A national campaign for electronic health records is driving business for at least 20 companies with thousands of workers ready to help stressed doctors log the details of their patients鈥� care 鈥斅爁or a price.聽Nearly聽1 in 5 physicians now employ medical scribes, many provided by a vendor, who join doctors and patients in examination rooms. enter relevant information about patients鈥� ailments and doctors鈥� advice into a computer, the preferred successor to jotting notes on a clipboard as doctors universally once did.
The U.S. has scribes today and their numbers will reach by 2020, estimates ScribeAmerica, the largest competitor in the business. After buying three rivals this year, it employs 10,000 scribes working in 1,200 locations.
Regulation and training are not rigorous. Scribes are not licensed. About a third of them are certified and that鈥檚 voluntary, according to the sole professional body for scribes. was created by ScribeAmerica鈥檚 founders in 2010.
鈥淭his is literally an exploding industry, filling a perceived gap, but there is no regulation or oversight at all,鈥� said , regional chief medical informatics officer at Christus Santa Rosa Health System in San Antonio, which uses scribes.
Others suggest that scribes can be a benefit to doctors and patients by shouldering the minutia of recording many of the details on a computer. 鈥淭hey鈥檙e capturing the story of a patient鈥檚 encounter 鈥斅燼nd afterward, doctors make sure everything is accurate. That way, the doctor can focus on interacting with the patient and give them good bedside manner,鈥� said Angela Rose, a director at the American Health Information Management Association, a professional group that has published a set of best practices for scribes.
The minimum qualification to be a scribe is generally a high school diploma, but some pre-med students take the jobs to gain experience from shadowing doctors. One company, says it prefers candidates with at least two years of college and it only hires pre-med, nursing or EMT students. ScribeAmerica provides two weeks of training to new scribes while a large rival, PhysAssist, gives one week. That鈥檚 followed by close supervision in care settings for one week at ScribeAmerica and 72 hours at PhysAssist.
Vendors stress the potential benefits for doctors when they spend less time on record keeping. 鈥淒on鈥檛 let paperwork stand between you and your patients,鈥� PhysAssist tells physicians 鈥淚magine a doctor not being able to make correct diagnoses because documentation distractions caused her to miss a symptom.鈥�
Another selling point involves money. ScribeAmerica says physicians using scribes can gain enough time to see five to eight more patients a day, boosting a primary care practice鈥檚 annual revenue by .
Not everyone is sold. Patrick Tempera, a gastroenterologist in Union City, N.J., said he uses scribes but does not allow them to come into the exam room with him because patients discuss sensitive health matters with him.
鈥淧atients might not tell the doctor in full disclosure certain personal things if there鈥檚 someone else in the room,鈥� he said.
Federal law limits some of the work that scribes can do. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the 2009 stimulus package and sent $32 billion to doctors, hospitals and other providers to spur them to move to electronic health records (EHRs), mandated that unlicensed workers, which includes scribes, not enter orders such as those for prescriptions and X-rays. However, sometimes scribes are allowed to enter pending orders, subject to a doctor鈥檚 review and approval.
A key hospital accreditation group also stresses those limitations. The Joint Commission, which accredits hospitals, said in that scribes can enter information such as family history, symptoms and doctors鈥� tentative diagnoses into EHRs. But it said聽scribes should not put in orders for prescriptions, X-rays or tests.
One concern is that scribes don鈥檛 have the background to make sure they put the right information in the orders.
Doctors are also responsible for reviewing scribes鈥� entries, making corrections if needed and signing off before leaving the patient care area, according to the guidelines.
But there is no enforcement mechanism to ensure adherence.
Some health care experts have raised concerns that sometimes scribes could be pressured to make the entries to save doctors time.
鈥淲e鈥檙e concerned that there will be a situation where inevitably these scribes are used to enter an order,鈥� Gellert said.
Lap-Heng Keung, a scribe at MetroSouth Hospital in Blue Island, Ill., said he鈥檚 never been asked to enter orders and wouldn鈥檛 be comfortable doing so.
鈥淲e don鈥檛 have the same expertise as providers鈥here are so many drugs that sound the same but have one letter difference. It鈥檚 not within our scope of skill,鈥� said Keung, who is studying information technology and taking pre-med courses at the Illinois Institute of Technology.
Even so, some scribes may face pressure to go beyond their training.
鈥淧ut yourself in the position of a 21-year-old pre-med student, here鈥檚 a doctor in the ER, you want a letter of recommendation so you can go to medical school 鈥斅爄t鈥檚 a lot of pressure,鈥� said Cameron Cushman, a vice president at PhysAssist. He said company officials work with scribes to help them know how to handle that situation. 鈥淲e [say] 鈥︹�檡ou鈥檙e going to be starstruck by these doctors, but you have to play your role and if you don鈥檛, there will be consequences.鈥欌��
Cushman says the company has been fired by clients 10 to 20 times 鈥斅爉ostly by smaller emergency room providers and outpatient clinics 鈥斅燽ecause it refuses to let scribes enter orders into electronic health records.
Surgeon Richard Armstrong of Newberry, Mich., said doctors are still coming to grips with the demands of electronic health records. Armstrong uses a transcriptionist to type his notes, but he enters all EHR information himself. A doctor for 34 years, Armstrong said he doesn鈥檛 use scribes because he鈥檇 have to check their work, and he鈥檚 more confident in his ability to do the job accurately.
鈥淲e鈥檙e forcing a technology into primetime onto physicians who don鈥檛 know how to handle it. And they鈥檙e using scribes because they need assistance,鈥� Armstrong said.