November 19, 2012
Medical Scribes Make Their Presence Felt
By Mary Anne Gates
For The Record
Vol. 24 No. 21 P. 14
The differences between medical scribes’ and medical transcriptionists’ roles are as varied as the individuals performing these seemingly similar but disparate tasks.
Both medical transcriptionists (MTs) and medical scribes are required to accurately document a patient’s medical record. However, as much as day is unlike night, each discipline documents its findings in different ways and in different settings.
“In general terms, MT documentation is a passive, stationary, one-way process, while scribe documentation is an active two-way process,” says Luis Moreno, MD, chief medical officer of ScribeAmerica. “For example, with regard to EMR documentation, MTs essentially document heavily using free text as they listen to a recording and document verbatim.”
“On the other hand, scribes document into structured paper or electronic templates with comparatively minimal use of free text,” explains Kristin Hagen, executive director of the American College of Clinical Information Managers (ACCIM). “Scribes don’t listen to recordings. Instead, they listen directly to the physician in person, clarify physician responses in real time, and prompt physicians to provide certain details when the template requires it. Scribes operate in a continuously dynamic, bilateral communication process. Documentation is ongoing by the scribe, adhering to The Joint Commission standards, where information is electronically inputted by date, timestamp, and both physician and scribe attestations.”
Medical Scribes and The Joint Commission
Recently, The Joint Commission clarified a previous response to a question about the use of unlicensed persons as medical scribes. The clarification resolved the debate on whether scribes can work with physician assistants by making it clear they can. However, the commission adopted a more conservative view on computerized physician order entry.
“The Joint Commission revised the frequently asked question on the use of unlicensed persons acting as scribes in order to include physician assistants and advanced practice nurses in the practitioner group that can use scribes,” says Bret Coons, a spokesperson for The Joint Commission. “We also determined that allowing scribes to enter orders into the medical record added an unnecessary risk to patient safety. Allowing scribes to enter orders into the medical record increases the potential for an order to be acted on before it is authenticated by a practitioner.”
Presently, specific scribe certification is not mandated when a person is interested in becoming a scribe or already working as a scribe. However, any accredited healthcare facility using scribes must meet existing Joint Commission standards.
“The Joint Commission does not prohibit the use of scribes,” Coons says. “If an accredited healthcare organization chooses to use scribes, [we] will expect the use of scribes to fall within what is allowed by our standards. … The Joint Commission requires that their use complies with all of the applicable human resources, information management, leadership, and rights and responsibilities of the individual chapter standards.”
The experience and educational backgrounds of current or aspiring scribes is not necessarily a factor in whether they can be employed. “Some scribes have participated in formal training programs, but formal training of unlicensed persons acting as scribes is not required by The Joint Commission,” Coons explains.
Hagen views The Joint Commission’s response as a sign of the increasing role scribes are taking on within the healthcare industry. She believes that as the number of practitioners who can use scribes increases, it may proportionally increase the number of people employed as scribes.
“[The Joint Commission] guidelines regarding proper scribe use reinforce the growing acceptance and usefulness of scribes in medical record documentation and in optimizing physician workflows,” Hagen says. “[The] clarification meant that thousands of new employment opportunities for scribes would now become available.”
Documenting a patient’s medical record is just one aspect of a scribe’s job description. Besides documentation, scribes often find themselves carrying the additional responsibility of assisting clinicians to achieve greater productivity.
“Unlike MTs, scribes also monitor the time it takes for medical test results to return and prompt the appropriate department or individual when delays in resulting become evident,” Moreno says. “Scribes also assist the doctor in identifying which critical patients, per the tracking board, need to be seen next, keep track of a patient’s duration of stay, and provide an additional point of communication for nurses looking to ask nonclinical questions of the doctor—for instance, ‘Has the doctor seen the patient in bed eight yet?’”
Other benefits with respect to improving physician productivity involve creating efficient workflows. “The medical scribe has a multifaceted role where he or she is working directly for the physician, nonclinically, thinking ahead of what steps need to be considered to improve patient throughput. The scribe may prompt their physician to pick up the next patient in the waiting room, thus increasing the number of patients a physician may see during the shift,” Moreno says.
Medical record documentation and helping to increase physician productivity are two of a scribe’s main responsibilities. However, the job, according to Hagen, does not end there. Scribes are likely to find themselves performing myriad other nonclinical duties as the patient moves through the healthcare system.
“Additionally, physicians may ask the scribe to grab a blanket, input results, or track other ancillary tasks nonclinically related to direct patient care, such as calling a family member or inquiring with registration about a patient’s insurance status when the physician needs to determine to where he or she can transfer a medically stable patient,” Hagen says.
Conversely, there are tasks that fall outside a medical scribe’s realm. For example, every aspect of patient care considered to be clinical is out of bounds.
“Medical scribes [play] a nonclinical role and cannot perform any direct patient care. Anything that involves clinical assessment, clinical interpretation, touching the patient, handling body fluids, medical instruments, or medical decision making, the scribe may not assist,” Hagen says.
MT to Medical Scribe—Maybe, Maybe Not
Although many MTs have an in-depth knowledge of medical terminology, there are some within the healthcare industry who, while acknowledging MTs’ skill sets, express concern about them understanding the full ramifications of making the transition to a medical scribe. Count Hagen among those with doubts.
