The average physician in an outpatient setting spends 1–2 hours an evening finishing their medical records.1 This has led providers to look for new ways to decrease EHR frustration and improve patient interactions, while still maintaining personal satisfaction. Is a scribe a possible fix for documentation tasks? What should you consider before hiring a scribe? Is there a risk of introducing a scribe into the physician-patient experience?
KEY CONSIDERATIONS
The Joint Commission (TJC) released updated information2 in April 2020 about using scribes that identified the following potential quality and safety issues:
- Unqualified staff performing documentation assistance
- Unclear role and responsibilities when providing documentation assistance
- Documentation assistants using the physician log-in rather than independently logging in to the EMR
- Failure of physicians or licensed independent practitioners (LIPs) to verify orders or other documentation entered during clinical encounter
TJC also updated its definition of a scribe to say that “A documentation assistant or scribe may be an unlicensed, certified (MA, ophthalmic tech) or licensed person (RN, LPN, PA) who provides documentation assistance…consistent with the roles and responsibilities defined in the job description, and within the scope of his or her certification or licensure.”
At a minimum, TJC noted that all persons performing documentation assistance have education or training on the following:
- Medical terminology
- Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- Principles of billing, coding, and reimbursement
- Electronic medical record (EMR) navigation and functionality, as appropriate based on job description
- Computerized order entry, clinical decision support and reminders, and proper methods for pending orders for authentication and submission
The amount of training will be dependent on a person’s experience and skills. TJC says that clarity regarding roles and responsibilities of a scribe should consider the following:
- Policies and procedures: Each organization should develop a policy/procedure regarding processes associated with personnel providing documentation assistance. Policies may include proper log-in procedures (such as prohibition of documentation assistants from using the physician or LIP’s log-in), the scope of documentation that may be entered, requirements for physician review of information and orders entered by the documentation assistant, and the order entry and submission process.
- Job description: All organizations utilizing personnel to provide documentation assistance must have job descriptions that define the minimum qualifications to perform this function and the allowable scope of activities that can be performed. Job descriptions should also specify plans to periodically assess performance and continued competence.
- Orientation and ongoing training and education to the role must be provided.
- Organizations that contract for the services of a documentation assistant must ensure that the quality of the service is the same regardless of whether it is provided directly or through a contractual agreement. At a minimum, the organization should ensure the scribe meets all of the same competency and training described previously.
Orders: All types of personnel performing documentation assistance may, at the direction of a physician or another LIP, enter orders into an EMR. The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders. Documentation assistants who are not authorized to submit orders should leave the order as pending for a certified or licensed personnel to activate or submit the orders after verification.
POTENTIAL CANDIDATES FOR SCRIBES
EMTs are often a good choice as are interested medical assistants and premed students. The training is at least 1-2 weeks and certainly differs depending on the setting where the scribe would be working. Various companies can help with the training or it can be on the job. There are companies that provide virtual scribes with real time data entry done on an online basis. This is an interesting solution to doing the training and quality control yourself.
THE UPSIDE
Data is scarce about how scribes might affect productivity. One EM study suggested that a scribe can increase productivity by 0.8 patients an hour.3 Another University of Chicago study4 found that an average of 1.3 new patient visits per day was required to recover the cost of a scribe at the one-year point. And for returning patient visits, it is two or three patients per day. The physician satisfaction was higher in this study and physicians felt less rushed. This allows providers to do what they do best—see patients. It also improves patient access which is an important patient satisfier.
Finally, a Journal of Urology study5 examined patients who were seen in scribe or non-scribe visits. With scribes, patient comfort was high and 93% of patients expressed satisfaction at having scribes in the room.
OTHER OPTIONS
One Colorado hospital system has created an inventive alternative solution. Instead of providers sharing medical assistants (MAs), it has created a system where there are two MAs per provider. Each MA acts as scribe and does pre-charting then also stays after the provider leaves to go over medications and workup. This has been a boost for MAs who have more job satisfaction and it allows for the patient to not feel rushed.
POTENTIAL DOWNSIDES
An integral part of the provider-patient relationship is the patient interview. Certainly, a third person in the room may be perceived as threatening and might alter the course of discussions. One best practice is to introduce the scribe and ask permission for the use of a scribe. Turnover with scribes is another key issue. Premed students who might be the best place to find a scribe are clearly looking to move on so they might only be around for a year or two. Ramp-up time can also be a challenge as one study6 noted that it took four weeks for each new scribe-physician team to get up to speed and adjust to each other. And a scribe who calls in sick might convert your busy clinic to one that is now 3–4 patients overbooked.
1 https://pubmed.ncbi.nlm.nih.gov/27595430/v
2 www.jointcommission.org/standards/standard-faqs/nursing-care-center/record-of-care-treatment-and-services-rc/000002210/
3 Acad Emerg Med. 2010;17:490-494.
4 https://pubmed.ncbi.nlm.nih.gov/33017564/
5 J Urol. 2010;184:258-262.
6 Fam Pract Manag. 2016 Jul-Aug;23(4):23-27.
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in 1Q21 Copiscope.
