from their ability to see and care for patients. Due to EMR system implementation, many hospital departments and physicians practices have reported drastic decreases in their typical productivity rates. EHR programs can run slowly, have system glitches, and require multiple steps in the documentation process. These and other issues underscore the rising need for scribes in all healthcare settings. Studies suggest that physician productivity can decrease as much as 30% as they take the time to learn a new and complex EHR system. In response to the decrease in productivity, physicians are hiring scribes to document and enter their patient data.

Difficulty associated with the usability of EHRs remains an important source of professional dissatisfaction; early adopters reported the technology could at times interfere with communication during visits and with patient–clinician eye contact. Evidence suggests some physicians using EHRs may also engage patients in fewer physician-initiated gaze patterns (signaling a lack of attention toward the patient), and that EHR use may contribute to a sense of separation among some patients when the EMR monitor is kept away from the patient’s view. In response to concerns like these, a recently published primary care consensus statement concluded that many EHR systems need marked refinement to promote greater patient engagement. Physicians are also likely to see patient satisfaction increase with the use of a scribe. Having a scribe in the room allows a physician to come out from behind the computer or paper file and really talk to, educate, and connect with a patient. Utilizing a scribe also allows a physician to establish a better work/life balance; he or she can afford to spend more time on personal interests and with his or her family. With EHR systems, many physicians are writing their typical examination notes the old-fashioned way and then later spending more than two hours documenting in the EHR. This increase the risk of error, since the physician is documenting the visit hours after it actually took place. Small details can get overlooked and turn into bigger problems. Scribes help physicians cut down on after-hours office time needed to document their day’s work. Oversight is still needed when working with a scribe, but the hours of tedious documentation are sure to decrease. Currently, there are no official accredited scribe programs or requirements for someone to work as a scribe. Therefore, when seeking to employ a scribe, make sure to do some research. Whether you conduct your own search, employ a scribe company, or employ a recruitment company, it is important to make sure your scribe is a professional who is experienced with medical terminology and documentation. A new trend that many scribe companies are following is to employ medical students as scribes. They are knowledgeable and eager to gain firsthand experience afforded by working with a physician. Also, you may seek to employ a medical scribe who is professionally trained, such as a nurse, a transcriptionist, or a scribe who has gone through a training program.

Will scribes become a permanent fixture in the medical offices and hospital wards across America? Consider these four points when integrating a scribe into your practice: recruitment; training; compliance; and efficiency.

RECRUITMENT

If patient satisfaction is decreasing, then it might be time to recruit a scribe. Scribes can make a practice, or hospital, more efficient and help the physician be more engaged during the visit. Technology plays a role in many facets of healthcare; finding a candidate who is familiar with or willing to learn your EHR system will help in the long run. For example, if a candidate is a pre-med student without EHR experience, there is a good chance that he or she is among the tech-savvy generation that will pick up using the system quickly and efficiently. A scribe could be a pre-med student seeking insight into the medical field. A transcriptionist or medical assistant would also have the healthcare and technical background to take on the duties of a scribe. Hiring someone who is interested in healthcare, familiar with medical terminology, and has a proven work ethic will be a benefit a medical practice’s workflow and will lower the risk of turnover.

TRAINING

Practices must take the proper time to train the scribe. First, the practice needs to train the scribe on the EHR system. Second, scribes must learn which specific notes the physicians wishes to be recorded for proper documentation and billing purposes. Scribes retrieve data from previous visits for the physician to review prior to each visit. The medical chart is a legal document that the physician signs off on; ultimately, the scribe writes notes and makes the documentation process more fluid than if the physician was recording notes hours after an encounter. The scribe must become an integral part of your practice, learning the physicians’ style and preference and forming a true team atmosphere. Physicians who are hesitant to integrate scribes into their practice should consider the benefits of adding another member to their team.

COMPLIANCE

Scribes play a major role in a practice’s compliance metrics. Scribes must undergo HIPAA training in order to understand their responsibility in patient privacy both in and out of the examination room. They learn appropriate codes and billing reimbursements for the physician to be paid accordingly. Patient privacy is always a concern for patients and physicians. Some patients might be concerned about privacy and having a scribe in the room. The physician is responsible for educating patients about the role of the scribe and why having a scribe in the room is actually beneficial to their continuum of care. The importance of explaining the role of the scribe should not be overlooked if patients raise concerns. The scribe is not acting as a second opinion in the room, which is an important concept to understand. Even though the scribe may be knowledgeable, he or she is not licensed and cannot voice a medical opinion. Therefore, the documentation is strictly from the doctor’s own diagnosis and observations.

EFFICIENCY

Physicians typically lack time to properly learn their EHR systems. By hiring a scribe who assists with EHR data entry, it is estimated that physicians are able to see one additional patient per hour, increasing revenue and patient satisfaction. Of course, even though there are physician and patient benefits in employing a scribe, the physician should still acquire a basic understanding of how the EMR system works. With advances in technology and integration of EHR systems, it is not surprising that new roles, such as scribes, will be created. Integration of this position serves to increase compliance, patient satisfaction, patient flow, patient volume, and patient outcomes. We anticipate a continued increase in the recruitment and utilization of scribes, as well as continued efforts toward their training and use to reach maximum efficiency. Medical, legal, financial, and patient safety demands have led to increased documentation during patient visits. Eighty percent of practices now use an EHR system to assist with that documentation. For example, orthopedic practices might reduce the burden of documentation on the surgeon by hiring a medical scribe. As EHRs continue to be integrated within healthcare settings both large and small, policy makers, healthcare administrators, and clinicians will need new tools to improve productivity, quality, and outcomes. Current evidence suggests medical scribes may improve clinician satisfaction, productivity, time-related efficiencies, revenue, and patient–clinician interactions.

Nicola Hawkinson, DNP, RN

CEO, SpineSearch, LLC

nicola@spine-search.com

REFERENCES

1. The Joint Commission. Use of unlicensed persons acting as scribes. www.jointcommission.org/standards_information/jcfaqdetails.aspx ?StandardsFaqId=426&ProgramId=47. 2. American College of Emergency Physicians. Scribe FAQ. www.acep.org/ Physician-Resources/Practice-Resources/Administration/Financial- Issues-/-Reimbursement/Scribe-FAQ/