“MTs expanding into the role of a medical scribe must understand key differences,” she says. “Medical scribes operate on site in scheduled shifts and document in real time at the point of service under the constant and direct supervision of the medical provider. Scribes must be adept at clinical documentation while in constant motion, possess excellent communication skills, and [have] the composure needed to communicate and work under the demands of highly trained medical personnel.”
“Healthcare documentation specialists [formerly known as medical transcriptionists] are well qualified to transition to medical scribe positions,” says Susan Dooley, a professor and program manager for health information/medical transcription at Seminole State College of Florida. However, she points out several factors MTs should consider before making the leap.
“A drawback for some healthcare documentation specialists is that scribes must work on site, which limits the pool of employment possibilities somewhat for people who have worked remotely,” Dooley says. “It is also apparently a very physical job, requiring the scribe to be on his or her feet all day, sometimes literally running after the doctor. For many of us who have worked in sedentary positions, this can be a challenge. Still, I think scribing is a viable alternative for many.”
Moreno disagrees with those who suggest medical students might be promising scribe candidates while they transition through medical school. “Medical students are not ideal candidates because they do not have the time to commit to working as a medical scribe,” he notes. “On the other hand, college prehealth students do make the best scribes. Prehealth college students such as premed, prenursing, prepharmacy, pre-midlevel practitioners, medical assistants, and emergency medical services personnel make ideal medical scribes.”
Training for scribes can vary widely. Reportedly, some in the healthcare industry will hire a scribe who has nothing more than a high school diploma, while others hire scribes who are in the process of earning advanced degrees in various areas of healthcare. Because education levels for MTs can differ, highlighting real-world medical language experience can be a distinct advantage.
“Some organizations are requiring only a high school diploma, while others are requiring experience in medical terminology. Applicants who want to transition to scribing from medical transcription/healthcare documentation should play up their fluency in the language of medicine as well as their other core knowledge areas of anatomy and physiology and human diseases, medical procedures, and of course the ability to quickly document what was said,” Dooley says.
A well-trained MT has the educational foundation to become an effective medical scribe. However, additional training is required in EMR documentation using products from various vendors that feature medical scribe-specific software. Plus, MTs need an understanding of how medical scribes fit into physician workflow, Hagen says.
According to Moreno, medical scribe training programs feature preclinical and clinical topics. The preclinical training subjects include medical terminology, basic anatomy, core measures, coding basics, billing documentation, HIPAA compliance, and EMR training. On the clinical side, there are classes in EMR documentation, clinical scenarios, and dispositions to include discharges, admissions, and transfers.
Where the Jobs Are
As a result of The Joint Commission standards, medical scribes can be employed by any accredited healthcare facility. However, according to industry experts, most scribes are not hired directly by an accredited institution. Rather, they are usually employed by a third-party entity.
“While medical scribes are hired by hospitals, clinics, surgery centers, and physician groups, the majority are hired by third-party recruiting agencies,” Hagen says. The nation’s largest medical scribe vendor and scribe education company, ScribeAmerica, currently employs nearly 2,000 scribes in over 170 hospitals located in 31 states. This represents approximately one-third to one-half of the entire medical scribe market.
Salaries and benefit packages for medical scribes vary by employer, geographical region, experience, and training. “An entry-level scribe who has successfully completed training typically starts at between $10 and $16 per hour depending on geographical location and the employer for whom they work. A local scribe manager will make between $14 and $20 per hour with or without benefits. At ScribeAmerica, a regional scribe manager, known as a project leader, earns between $42,000 and $96,000 per year with benefits,” Moreno says.
Exactly where scribes are employed within the healthcare community can make a big difference in job performance and satisfaction. “Scribing is mostly seen in the emergency room environment, where fast-paced action and the need for immediate documentation of the encounter are paramount,” Dooley says.
Medical scribes who have worked at least 200 hours as a scribe and meet certain criteria can upgrade their status to a certified scribe or certified clinical information manager through the ACCIM. “Clinical information managers earn a certification first by completing an electronically signed affidavit with ACCIM,” Hagen says, adding that prospective certification candidates must meet the following criteria:
• complete a designated competency medical scribe training program;
• meet an initial 90-day probation period with an on-site employer;
• independently document a minimum of 200 hours of physician-scribe interaction; and
• be in good standing with a medical scribe employer.
“Following approval of the affidavit, electronic access is granted to take the Clinical Information Manager Certification and Aptitude Test (CIMCAT),” Hagen says. “An 80% [score] or greater must be achieved by the candidate to earn the designated certification as a certified scribe or certified clinical information manager. After successful completion and applying for certification, a CIM will be granted a certificate and a CIM ID number, which will be used for identification purposes. CIMs are required to complete 20 hours of continuing CIM education each year following. ACCIM sets the standard and administers the program based on The Joint Commission, Centers for Medicare & Medicaid Services, and national clinical documentation standards.”
Whether a person is designated as a scribe or a CIM is inconsequential in the day-to-day responsibilities of medical scribing. From documentation to providing nonclinical services, a scribe will perform the same function as a CIM.
“Industrywide, medical scribe vendors and clients alike use these two terms interchangeably,” Moreno says. “The point of distinction therefore rests with whether the CIM or scribe is certified.”
— Mary Anne Gates is a medical writer based in Fort Wayne, Indiana.