Using Medical Scribes in a Physician Practice
With the push to develop and deploy electronic health records (EHRs) and the need for more detailed documentation, there is a growing concern in the medical community regarding the time expended to capture information—electronic or otherwise. The time providers spend during a patient visit capturing and entering data rather than focusing on the patient can be a hindrance to the quality of care. One current solution gaining popularity is the use of scribes. Scribes can provide many benefits to the practice of medicine, ultimately impacting the overall quality of healthcare delivery.
The Joint Commission defines a medical scribe as an unlicensed individual hired to enter information into the electronic health record (EHR) or chart at the direction of a physician or licensed independent practitioner. A scribe can be found in multiple settings including physician practices, hospitals, emergency departments, long-term care facilities, long-term acute care hospitals, public health clinics, and ambulatory care centers. They can be employed by a healthcare organization, physician, licensed independent practitioner, or work as a contracted service.
This practice brief will explore some of the benefits and challenges of scribes within the physician practice setting. In addition, this practice brief will provide recommended practices for the use of scribes. Key components for implementation of a successful scribe program will also be discussed.
Roles and Responsibilities
A scribe’s core responsibility is to capture accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter in a timely manner. Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider. The general duties of a scribe may vary and can include:
The role of a scribe is dependent upon the provider practice and setting. It is possible for a provider to select a clinical assistant (non-licensed clinical staff) who has performed clinical duties and worked with the provider to perform scribe services. It is not recommended, however, to allow an individual to fill the role of scribe and clinical assistant simultaneously during the same encounter. This practice raises legal and other issues regarding job role and responsibilities.
EHR security rights (role-based access) for a scribe and clinical assistant are different. Scribes have nearly the same security rights as a provider, while a clinical assistant enters information independently and only within the individual’s scope of practice. Thus, the individual security rights are more limited for clinical assistants than those of the provider and must be considered in the decision making process.
When a scribe is also acting as a clinical assistant during the same encounter, the scribe will log in with one set of security rights as a clinical assistant, log out, and then log back in with another set of rights to perform the scribe duties. The dual role results in the scribe logging in and out between roles multiple times during one encounter—wasting valuable time and resources. To avoid this situation, some practices limit the scribe to filling only one role during a single encounter.
The role of a scribe in the practice must be clearly defined and communicated, with documented job descriptions and set policies and procedures, to optimize their use and minimize challenges. It is also important to obtain a signed agreement between the provider and the scribe delineating expectations and accountability.
Scribe Legal Considerations
Since medical scribes are a relatively new phenomenon in healthcare, it is difficult to find information addressing the legal issues that have surfaced as a result of using scribes. Regulatory agencies have not forbidden the use of scribes, but regulatory requirements and guidance concerning their use differ. As a result of these differing guidelines and requirements, scribes may have more responsibilities in one care setting but face greater restrictions in another.
It is also important that individual state laws are thoroughly reviewed to ensure compliance and proper use of scribes by mid-level providers. For example, in some states physician assistants are not considered licensed independent practitioners and therefore may not be eligible to use scribes.
A scribe’s responsibilities are ultimately controlled by the regulatory requirements and policies established by a healthcare setting, and the level of risk an employer is willing to accept. As the use of scribes becomes more prevalent, the potential for expanded legal guidance and direction grows. Practices must monitor federal, state, and regulatory changes to ensure their practices consistently meet compliance with standards.
Implement Scribe Documentation Guidelines
When using scribes, documentation guidelines for the place of service (i.e., inpatient, outpatient) must be followed. In addition to the normal documentation requirements of an encounter, a scribed encounter also carries separate authentication duties. It is imperative that any and all entries regarding a patient’s health information be completed in the presence of and at the direction of the provider. It is also important that authentication of each entry be completed in a timely manner as defined by a practice’s policies and regulatory requirements.
Scribes accompany providers into the exam room and enter information in real time, using their individually assigned security rights to access the EHR. Providers should direct the scribe on the proper responses for advisories and other alerts that may appear on the screen.
Third party payers may have specific guidelines for how a scribe documents and how the electronic signature must be applied. Each facility must contact their third party payers for any further requirements.
In 2011, the Joint Commission released guidelines recognizing that scribes may be used across various settings. The guidelines help to regulate the use of scribes:
Managing Scribe Costs
Incorporating scribe services requires budgetary consideration and determination of where costs will be allocated. There are generally three options for cost allocation:
One option—that the provider employs the scribe—assumes that providers receive the greatest benefit from scribe services and should pay for the service directly. The cost of a scribe program can be offset if there are significant measurable increases in provider revenue. For the allocation to be made as a provider cost, providers can pay a scribe a set hourly wage based on the added value the scribe offers the provider in terms of revenue, time, and increased productivity.
