Computer Scribes for Physicians
Medical scribes are trained data entry professionals who specialize in the documentation of physician-patient interactions during medical encounters. Although the use of scribes and other transcription services began in the era before widespread use of the electronic health record (EHR), they have found a new role in facilitating physician interactions with the computer during clinic and hospital visits.(1,2) Their use can also improve physician productivity and generate higher revenues by reducing physician time spent on documentation, increasing the number of patients seen, and providing higher quality clinical documentation for billing.
For discussion of other clinical documentation methods, see: Physicians and EHR Documentation strategies
Most scribes perform functions in real-time directly alongside medical providers in person utilizing computers on wheels (COWs), laptops or tablet computers. They may also provide remote transcription services of recorded physician notes.
The primary role of scribes involves documenting while the physician interviews and then examines the patient. Typical documentation in a single clinic or emergency department encounter would include:
-History of present illness
-Past Medical & Surgical History
-Social & Family History
-Review of Systems
-Medication & Allergy Information
-Physical Exam Findings
-Re-assessments and Plans of Care
In addition to active documentation, scribes can help providers navigate the EHR and retrieve prior medical information during the encounter. Physicians are ultimately responsible for all documentation created by the scribe and are expected to review any notes before officially signing them.
As unlicensed medical professionals, scribes are not able to process verbal orders or complete orders in the EHR. Depending on hospital policy and the EHR system capabilities, some scribes are able to put orders into the system pending review by the physician who can respond to any alerts such as allergy warnings or medical interactions.
Rules and Regulations
Guidelines regarding the scope of practice of scribes have recently emerged to address their growing use. The Joint Commission released their first set of recommendations on the use of scribes in 2011 and revised them in 2012. They defined a scribe to be: “an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant). It is the Joint Commission’s stand that the scribe does not and may not act independently but can document the previously determined physician’s or practitioner’s dictation and/or activities.” Despite their lack of licensed status, all scribes must be trained to be compliant with HIPAA and medical confidentiality. Regarding scribes and their participation in order entry, The Joint Commission did not expressly prohibit the practice, but stated that it “does not support scribes being utilized to enter orders for physicians or practitioners due to the additional risk added to the process.”(3)
Additional guidelines on the use of scribes are available through The American Health Information Management Association, one of the oldest professional organizations for the field of medical record management. Their guidelines also support The Joint Commission’s recommendations and further discuss the need for minimum competencies and training required to be a scribe.(4)
Currently, the only national certification available for scribes is provided by the American College of Clinical Information Managers. This exam, the Clinical Information Manager Certification and Aptitude Test (CIMCAT) assesses knowledge of medical terminology, documentation and EHR training, but is currently is not officially required before working as scribe.(5)
Benefits of Scribe Usage
A few studies have demonstrated the benefits of having scribes in different clinical settings. Arya et al. studied the impact of scribes on quality performance indicators in an emergency department (ED), and showed statistically significant increases in the numbers of patients seen and relative value units (RVUs).(6) The ED is seen as a particularly ideal environment for scribe usage, as encounters are often brief and scribes reduction in documentation workload can allow for more patients to be seen. By one estimate, at a cost of $20-26 per hour for a scribe, physicians can boost their revenues by $50-60 per hour.(7)
Another study on the impact of scribes in an outpatient urology clinic examined attitudes of patients and physicians to the use of scribes.(8) Both physicians and patients were accepting of the scribe in the clinic setting. Physician perceptions of their office hours increased dramatically when a scribe was present (69% vs 19%, p < 0.001). Although the small increase in patient satisfaction (93% vs 87%) did not reach statistical significance, patients were comfortable having sensitive urologic information discussed in front of the scribe, which could have reflected acceptance of the scribe as part of the medical team.
1. Lynch TS. An emergency department scribe system. Journal of the American College of Emergency Physicians. 1974;3(5):302–303.
2. Allred RJ, Ewer S. Improved emergency department patient flow: five years of experience with a scribe system. Ann Emerg Med. 1983;12(3):162–163.
3. Use of Unlicensed Persons Acting as Scribes. The Joint Commission; 2012. Available at: http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?StandardsFAQId=426&StandardsFAQChapterId=66. Accessed July 22, 2013.
4. Campbell LL, Case D, Crocker JE, et al. Using medical scribes in a physician practice. J AHIMA. 2012;83(11):64–69.
5. Certification/Training. American College of Clinical Information Managers Available at: http://www.theaccim.org/certification. Accessed July 21, 2013.
6. Arya R, Salovich DM, Ohman-Strickland P, Merlin MA. Impact of Scribes on Performance Indicators in the Emergency Department. Academic Emergency Medicine. 17(5):490–494. doi:10.1111/j.1553-2712.2010.00718.x.
7. Meyer H. The doctor (and his scribe) will see you now. Hosp Health Netw. 2010;84(12):41–2, 44.
8. Koshy S, Feustel PJ, Hong M, Kogan BA. Scribes in an Ambulatory Urology Practice: Patient and Physician Satisfaction. Journal of Urology. 2010;184(1):258–262. doi:10.1016/j.juro.2010.03.040.
Submitted by Levon Utidjian