Use of Medical Scribes in the Ambulatory office Setting

Use of Medical Scribes in the Ambulatory Office Setting

Michael Weinstein, M.D.

Capital Digestive Care, LLC

Executive Summary        

        The physicians of Capital Digestive Care (CDC) continue to register complaints about the electronic health record implemented in 2012.  Accurately documenting office visit encounters is a frequent problem and many providers are unable to stay current with the medical record tasks assigned to them for review and approval.  Although it has not been measured, most physicians say that their work day has lengthened by more than an hour.  Using a medical scribe could decrease complaints but what evidence is there that physician satisfaction is improved and at what cost to the practice?  

        A search of the literature and the internet sheds some light on several aspects of medical scribe use in the ambulatory setting.  The available information about medical scribe services can be divided into the categories of the role and responsibilities of medical scribe, legal and regulatory issues, medical scribe education and qualifications, financial and economic aspects, and physician and patient satisfaction.   Unfortunately the majority of available literature concerns the use of medical scribes in the Emergency Room or other hospital based clinics.

        The reported experience on scribe use in ambulatory medical offices is not sufficient for the board to decide if CDC should implement a medical scribe program throughout the practice.  Although we might find other large gastroenterology practices with medical scribe experience, our own typically skeptical physicians will not accept outside opinion as sufficient to invest money in a long term scribe program.  There is a documented record keeping problem and enough published material about scribe benefits that the logical next step is to conduct a trial of scribe use at a few selected CDC offices.  

Electronic Medical Record Problem

        The implementation of electronic medical records promised improvements in health data analysis, interoperability of medical records across sites, and medical practice efficiencies.   Those promises have not been achieved more than two years after implementation.  In 2010, the full-time CDC physician saw an average of 155 patients per month.  In 2014 the average was 145 patients per month.  The ability to complete office note documentation and medical record tasks varies greatly amongst the physicians.  At any one time, one third of CDC providers will have open office notes more than a week old.  In a recent CDC managers meeting, the billing staff reported that they frequently delay claim submission for the entire practice and expend time tracking down physicians to submit completed documentation.  Incomplete tasks now number in the thousands for more than a dozen physicians.  Every office has reported increased staff overtime because physicians chronically run behind.  Patient satisfaction surveys also indicate frequent problems with long office wait times.  

        A significant number of CDC physicians need an alternative to their current method for completion of office note and EMR tasks.  Medical scribes have taken hold in hundreds of hospital emergency room programs and the American College of Emergency Physicians summarized that experience in an information paper. (Jaquis 2011)  Dr. George Gellert (2015, pg. 1316) reminds us that “this industry should be viewed as what it is: a workaround or adaptation to the suboptimal state of today’s EHRs”.  Therefore, in addition to looking at use of medical scribes, CDC should continue to request improvements in software from its EMR vendor.

Medical Scribe Experience in the Ambulatory Setting        

        The available information on medical scribe use in the ambulatory setting can be divided into the categories of the role and responsibilities of medical scribes, legal and regulatory issues, medical scribe education and qualifications, financial and economic aspects, and physician and patient satisfaction.      

Roles and Responsibilities

        Medical scribes can assist physicians in the office setting with several aspects of visit documentation and electronic chart maintenance.  Potential roles for a scribe include:

• Transcribing medical information from patient completed forms and recording patient histories as obtained by the physician.
• Transcribing details of the physical exam.
• Recording a physician’s consultations with family members or other physicians.
• Documenting procedures performed by providers.
• Checking on lab results, X-ray reports, or other patient data and entering the results into patient charts.
• Recording physician-dictated differential diagnoses, assessment, planned work-up, and instructions for patients after the visit. (Grace 2007)

        Because medical scribes tend to be younger and more technologically adept they can add to a physician’s efficiency by collecting and organizing data for physician viewing, alerting the physician when medical record information is incomplete or inconsistent, and performing other clerical work as needed including faxing, completing letters, and returning messages.  

Legal and Regulatory Considerations

        Most of the available regulatory information concerns the use of scribes in the hospital setting where compliance with Joint Commission rules is necessary.   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.  (Campbell 2012) There are a number of rules about signing charts, recording orders, and competency testing.  The legal issues of using medical scribes in the ambulatory setting are not clear from the available literature.  A scribe’s responsibilities are determined and controlled by the policies of the employer and the amount of risk the employer wishes to accept.   No agency of state or federal government currently monitors, or regulates, the growth or activities of the medical scribe industry. (Gellert 2015)

Scribe Education and Qualifications

        Training a scribe can take up to three months but can be faster because the most common applicants for the position are aspiring pre-medical students or even medical students looking to get exposure to the clinical setting.  Qualifications include:

• Knowledge of medical terminology.
• Familiarity with the physical exam process and ability to record exam details.
• Computer proficiency with keyboard skills able to accurately record information.
• Professional demeanor and recognition of patient privacy considerations.
• The ability to multitask and work calmly in stressful situations.

        The training for scribes provided by one of the largest scribe companies is intensive and time-consuming.  A training program requires approximately 100 hours of both classroom and practical on-site training.  (C. Newman, personal communication, January 12, 2015)