The creation and implementation of electronic medical record (EMR) systems in medical settings has led to drastic changes in the way many fundamental functions in healthcare are carried out. Countless tasks that were previously done with a doctor’s verbal or written order now must be entered into the computer using an EMR. The expectation that patient encounter information be directly recorded in the computer has widely replaced dictation and transcription.
These alterations in the healthcare process can leave physicians drowning in unfinished notes while other departments and entities like insurance companies bark for their completion. Many perks and opportunities come with EMRs, but the time consumed by them can be damaging to efficiency and team morale.
Medical scribes are a growing solution to the demands of EMRs. With a scribe, physicians can see more patients, and are able to do so in a more patient-centric way than without a scribe. Medical scribes allow physicians to maintain, or even exceed, their pre-EMR efficiency while enjoying all the benefits provided by this exciting new period in healthcare. There are many factors to consider when starting a medical scribe program.
1. Startup costs
If you’ve decided to introduce scribes into your facility, then there are several considerations you will want to make. Chief among these will likely how much are you willing pay for healthcare scribes. A cost and benefit analysis is warranted when starting a program. You want to ensure the cost of the scribes are covered by any additional revenue. Walker and colleagues (2016) analyzed the startup costs for a scribe program in an emergency department. Their findings are summarized below:
- Out of 10 trainees recruited, 9 completed classroom work prior to clinical training, 6 were offered clinical training after a simulated assessment, and 5 completed clinical training to be considered competent scribes
- Clinical training for this scribe cohort took between 68 and 118 hours
- Medical students achieved competence faster than pre-medical students
- One person with an alternative background did not complete training
- Based on a wage of $15.91/hr, recruitment and startup cost was $3111, education was $1257, administration was $866, and clinical shift costs were $1137
- $6317 startup cost per scribe
Many hospitals and clinics are seeing substantial increases in revenue compared to not having a scribe. While the additional expense might make administrators cringe, especially if they have just installed an new EMR system, the cost of implementing scribes in many settings has been largely overshadowed by the gains they make possible. Bank and Gage (2015) conducted a study in a cardiology clinic using 10 cardiologists with scribes and 15 cardiologists not using scribes. They found that scribes generated an additional $1,372,694 in revenue with a scribe expense of $98,588.
2. Outsourcing vs In-House Scribe Program
Another decision to make will be exactly how you’re going to get your scribes. There are a few ways by which this can be achieved. Outsourcing your scribe program is one option that may save your facility some implementation headaches.
Contract with a Medical Scribe Company
There are many large companies, such as Scribe America and Elite Medical Scribes, that offer scribe services to healthcare facilities. These companies handle all the details of beginning your scribe program, including hiring and training of scribes. Large scribe companies like these may be found more frequently in hospitals, but as time goes on you can also find them offering their services for different types of clinics.
Hire Scribes Directly
Self-starting an in-house scribe program is another option that can provide more direct control of cost and scribe functions. Since the functions of a scribe include many clerical tasks expected of healthcare providers, it is feasible that one of your providers could be the person who develops your scribe program. This isn’t uncommon, and the scribe program at the facility where I currently work was started by a physician in this way. This person will likely have an above average to superior knowledge of computers in general and EMR systems. They’ll be familiar with the requirements for documentation and billing, and have a good handle on the regulatory landscape.
Medical Assistants as Scribes
Cross-training other members of the healthcare team is another option that has been used to prevent providers from having to document on their own. This might be the most feasible option for small or individual practices where hiring a medical scribe is less achievable. Medical assistants are one heavily utilized group for medical scribe duties, although there are other groups within healthcare facilities that can adopt different scribe functions. Medical assistants in many settings may handle virtually every aspect of routine patient visits short of seeing them as a provider and checking them in at the front desk. Instead of leaving the patient after working them up in preparation for the the physician, medical assistants-scribes will stay with the patient and complete the healthcare scribe duties for that visit, too. After the visit, they’ll “become an medical assistant again,” and fulfill all checkout procedures usually carried out by a medical assistant.
Advantages of Using Medical Assistants as Scribes
1. Removing a link in the chain of work and reducing the number of people exposed to protected health information.
2. Medical assistants are clearly allowed by CMS to enter orders for physicians, although there is ambiguity regarding scribes without an MA certification and entering orders.
3. Having MAs enter orders at the physician’s direction allows them to clarify instructions and reduce errors, as well as prepare for any action they may need to take on the orders as a medical assistant.
3. Regulatory Considerations
In implementing your scribe program, there are many regulatory considerations to be made. The Joint Commission has been watching the scribe surge closely, and has provided a few prominent statements providing regulatory guidance on scribes. Any changes to the record must meet specific criteria to be considered complete. Furthermore, there are requirements dictating what parts of a note a scribe can complete, and what permissions and oversight are required for each. Like with any other healthcare employee, any changes made to an encounter note or other patient records most be notated in a way that identifies the scribe. The dates and times of those changes must also be noted. Finally, the supervising physician must review, revise, and certify the accuracy of any note that a scribe has worked on (4).