A second option would allow the practice assuming responsibility for the cost to regulate what scribe service will be used, the hourly rate, and education and training requirements. Current transcription compensation models (i.e., paying per line, per minute, or a combination) are a good tool that can be used to determine how to pay for scribe programs.1 Governance of a scribe program at an organizational level presents other options for scribe compensation. For example, scribe reimbursement could include using the existing employee base and redefining currently existing job roles instead of layoffs or sharing scribes among specialties.
The third alternative is for providers and organizations to cost-share given the mutual benefits of using scribes. In this arrangement, providers who use scribes are responsible for a certain percentage of the cost. A thorough analysis should be completed to determine how the costs of a scribe will be allocated. An accurate and comprehensive analysis includes, but may not be limited to:
Benefits Include Freeing Physicians from Data Entry
As previously stated, scribes are responsible for capturing medical information at the point of care which allows the provider to focus on bedside manner and provide hands-on, attentive, face-to-face care that increases both patient and provider satisfaction.
In today’s healthcare environment of increased regulations, documentation incentives, and reimbursement requirements, charting and documenting takes time. Scribes can help to reduce the documentation time needed by the provider during a visit. Many providers feel the pressures of increased clerical responsibilities and learning curves with the implementation of new and upgraded systems. The use of scribes can help to increase provider morale by reducing the amount of clerical tasks and resulting stress while learning a new system.
EHRs are becoming more commonplace in today’s practice. The patient may perceive their visit negatively if the provider spends the majority of their time looking at a computer monitor instead of the patient. A scribe can enter information into the EHR without intrusion or interruption, allowing the provider to focus more on the patient diagnosis and treatment plans.
Employing scribes to capture and enter health information into the EHR during a patient encounter may improve the overall quality of documentation—not only in the level of granularity, but also in the level of specificity. Improved documentation in turn can be used to support achieving “meaningful use” EHR Incentive Program criteria as well as improving compliance with quality monitors and billing and reimbursement.
Provider efficiency and productivity can increase with the use of scribes as well. When implemented with a successful clinical workflow, providers may see more patients rather than spend valuable time documenting.
The documentation completed by scribes is also often available more quickly for review. As a result, documentation by a scribe can be more detailed and more comprehensive. When the provider is verbally summarizing decisions and plans, the scribe is able to capture the details of the encounter in the provider’s words and in real time.
Cost, Workflow Challenges
The implementation of any new system, program, or practice brings its own separate set of challenges that must be considered and managed carefully. The use of a medical scribe is no exception to that fact. Challenges include:
Tips for Managing and Monitoring Scribes
Scribe documentation must be managed and maintained with the same quality assurance and compliance expectations of other patient care documentation. It is crucial that scribe programs are included in the organization’s overall compliance program. It should be closely monitored for accuracy and adherence to applicable guidelines through the development of policies and procedures, training, and overall management.
Policies and procedures identify responsibilities and outline requirements for scribes. They also set the tone and define expectations and accountability. When creating policies and procedures for implementing a scribe program, the following considerations, at a minimum, should be taken into account (see “Appendix A,” for a sample medical scribe policy):
Communication is a tool necessary for meeting compliance. All staff must be educated and receive ongoing training for adherence with policies, procedures, and overall management expectations. Monitoring is also a key factor towards meeting compliance. The use of medical scribes must not only be audited for documentation quality and good privacy and security practices, but also to ensure that policy and procedures are being followed.
Monitor Scribe Education and Qualification
The demand for medical scribes is rising and many organizations are rightfully concerned about the appropriate skill set, competency, and training of scribes when implementing a scribe program. Though endorsed by the American Healthcare Documentation Group (AHDG), the only certification program offered for scribes in the nation is issued by the American College of Clinical Information Managers (ACCIM). To be eligible for certification as a clinical information manager (CIM), individuals must have worked at least 100 hours as an unassisted scribe and have received training in an approved CIM training program. The Clinical Information Manager Certification and Aptitude Test (CIMCAT) verifies skills and knowledge in the following areas:
ACCIM also offers maintenance of certification through the Medical Scribe Continuous Certification (MSCC) to develop and maintain the highest professional quality of medical scribes. Further, ACCIM also certifies scribe programs to set apart those that offer a higher level of professionalism and skill set from those that do not.
Recommended Scribe Practices
There is no right or wrong answer to the implementation and use of medical scribes. The lessons learned from the early adopters of medical scribes helps to establish best practices and guidance for the industry. Regardless of practice type or size, the decision to use a scribe is a significant one and must be carefully managed and maintained as such. Below are recommended practices for optimal outcomes when implementing a scribe program.
Set Scribe Program Goals
It is essential that the healthcare entity set clear and specific goals. Goals can include increasing revenue, provider productivity, patient satisfaction, timely record authentication, or an improvement in provider morale. Regardless, all goals should be clearly stated and metrically tracked. Establishing specific measurable objectives for the medical scribe program may involve an interdepartmental team that includes multiple disciplines.
