November-December 2020

HIM Challenges: Scribes Struggle to Fit Into a Different Reality
By Maura Keller
For The Record
Vol. 32 No. 6 P. 8

As the world continues to grapple with the ongoing COVID-19 crisis, health care industry professionals are asking, “What’s next?” and “How is the pandemic going to permanently alter our industry?”

As more and more hospitals reduce staff and cut back on schedules in order to minimize financial woes, one specific group within the health care industry—scribes—is being particularly impacted.

Newly Evolving Roles
Mary, a former chief medical scribe who is now in medical school and who would like to remain anonymous, worked as a scribe for the last three years—first at an urgent care facility, where she functioned both as a medical assistant and a scribe, and then as the chief scribe at a quaternary referral center hospital.

In her role as chief scribe, Mary had a wealth of “traditional” scribing duties in clinical settings and also was responsible for handling the interviewing, training, and management of other scribes.

“I had an attending physician who helped with scribe management, but he served more in an advisory role,” Mary says. “I have only ever been employed directly by the hospital/health system. By alleviating documentation burdens for the physicians, I was able to help them enjoy work more, thus improving the quality of patient care they received.”

As a result of COVID-19, the hospital where Mary was previously employed before starting medical school furloughed all of its scribes. “Friends still working there, including the current chief scribe, say they haven’t been given any guidance on when or if they should expect to return to work, and they are left wondering if they need to apply for a new job,” Mary says.

Since the widespread arrival of EHRs, scribes have filled a vital role within the health care system, proliferating emergency departments and outpatient clinic settings and helping improve doctors’ productivity.

Peter Reilly, president and CEO of the American Healthcare Documentation Professionals Group, says many organizations in ambulatory and clinic settings have shut down or greatly reduce their operations.

For example, in a recent Healthgrades survey, more than 94% of respondents said that their operations had seen a decrease in patient volume of more than 25% and 78% reported patient volume had decreased more than 50%. As a result, scribe work hours have been reduced.

“We have heard from several scribe management companies for both premise-based scribes and virtual scribes that they have reduced hours, frozen hiring, and even furloughed staff,” Reilly says. “This is also consistent with what we are seeing in our transcription services business. Dictation volume is down in the absence of everyday and elective health care services.”

In the face of a highly contagious disease, everyone is concerned about placing people in harm’s way. “As a result, unless necessary, hopefully all individuals who are needed stay as far away from patients as possible,” Reilly says.

The Greater Good
On the flip side, in situations where patient volume is high, shifting the administrative and health care documentation burden to others is extremely helpful.

As Reilly explains, in this environment, the use of remote medical scribes can be advantageous. In terms of capturing encounters as the patient is being seen by the provider (medical scribe) vs capturing the patient story post encounter (dictation), the former dynamic moves the needle closer to the dictation (after visit) end of the spectrum.

In situations where scribes are being used, this either places them in a remote location that limits some of the value premise-based scribes offer or moves them closer to acting in the role of transcriptionist rather than the pure definition of a medical scribe.

Although certain areas of the country are being inundated with COVID-19 cases more than others, at this point scribes are being used everywhere and in just about every care setting. “Of course, there are geographic areas where scribes have been being used a lot longer and those markets have a higher saturation of scribes than others,” Reilly says.

Robert Merold, managing director at Execullence, says physicians are not great “data entry clerks” so there is a lot of important information that either is not captured or is contained in free text notes that can’t be searched. For example, it’s been reported that the stage of a cancer patient’s condition is captured in structured EMR data only about 40% of the time.

“Scribes have proven their value for greatly improving the amount of structured information captured, whether for medical quality registry programs like the NCDR [National Cardiovascular Data Registry] at the American College of Cardiology or to support more precise billing that enhances reimbursement,” Merold says.

Mary, the former scribe, agrees. “When physicians are removed from the training process, scribes become machines. The very best scribes are able to predict what the doctor is thinking and do things like pull up an echo in advance or pull together discharge paperwork,” she says.

The pandemic makes the need for better, scribe-generated data more imperative. Paradoxically, scribe positions are more at risk due to short-term financial pressures. As Merold explains, an enlightened approach would be for national policy makers to underwrite more scribes, strategically placed, to support future surveillance and pandemic response.

“The pandemic also underscores the importance of real-time clinical data for analysis, helping policy makers understand what is happening and what is proving effective,” Merold says. “This is an acceleration of the growing movement at the FDA and elsewhere to tap into so-called real-world evidence that is broader and more granular than traditional randomized clinical trials that often are conducted among healthier patients than are found in the general populations.”

On the Horizon
On the more practical side, Mary worries that scribes who are currently furloughed or laid off may not have jobs to return to. “So many administrators don’t recognize how valuable scribes are to physicians, and I can picture this being a sticking point as budgets remain tight for the next several months,” Mary says. “I think that scribes will continue to be more widely utilized in other settings, particularly primary care. In a nation with such a primary care shortage, scribes are a very reasonable way to alleviate some of the administrative burdens that discourage residents from choosing a career as an outpatient physician.”

For many scribes who plan to attend medical school, a position in a hospital or another clinical setting can be a valuable mechanism to introduce them to the nuances of the field and open opportunities for advanced learning—something that is being taken away during the pandemic.

“An almost unsettling number of my peers entered medical school as these science and research robots who had spent very limited time in clinical settings. Or, if they had been in clinical settings, they never had the opportunity to be active learners,” Mary says. “Rather than being encouraged to ask questions—when appropriate, of course—or read independently, they clicked boxes in the EHR without much thought and assumed that they would learn the ‘why’ once they got into medical school. I am so thankful that I had the opportunity to see what the real, day-to-day life of a physician is really like, as well as to have a head start on being able to recognize which details were pertinent and which were just fluff.”

Like elsewhere in society, there will be a new normal moving forward after COVID-19. The changes in health care delivery will be more significant than other industries, including a reshaping of the roles played by scribes.

“Specific to the use of medical scribes or other roles to support our health care providers, I hope for all of our sakes that the pendulum swings back in the direction of focusing on patient care vs data capture,” Reilly says. “Yes, data capture to a point is helpful, but if it takes a physician away from taking care of the patient in front of them, it defeats the fundamental value each patient is looking for: to get better.”

— Maura Keller is a Minneapolis-based freelance writer and editor.