Over the last few decades, the practice of medicine has increased in complexity and pace. Financial pressures force doctors to see patients in time-squeezed appointments. And the widespread use of Electronic Health Records (EHRs) has introduced a litany of frustrating, time-consuming issues. Unfortunately for patients, doctors can struggle to focus on their patients with their eyes and minds focused on their computers. Certainly, this diversion of attention can impact the quality of doctor-patient communication. Yet, effective doctor-patient communication is critical for good healthcare. What’s the answer? Many doctors use medical scribes to allow them to focus more on patients and less on EHRs. But can doctors use medical scribes without patient consent?
What do medical scribes do?
Scribes are essentially “documentation assistants” or “data care managers” who work with doctors* to enter and retrieve medical information. Scribes must accurately capture and document information from medical appointments. The general duties of scribes may vary and can include:
- Assisting doctors in navigating EHRs.
- Responding to various messages as directed by the doctor.
- Locating information for review (i.e., previous notes, reports, test results, and laboratory results).
- Entering information into the EHR as directed by the doctor.
- Researching information requested by the doctor.
Federal law places some limits on the scope of work allowed by scribes. For instance, the HITECH Act mandates that unlicensed workers, which includes scribes, not enter orders such as those for prescriptions and X-rays.
It’s important to note that in some cases, the role of scribe is filled by medical professionals who take notes and provide clinical assistance. This blog post focuses on medical scribes who solely work as documentation assistants.
The evolution of doctors’ use of medical scribes.
In the 1970s an emergency room started using medical scribes to help doctors provide proficient care to large numbers of patients while keeping records accurate and secure. However, scribes were not commonly used until the 2009 federal HITECH Act provided incentives to increase the use of EHRs. Although EHRs were supposed to make it easier for doctors to keep accurate records, in reality, doctors find EHRs’ poorly designed interfaces burdensome and time-consuming. The time needed to document appointments, enter orders, retrieve test results, and coordinate care increased significantly. Thus, the increased demand for scribes who can ease the burden of EHRs while improving the quality of appointments.
A quick summary of the burdens of EHRs.
A 2016 study found that doctors spent only 27% of their total time on direct clinical time with patients, while spending 49.2% of their time on EHR and desk work. Moreover, while in the exam room with patients, doctors spent almost 53% of their time directly with patients, with 37% of their time spent on their EHRs and desk work. Furthermore, doctors reported working 1-2 hours each night, primarily on EHR-related tasks.
Finally, EHRs contribute to doctor burnout, a growing public health crisis which can impact the quality of care.
How many doctors use scribes?
Today, the use of scribes continues to grow as increasing numbers of doctors and patients accept their use. In 2015, approximately 15,000 scribes worked with US doctors. Research shows this number could reach 100,000 in 2020.
Does the US government regulate the training and licensing of medical scribes?
No! Importantly, this is a highly unregulated practice – there are no laws regarding licensing and training. For instance, a high school diploma is the only job requirement – no medical background needed. Moreover, there is no certification or licensing process, although scribes generally receive training before starting work. However, most scribes receive training upon hire.
Are scribes in the exam rooms with patients?
Maybe. There are several ways in which scribes partner with doctors to record appointment information. Firstly, many scribes work alongside doctors in their offices entering information in real time. However, increasingly scribes work remotely from near and far locations. These remote scribes either take notes via a live audio or video feed, or enter information previously recorded by a doctor. Interestingly, the live video feed may come from a tiny camera mounted to the doctor’s eyeglasses.
Do doctors hire and train their own scribes?
Doctors rarely hire and train the scribes they work with. Instead, the majority of scribes come from one of 20+ vendors who provide local and international scribes. In 2020, the majority of scribes used by US doctors work from US locations. Regardless of location, many scribes are young, educated people who hope for careers as healthcare providers.
Each agency determines their own training protocol. For instance, one large agency from India reports a 3-month training curriculum that includes medical terminology, anatomy, physiology and mock visits.
What are the advantages of medical scribes?
Above all, scribes allow doctors (and other medical professionals) to focus on the patients, not the computer. Clearly, this improves the interaction and communication between doctors and patients.
