A physician’s responsibility is to provide the best possible care for sick patients.  A key for delivering quality healthcare is open communication between the physician and patient to discuss issues and develop a care plan.  Today, providing quality care is becoming more difficult due to increasing patient loads and administrative challenges.  This dilemma has become a catalyst for the growth of Medical Scribes (often referred to as scribes).

Scribes help Physicians by documenting the patient encounter and retrieving diagnostic results, nursing notes and other information recorded in the patient’s electronic record.  The introduction of electronic health records (EHRs) has created an overload of documentation. The associated clerical responsibilities slow physicians down and take them away from one-on-one patient care.  To relieve their documentation overload, physicians have turned to scribe services for assistance.

The Rules Governing Scribes

Scribe companies operate with few requirements.  There are virtually no regulations required outside of the healthcare industry and the main bodies that regulate healthcare. The Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC), have no rules or guidelines that limit, endorse or prohibit the use of scribes.  TJC permits scribes to document previously determined and approved physicians’ dictation and activities but does not authorize scribes to act independently, except obtaining past family social history and a review of systems, a technique providers use to gain the patient’s medical history.  CMS does not provide official guidelines on the use of scribes and does not bar non-physician providers, such as physician assistants, nurse practitioners and clinical nurse specialists, from using scribes.

With few rules governing scribes, the value proposition for physicians is enticing; however, using scribes is not without risk.  When a physician is removed from a part of the care continuum, it opens the door to miscommunication that can negatively affect patient care.  Since the industry is minimally regulated, and with only a high school diploma required, scribes are not required to have medical backgrounds or to become certified.  That said, there is a potential for scribes to misinterpret a physician’s instructions and make documentation mistakes that would negatively affect patient care.  However, even with these risks, the industry segment has grown rapidly, and physician acceptance has been high.

The Role of a Medical Scribe

A medical scribe is a paraprofessional who specializes in charting physician-patient encounters in real time during medical examinations.  They are called clinical scribes, emergency room or emergency department scribes or just scribes.  A scribe can work on-site at a hospital or clinic or remotely from an HIPAA-secure facility.  Medical scribes who work at off-site locations are known as virtual medical scribes.

Scribes can generate referral letters for physicians, manage and sort medical documents within the EHR system, and assist with e-prescribing.  Essentially, scribes are data care managers who enable physicians, medical assistants and nurses to focus on patient intake and care.  By managing data for physicians in real time, scribes free the physician to spend more time with the patient and improve productivity.

A scribe must be trained in health information management technologies to support their work.  They follow a physician through their work day and chart patient encounters using a medical office’s EHR.  EHRs can be shared across various healthcare settings and made available through network-connected information systems or other information networks and exchanges.  They include an array of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs and personal data, such as age, weight and billing information.

The role of a scribe entails more than shadowing a physician and capturing patient interactions. According to the American Healthcare Documentation Professional Group, scribes:

1. Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including, but not limited, to:

• Patient medical history and physical exam;
• Procedures and treatments performed by healthcare professionals, including nurses and physician assistants;
• Patient education and explanations of risks and benefits;
• Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up; and
• Referral letters as directed by the physician.

2. Prepare referral letters as directed by the physician via dictation or summary of the medical record. Also, they ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, research contact information for referring physicians, coordinate referrals and prepare operative reports.
3. Provide quality control oversight by spotting mistakes or inconsistencies in medical documentation. Since information documented in the medical record must be approved by a physician, scribes must ensure that all clinical data, lab or other test results and the physicians’ interpretation of the results are recorded accurately in the medical record.  Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
4. Scribes collect, organize and catalog data for the physician quality reporting system (PQRS) and other quality improvement efforts and assist in developing and maintaining systems to track patient follow-up and compliance.

Physicians Cope with EHRs Added Administrative Tasks

In the 1980s computers became a mainstream addition to small business operations.  Physicians, typically operating as a small business, initially pushed back on the concept of using computers to help run their practices because of their cost, complexity and lengthy learning curve.  However, price compression and the creation of Windows-based, user-friendly interfaces quelled their concerns.  Small business computers became widely accepted by physicians to help them manage the vast demands of providing patient care.

During that same decade, computer systems for medical applications began evolving into fully automated EHRs.   EHRs became available to physicians to manage the clinical side of their businesses.  Like all computerized technologies, EHRs have experienced rapid transformation over the past 20 years. Improvements in the technology have greatly accelerated since the January 2009 passage of the Health Information Technology for Economic and Clinical Health Act (HITECH), a $30 billion effort to transform healthcare delivery through the widespread use of EHR technology.

For decades, physicians hoped EHRs would help them manage the overwhelming demands of practicing medicine.  Instead, for some physicians, EHRs have become more of a hindrance than a solution to the problem they set out to solve.

Today, the administrative tasks associated with EHRs are cutting into the physicians have to spend with patients. According to a time-motion study conducted by the American Medical Association (AMA) and published in the Annals of Internal Medicine (AIM), nearly half a physician’s work day is now occupied by EHR data entry.  Also, from 2011 to 2014, 54 percent of study participants said they experienced some signs of burnout, an increase of 46 percent over the three-year period. Today, the administrative and clerical burden of working with EHRs is widely recognized as a leading cause of physician burnout.

Physicians are coping with their new administrative duties, but they are not happy about it.  The demands of data capture with EHRs have become a real impairment to practicing medicine.  In 2004, only 20.8 percent of physician offices used EHRs.  As of 2015, nearly 9 in 10 (87 percent) of office-based physicians had adopted an EHR system.  The expansion of EHRs is not indicative of the satisfaction level of the physicians who use them.  A 2013 study, Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy, published jointly in October by the AMA and RAND Corporation, found that EHRs were a major contributor to physician dissatisfaction.

The study indicated that for many physicians, the current state of EHR technology significantly worsened their professional satisfaction.  The factors associated with EHRs that were a common source of frustration included poor usability, time-consuming data entry, interference with face-to-face patient care, an inefficient and less fulfilling work environment, the inability to exchange health information and disintegration of clinical documentation.

Summary

The financial implications for the use of medical scribes in care delivery are substantial. Physician services are 21 percent of health expenditures in the U.S. and are the catalyst for the care cycle. They are highly compensated individuals who are being asked to do more with declining reimbursement.  Any change that improves physician productivity and efficiency (without impairing quality or physician or patient satisfaction) should have significant financial benefits for physicians, patients and the entire healthcare system.

EHRs enable the electronic documentation of diagnosis and treatment plans for patients.  They offer the ability to capture information that meets the requirements of meaningful use and value-based care reimbursement models.  Conversely, EHRs have added a new level of administrative burden on the physician’s shoulders that has taken a toll on physicians.  Scribes have rapidly emerged to relieve physicians of much of this administrative responsibility. Using scribes offers the opportunity to increase physician productivity and reduce job dissatisfaction and burnout.   The use of scribes could help physicians maximize the value of EHRs, improve their financial returns, and ultimately, enhance the quality of patient care.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Global Services for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at [email protected]

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