Medical Scribe

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Rapid implementation of Electronic Medical Record systems took place across the United States healthcare organization after the introduction of the HITECH Act in 2009. Entering orders and documenting in the EMR consumed a significant portion of clinician's time. This inefficiency gave birth to the medical scribe industry.

The Joint Commission defines medical scribe as "A documentation assistant or scribe may be an unlicensed, certified, (MA, ophthalmic tech) or licensed person (RN, LPN, PA) who provides documentation assistance to a physician or other licensed independent practitioner (such as a nursing practitioner) consistent with the roles and responsibilities defined in the job description, and within the scope of his or her certification or licensure" (1)

A 2019 qualitative study indicated that enhanced scribe training, including broad health topics, use of the EHR, and customized training about an individual provider's workflow, along with the training of the provider on how to best use a scribe, may increase patient safety.(2) An observational study showed integrating scribes into a primary care clinic can produce positive outcomes that went beyond reducing clerical burdens for clinicians. It showed scribe might even benefit patient experience, quality of care and joy of practice.(3)

The Joint Commission does not support or prohibit the use of documentation assistants. The Centers for Medicare & Medicaid Services (CMS) does not provide official guidance on the use of documentation assistance. The Joint Commission recommends that scribes need to have training in medical terminology, HIPAA, principles of billing, coding, and reimbursement, EMR navigation, CPOE, CDS, proper methods for populating pending orders. (1)

Medical Scribes have generally assisted clinicians with documentation like writing history and physicals, daily notes, visit notes, discharge summary. However, some places do expect scribes to work on CPOE. The Joint Commission came out with general guidance on the orders. It said, "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 certified or licensed personnel to activate or submit the orders after verification. Transcribing orders into the EMR while providing documentation assistance is not considered a verbal order" (1)

There are more than 20 companies across the USA, providing scribe services to the health care industry. They also train and certify their candidates through various training and examination methods. The American College of Medical Scribe Specialists (ACMSS™), a Non-Profit Organization, offers a Medical Scribe Certification and Aptitude Test (MSCAT) for certification of scribes.(4) More details on their website https://acmss.org/. Basic education of a scribe can vary highly from high school students to university graduates. Generally, the pay is low, ranging between minimum wage to $12/hr. (5) A significant number of scribe candidates are aspiring physicians and nurses. There is no clear oversight by government agencies on scribe vendors. It is up to health care and clinicians to validate the competency of scribe vendors and individual scribes.

Although there are several advantages of using scribes at point of care, clinicians should maintain clear supervision as clinicians are ultimately responsible for their patient's health and their medical licenses. A booming scribe industry highlights the inefficiencies of electronic medical records systems and also the clerical burden of the healthcare system. It is possible that once EMR usability improves, the scribe industry might plateau. Informaticians and clinicians must continue to push EMR vendors for better usability and workflow integration of their products.

1. Commission TJ. Documentation Assistance Provided By Scribes 2020 [Available from: https://www.jointcommission.org/en/standards/standard-faqs/nursing-care-center/record-of-care-treatment-and-services-rc/000002210/] Accessed 26 April 2020

2. Corby S, Gold JA, Mohan V, Solberg N, Becton J, Bergstrom R, et al. A Sociotechnical Multiple Perspectives Approach to the Use of Medical Scribes: A Deeper Dive into the Scribe-Provider Interaction. AMIA Annual Symposium proceedings AMIA Symposium. 2019;2019:333-42.

3. Sattler A, Rydel T, Nguyen C, Lin S. One Year of Family Physicians' Observations on Working with Medical Scribes. J Am Board Fam Med. 2018;31(1):49-56.

4. Gellert GA, Ramirez R, Webster SL. The rise of the medical scribe industry: implications for the advancement of electronic health records. JAMA. 2015;313(13):1315-6.

5. Bailey M. The pay is low, the typing nonstop, but the medical scribe business is booming statnews.com2016 [Available from: https://www.statnews.com/2016/04/25/scribes-emergency-room/.]Accessed 26 April 2020

Submitted by (Dr Adarsha Kattaya)