The widespread adoption of electronic health records (EHRs) has led to a number of unintended consequences—particularly a negative effect on doctor satisfaction and practice workflow. Medical practices have tried many different solutions to help alleviate the burden, and one of the most common solutions is the adoption of medical scribes.
Scribes are now the fastest growing medical field. However, in spite of this rapid growth, there is little standardization in training scribes or defining their appropriate function with the EHR.
Though studies have lauded the potential benefits of scribes for nearly 30 years,1 the number of scribes is rapidly increasing today because of the need to untether the doctor from the EHR. According to one survey, nearly 20 percent of physicians now use scribes, with 10 percent planning on hiring scribes in the near future.2 Estimates suggest that the number of scribes will grow almost five-fold by 2020 to over 100,000, with one scribe for every nine physicians.3 Reports document scribe use in almost every practice setting and across a wide variety of specialties.
How does this affect the delivery of care? A number of studies suggest that scribes can enhance physician efficiency, improve physician satisfaction, and increase billing in a variety of clinical settings. Patient satisfaction can also increase, due to improved physician-patient interactions during office visits.
A Lack of Training and Standardization
In spite of the rapid growth and potential benefits of scribes, the healthcare community has generated very little regulation or standardization for scribe training, and researchers haven’t conducted any assessment of scribes’ ability to safely interface with the EHR. Recently, The Joint Commission stated that, at a minimum, all scribe-generated orders must be signed by a provider prior to implementation and that organizations must document the competency of scribes for the functions the organization deems appropriate.4
The Joint Commission also went so far as to require authentication of all EHR entries from a licensed practitioner.5
Scribes are considered a distinct group, but that group’s composition is varied. Scribes have a wide variety of backgrounds, including premed students and certified medical assistants.6
Dedicated scribe organizations, which provide scribes for individual practices and healthcare organizations, may train recruits on basic medical terminology, note structure, documentation, and EHR basics. Other scribes may receive on-the-job training from the doctor who is their employer. There is no licensure requirement for scribes. Most healthcare organizations set up their own training that is specific to local clinical workflows and dependent on the level of scribe functionality deemed appropriate by the organization.6
Once embedded in the organization, scribes may perform a variety of functions, including doing pure transcription of the encounter, using templates or macros within notes, placing orders, finding information in the EHR for the doctor, or even responding to patient messages.6 Unfortunately, few rules or standards currently exist that designate appropriate scribe activities.
Survey Shows Variable Roles and Functions
To better understand the role and functionality of scribes, The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, and Oregon Health and Science University (OHSU) conducted a national survey of The Doctors Company’s members. This survey, with 335 respondents, suggested that scribes are supplied from different sources, have disparate backgrounds, and their training is highly variable:
- 55 percent of scribes are trained by the doctor.
- 44 percent of scribes have had no prior experience.
- Only 22 percent of scribes have had any form of certification.
- Around 24 percent of practices that use scribes hire them as employees.
- Nearly 13 percent of practices use scribe staffing agencies.
The study also revealed wide variability in the tasks scribes are performing, including pure note writing, data entry (such as updating allergies), data extraction (such helping the doctor find information in the EHR), and order entry. A survey of a cohort of risk managers across the U.S. found a similar variance in scribe activities but significant differences between the two groups in what is considered in-scope for scribes.
The chart below shows the percentage of respondents in both groups who identified particular activities as appropriate for scribes.
||Risk Managers (%)
|Entering review of systems*
|Entering physical exam
|Entering progress notes
|Entering care plan
|Assisting in EHR navigation
|Locating information in EHR
|Responding to patient messages*
|Providing translation services*
|Signing physician notes
|Participate in decision making*
|*Statistically significant (Chi-Square) differences noted.
We have since gone to a number of sites around the country to directly observe and interview to determine what scribes are doing and how they are utilized.7 These studies confirmed that scribes can improve overall provider workflow and improve overall safety. However, this is dependent upon having established standards for training, assessment, and oversight for scribes, something that was not uniformly observed.
The Risk of “Functional Creep”
The combination of rapid growth in scribe use, lack of standardized training, variability in scribe experience, and variability in both EHR exposure and EHR workflows raises the concern that scribes may introduce potential negative unintended consequences to either workflow or documentation. Only one study to date has been conducted on the quality and accuracy of scribe-generated notes. To address this, OHSU is currently investigating the use of virtual, video-based simulation to assess the quality of scribe-generated notes and to provide practice-specific training.
In addition to concern over the wide variance in scribe activities, healthcare providers are worried about “functional creep”—scribes being granted the authority to perform more complex functions in the EHR over time. Scribes will slowly assume more and more complex EHR tasks, such as order entry, data finding, data interpretation, and entering of other data elements besides general notes. Given the already large number of negative safety issues associated with these complex EHR functions, it’s imperative that the healthcare community create methodology to ensure scribes can be effectively trained and their competency assessed for safe and effective use of the EHR.
Scribes in the Era of COVID-19
The COVID-19 pandemic has fundamentally changed how providers deliver care, with both a rapid expansion in the use of telehealth and the implementation of policies that limit the number of in-person staffing to minimize risk of infection and reduce use of personal protective equipment. With this has been a rapid transformation in how scribes are employed. At OHSU, we have already observed scribes moving to a virtual role, not only for in-person visits, but for virtual visits as well.8 This is associated with significant heterogeneity in the technology employed (audio only or audio with video) and how they are integrated into the workflow. Conversely, some practices have, for a variety of administrative reasons, lost their scribes, leaving providers unassisted. It will be essential that an organization proactively work to ensure that scribes are appropriately trained and supervised in these new workflows and that for providers for whom scribes are no longer an option, that their abrupt withdrawal does not create a situation where providers are unable to effectively function in their new work environment.
Dr. Gold is Vice Chair for Quality and Safety for the Department of Medicine and associate director of the Adult Cystic Fibrosis Center at Oregon Health & Science University.