Define Scribe Roles and Responsibilities
Scribes are responsible for capturing an accurate and detailed description of a patient encounter in the provider’s words. Scribes are clerical in nature and do not interview or have direct contact with the patient. They do not perform clinical services, administer medication, or perform treatments and procedures. Some facilities utilize clinical staff to perform scribe functions, so it is important to clearly define and differentiate their clinical duties from their scribe duties. When defining the role and responsibilities of a scribe, it is imperative that appropriate medical record access and signature authentication is established as well.
Communicate with Patients
The healthcare entity should communicate with patients and introduce the position of medical scribe. It is important to recognize that some patients may not want an additional individual in the room while they are examined or when discussing sensitive medical information. Educate the patient on how the presence of a medical scribe provides them with more interactive time with their provider. However, the patient always has the right to refuse the presence of additional staff (i.e., scribes, residents) in the exam room. If the provider realizes that the patient is uncomfortable discussing an issue with the scribe in the room, a pre-arranged verbal signal such as “please check with the nurse about the blue form” would allow the scribe to leave the room without adding to patient discomfort.
Exam Room Setup
Physician practices need to evaluate the size of the examination rooms. In some practices, these rooms are small and may not allow the presence of a third person in addition to the provider and patient. Another challenge may be placement of computer equipment. Some patients may become distracted if the scribe types on a noisy keyboard. It is important to minimize or eliminate distractions to patient care.
Evaluate the Scribe Program
The physician practice can monitor the success of the medical scribe program by measuring key indicators compared to the set goals. Examples of goals may include reductions in transcription costs, improvements in overall documentation, reduced turnaround time for authentication and increased patient satisfaction. Information from the John F. Kennedy Medical Center states that the use of scribes contributed to a 15 percent revenue increase and improved patient satisfaction scores.2 Objective benefits of a scribe program can generally be analyzed through standard metrics currently in use in the facility or practice. Other metric examples include, but may not be limited to, relative value units per hour or day, number of patients seen per hour or day, percent of clinical time versus administrative time, number of incomplete medical records, arrival to discharge time, or the number of provider queries for additional information.
Maintain Provider Engagement
Physician practices need to ensure that providers remain connected to all patient information. When the provider no longer personally dictates or documents the services performed, he or she may miss computer prompts or not review the medical information in the same manner. The provider’s review and authentication of the scribed documentation ensures medical procedures have been performed, ordered, and documented; electronic record alerts have been addressed; and patient care has been accurately recorded.
Appendix A: Sample Medical Scribe Policy
USE OF SCRIBES
PURPOSE: The purpose of this policy is to ensure proper documentation of clinical services when the billing provider has elected to utilize the services of a medical scribe. For the purpose of this policy, a scribe is defined as an individual who is present during the provider’s performance of a clinical service and documents (on behalf of the provider) everything said during the course of the service. Any individual serving as a scribe must not be attending to the patient in any clinical capacity and must not interject their own observations or impressions.
POLICY: Individuals serving as scribes must sign a scribe agreement prior to scribing. Scribed documentation must clearly support the name of the scribe, the role of the individual documenting the service (i.e., scribe), and the provider of the service. The provider is ultimately responsible for all documentation and must verify that the scribed note accurately reflects the service provided.
Appendix B: Sample Scribe/Provider Agreement
I hereby certify that I have reviewed the Use of Scribes Policy. I understand that as a scribe I am:
Scribed documentation must include the following elements:
I am aware that documenting in the EHR requires use of my own password/access to the EHR.
Documenting under someone else’s login is prohibited.
Scribe Name: _______________________________________________________________________
I, the undersigned provider, agree that the scribe will only perform duties as described within the Medical Scribe Policy. I also agree that I am solely responsible for the accuracy, review, and authentication of all health record information captured and/or entered by the above named scribe.
Provider Name: _______________________________________________________________________
Lisa L. Campbell, PhD, CCS-P, CCS
Sheila Bowlds, RHIA
American College of Clinical Information Managers. "CIMCAT." ACCIM website: May 2012. http://www.theaccim.org/the-clinical-information-manager-certification-and-aptitude-test-the-cimcat-purchase-page.
The Joint Commission. “Standards FAQs.” May 2011. http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?StandardsFAQId=345&StandardsFAQChapterId=66.
Karen Zupko and Associates, Inc. “EMR Scribes: Real-Time Tech Support Boosts Physician Productivity & Reduces ‘Paper Care’ Hassles.” February 2011. http://www.physiciansangels.com/download.aspx.
Nunn, Sandra. “Managing Audit Trails.” Journal of AHIMA 80, no. 9 (September 2009): 44-45.
Virtual Staffing. Physicians Angels. May 2012. http://www.physiciansangels.com/.
WPS Medicare. www.wpsmedicare.com.
The information contained in this practice brief reflects the consensus opinion of the professionals who developed it. It has not been validated through scientific research.