4. Medical Scribe Training
Training your scribes will be an important part of your program. If you outsource your scribes, then the company you hire will often develop the training program out of their basic format in consultation with your facility to fully meet its needs. If you start your own program, the basic training of scribes will be similar.
- New scribes will be trained and assessed in fundamental aspects of healthcare, such as medical terminology, pharmacology, as well as anatomy & physiology.
- They will also be taught about privacy and confidentiality regulations, and of course the etiquette for working in healthcare and interacting with patients, physicians, and coworkers.
- Throughout training, these fundamentals will be reinforced as scribes learn the different aspects of documentation and billing requirements.
- Trainees get heavy practice on the EMR system they will be using as a scribe so they can quickly become familiar with it. Their computer skills will be constantly tested throughout training. Any scribes who may have been misleading about their computer abilities when interviewing will be easily weeded out during this process.
5. How to Recruit Medical Scribes
Recruiting will be an important part of building your scribe force. If you enlist a scribe company, they will probably handle this for you. Recruiting your scribes will be like many other employees in your facility, but they have some distinctions from other positions. One of these is in the background or education you’re seeking in your candidates. Most people working in any healthcare facility possess some type of certification or licensure in what they do, but many scribes do not. This may complicate the recruitment process for some facilities and cause some concerns when it comes to using scribes. Given the amount of access scribes are given to EMR systems and patient records, this lack of licensure could be (and has been) troubling for some facilities and providers. Nonetheless, scribes are governed by the same HIPAA laws that govern any person handling PHI. Like other healthcare employees, scribes are expected to undergo regular training in HIPAA and other regulations.
6. What about Medical Scribe Certification?
The American College of Medical Scribe Specialists (ACMSS) is an organization that offers training and certifications to scribes. However, many potential scribes aren’t going to possess certifications at this point, especially since law doesn’t require it yet. Furthermore, there are few formal scribe programs housed within traditional colleges or universities. As scribes increase in popularity and demand, education and certification opportunities will likely increase. Inevitably, time will likely bring about a requirement for scribes to maintain some type of certification. The current lack of a requirement for certification makes this an accessible occupation for someone with little education beyond high school, but it can make finding qualified scribes a challenge for facilities.
7. Applicant’s Qualifications
At minimum, you’ll want someone with basic medical knowledge. Finding a scribe that is certified will increase your likelihood of finding a scribe who is capable of the duties of a scribe and committed to the position. Besides people specifically seeking careers as scribes, some other types of people who may show interest in a scribe position include those from other areas of healthcare, such as transcriptionists, billers and coders, EMTs, and other types allied health professionals. However, pre-health students are probably the largest group seeking scribe positions. Hiring heavily within this demographic will increase your likelihood of having candidates who are eager to learn as much as possible, and they’ll be driven to give maximum effort and produce high quality work so they can obtain strong letters of recommendation for school. On the other hand, hiring within this population can result in high turnover, as many of these employees will only be staying for a few years before they leave for school.
One way to reduce frequent turnover with student-scribes is to require a minimum commitment to get letters of recommendation for school. While you might have limited control over what some physicians will do for scribes they particularly like, requiring a commitment does cut down on short-term turnover and further drives home the point to student-scribes that the duties of a scribe are critical to patient care, and scribing is not just a glorified shadowing gig.
8. Human Resources and Payroll
The management and oversight of your scribes can vary with the option you choose. In many cases, scribe companies will have a few levels of scribe management onsite, but the remainder will be handled in a large structure of management offsite. Aspects such as payroll and scheduling will likely be handled by the scribe companies, as well.
Handling it all yourself will give you the most immediate control over the different aspects of your scribes, but also more burden. The management will be more direct, but it will require additional attention in scheduling and coordination. The scribes’ payroll will be done with the rest of your employees unless you decide otherwise. Your medical scribes can be managed by leaders in your facility with some success, such as nurse or medical assistant managers, IT managers, or medical records managers.
Managing the Medical Scribe Program
When setting up a medical scribe program it is important scribes are meeting expectations across all levels of an organization. The nature of the scribe position is so unique and integrative that it will often require a dedicated scribe manager. The manager not only has the knowledge to direct, coordinate, inform, and assist the scribes, but also general healthcare knowledge to organize the actions of the scribes around the expectations and responsibilities of the many other departments that can be in a medical facility. Each department will be using the scribes’ documentation to carry out their own functions, so it is important that each part of the facility understands how scribes fit into their worlds.
With the pace and intensity of treating patients, documentation should be a secondary concern to physicians. Scribes are an innovative way for the providers in your facility to capture the full potential of EMRs and the electronic age of healthcare while still seeing their patients efficiently without compromise, but there are some hurdles to overcome before you have them following physicians around your facility. The obstacles appear to be worth it, as adding scribes can increase your revenue and allow your physicians to refocus on their patients.