Furthermore, scribes can save doctors’ time, which is a precious commodity as doctors struggle to see patients in time-limited appointment slots. One study found the use of scribes decreased healthcare provider documentation time but interestingly did not change the amount of time spent at the bedside or communicating with other team members. Another study found that scribes led to significant improvements in overall doctors’ satisfaction, as well as satisfaction with chart quality, accuracy, and efficiency without decreasing patient satisfaction.
What are the potential downsides of scribes?
Certainly, the lack of medical training, and no required certification, can increase the risk for a scribe to misunderstand or misinterpret what the doctor says, leading to mistakes in the EHRs. Subsequently, any errors in EHRs can lead to medical errors when doctors make decisions for testing, diagnosis and treatments based on false information.
Additionally, notes from foreign scribes may need minor editing to compensate for differences in dialects and local vocabulary.
What do the experts say?
The Joint Commission, a US independent, nonprofit group that administers voluntary accreditation programs for hospitals and other healthcare organizations, evaluated the use of scribes. They identified the following potential quality and safety issues pertaining to the use of scribes:
- Unqualified scribes.
- Unclear definitions for scribes’ roles and responsibilities.
- Scribes using the doctors’ log-in rather than independently logging in to the EHR.
- Failure of doctors and other providers to verify orders or other documentation entered by scribes.
Do doctors have to get your permission?
If you doctor uses a scribe, do laws require they ask you for permission? Do you have a right to decline? The answer to these questions depends on where you live and your doctor’s inclination.
Interestingly, state laws vary on whether a doctor must notify a patient that a scribe is watching, listening, and recording information. However, for the most part, US federal laws (like HIPAA) don’t require doctors to get your consent before using a scribe, or otherwise sharing your health information, as long as the 3rd-party company signs a contract agreeing to protect patient data.
Additionally, most states are “one-party” states – thereby not requiring permission from all involved parties before recording conversations, including doctor-patient communication. Thirteen “two-party” states require both parties to agree. Visit this website to learn about recording laws in your state, including any exceptions or special provisions. Additionally, some states have special privacy protections for certain groups, like people with HIV/AIDS.
Although not all doctors must get permission before using a scribe, many doctors choose to do so.
What about digital scribes?
Can computer programs using artificial intelligence reduce or eliminate the need for humans to document medical appointments? Although many companies are developing or already market digital scribes, some experts believe digital scribes will never replace human scribes. Researchers evaluated speech-based technologies designed to automatically generate clinical documentation based on conversations between the doctor and patient. They concluded that AI solutions will likely only play a limited role due to the complexity involved.
Privacy and cybersecurity concerns.
Some patients do not like the idea that people other than their doctors are documenting their appointments. Although scribes are duty bound to maintain your privacy, if you cannot get past this concern, discuss it with your doctor.
Additionally, the use of remote scribes can open the door to cybersecurity concerns, particularly if the scribe companies have lax security. Ask your doctor what security measures his/her scribe provider follows to make sure your personal health information will not be compromised.
Can medical scribes impact your healthcare?
In short, I think scribes are a positive addition to the medical team. I personally have experienced several frustrating appointments where my doctor focused a majority of her time on the computer, negatively impacting my appointments.
Importantly, EHRs can contain errors, whether a doctor or scribe enters the information. However, if your doctors use a scribe, ask each of your doctors how they ensure the information in your record is correct.
If your doctor or scribe has entered your appointment information in real time, ask your doctor for a printout of the appointment notes before you leave. If the appointment notes are not immediately available, mark your calendar with a reminder to check the records in the near future.
I highly recommend you periodically review your records through your doctor’s online portal. Because errors in your record can follow you throughout your life, potentially impacting your care, notify your doctor if you find a mistake.
For more information on EHR issues, read my blog posts:
- Electronic Health Records Add to Doctors’ Stress.
- Electronic Health Records Problems.
- The Dangers of Medical Record Errors & Uncoordinated Care.
*NOTE – Although doctors and other healthcare providers may use scribes, for ease of reading, the term “doctor” includes all healthcare providers.