AAOS Now

Published 7/1/2015
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Jennie McKee

Are Medical Scribes Right for Your Practice?

An increasing number of hospitals and private practices are turning to medical scribes to increase productivity and profitability, as well as to enhance patient care and satisfaction. Medical students, medical assistants (MAs), and other professionals who serve as medical scribes are at the physician’s side during patient examinations, documenting the visits in real time. Although some critics have raised questions about patient privacy concerns and costs associated with hiring scribes, Michael Murphy, MD, contends that medical scribes are an invaluable tool in today’s healthcare environment.

“The unfortunate reality is that providers, practices, and health systems are being ‘crushed’ by ancillary duties,” said Dr. Murphy, an emergency department physician and chief executive officer of ScribeAmerica, a professional medical scribe training and management company headquartered in Fort Lauderdale, Fla. “The challenges involved include issues such as limited patient access to care and physician burnout.”

Dr. Murphy believes that medical scribes can increase a physician’s productivity and benefit physicians and patients. He went on to describe the various tasks scribes perform and offered advice on best practices for working with medical scribes during a session at the 2015 annual conference of the American Association of Orthopaedic Executives.

The role of medical scribes
A medical scribe accompanies the physician during a patient examination to document the visit in the patient’s medical chart in real time, explained Dr. Murphy.

“Each physician should be assigned a scribe,” he said. “At the beginning of the day, the scribe will preload the notes, check to see who the patients are, and determine whether any tests or other issues need to be brought to the physician’s attention. Then, the physician and scribe go into the examination room together.”

The medical scribe, who might be using a tablet device or laptop, should be logged in to the electronic medical record (EMR) system under his or her own username and password.

“It’s a violation of the Health Insurance Portability and Accountability Act if scribes use the physician’s username and password,” said Dr. Murphy. “Nurses can’t share a physician’s username and password, and neither can a medical scribe.”

As the physician evaluates the patient and takes the medical history, the scribe documents the physical examination and assessment plan in the EMR.

“The scribe would then document whether any preoperative testing is required and whether any other physicians need to be consulted,” said Dr. Murphy. “The scribe can start coordinating those things, document results from any tests, record prescriptions, and enter the aftercare instructions. The scribe can also help coordinate rehabilitation care.

“This frees the physician to focus on the patient. When the physician and scribe walk out of the examination room, the note is completed and signed,” added Dr. Murphy.

Working with medical scribes may improve physician job satisfaction and retention. “An in-parallel process with a medical scribe means that charts will be completed on time, thus decreasing overtime hours,” he said.

In Dr. Murphy’s experience, integrating medical scribes into a physician practice enables each physician to see an average of one more patient an hour, which equates to approximately eight more patients per day per physician.

“If the scribes are doing 85 percent or 90 percent of the documentation, it results in a significant time savings for the physicians, as well as improved patient access to care,” he said.

Implementation models
Various models for medical scribes exist, noted Dr. Murphy.

“The traditional model is a human person in the room with the physician,” he said. Another option is to use a virtual scribe, a professional who works remotely to perform the same duties as an onsite scribe.

“Smart phone apps can link a scribe virtually through audio and video, or audio only,” explained Dr. Murphy.“Virtual scribes can be used in areas that lack ideal scribe candidates. Low-volume providers who only need a scribe for 16 hours per week might also consider virtual scribes.”

A common question, he said, is whether MAs should be trained as scribes.

“We have been unsuccessful in taking and training MAs to become scribes,” he said. “Typically people who want to be MAs don’t want to be scribes.”

Instead, Dr. Murphy recommends hiring medical scribes and then training them to be MAs.

“If a practice uses a hybrid model in which an MA also functions as a scribe—and it’s working—the practice probably isn’t busy enough,” he said. “If a practice is seeing four or five patients an hour, the scribe is just keeping up, and the MA is just keeping up.”

Dr. Murphy noted that using a vendor to obtain medical scribes, rather than hiring medical scribes directly as employees, may have some medicolegal advantages.

“If scribes are practice employees, and the practice has a Recovery Audit Contractor (RAC) audit, the RAC auditors may see a significant increase in the practice’s billables after the scribes were hired. Outsourcing medical scribe services keeps things at arm’s length, to avoid the question of whether the scribes are leading physicians into increased charges. An outside scribe service is not going to be financially vested in the practice’s billables.”

If a practice does hire medical scribes directly as employees, he noted, the practice should put clear documentation in the employee agreement to ensure the scribe does not lead physicians into increased charges.

Other issues
The high turnover rate among scribes is another factor practices should consider, noted Dr. Murphy.

“The typical scribe candidate is a preprofessional who is aspiring to be a nurse, physician’s assistant, nurse practitioner, or physician, so turnover is inherent,” he said, noting that the typical tenure of a scribe is approximately 19 to 24 months.

That is why he advises practices to “staff scribes at 110 or 120 percent, as far as scheduling,” even if there’s an overlap with an MA, to ensure that every shift is covered.

“It’s also key to standardize documentation and billing,” he said. “It’s important to create templated ‘smart phrases’ for the EMR to standardize documentation, drive revenue, and protect the practice from a risk standpoint.”

He recommends that physicians who are part of a health system or hospital give information technology staff members ample lead time—perhaps 6 months or so—before bringing scribes into the practice, to ensure that all technology needs are met. This is particularly important if the practice will be using offsite scribes who will need virtual private network access to use the EMR from a remote location.

Integrating medical scribes into a practice successfully also requires physicians to have “skin in the game” and work with the scribes to achieve practice goals.

To maintain budget-neutrality after adding scribes, the practice manager and the physician will need to align the schedule to permit additional patient visits. Other important goals might include increasing patient satisfaction and ensuring that all charts are signed by the end of the day.

Although a certain amount of work is involved in adding scribes, noted Dr. Murphy, he believes it is worthwhile.

“There’s a significant return on investment,” he said. “In surgical fields, adding scribes will have a double impact because the surgeon will be able to book more surgical cases, see more patients, and provide better access to care.”

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org

Additional Information
The Joint Commission FAQ: Use of Unlicensed Persons Acting as Scribes

CMS FAQ 9058