As the use of electronic health records (EHR) has expanded in the United States, more licensed health providers have begun to rely on medical scribes to ensure fast, accurate documentation and maintenance of patient data.
How quickly has the use of EHR increased in the U.S.? According to the Office of the National Coordinator (ONC) for Health Information Technology, the percentage of U.S. hospitals that have enabled patients to view, download and transmit their health information increased to 69% in 2015 from 10% in 2013.
That rapid growth has created a professional opportunity for those who wish to enter the health informatics field as medical scribes.
A medical scribe – also known as a physician’s scribe, ER scribe or ED (emergency department) scribe, accompanies a physician, nurse, nurse practitioner or physician’s assistant during patient interactions and writes down or types in the relevant information to be used as part of that patient’s record.
The scribe performs many of the clerical duties that once were the physician’s responsibility. This frees doctors to focus more on diagnosing and treating patients.
According to ScribeAmerica, an agency that pairs scribes with physicians, there are more than 18,000 medical scribes in the United States. ScribeAmerica estimates that number will grow to 100,000 by 2020.
The groundwork for the growth of medical scribe jobs was laid relatively recently. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 created federal incentives for the use of EHR.
The utility of electronic records depends on speed and accuracy, which meant an additional clerical burden for healthcare practitioners. Enter the medical scribe, similar to a medical transcriptionist with the added responsibility of being present during an examination to record doctor-patient interactions.
The Joint Commission, which grants accreditation to healthcare organizations, issued guidelines for medical scribes in 2011. The American Health Information Management Association (AHIMA) followed with its guidelines in November 2012.
The AHIMA list of duties for a medical scribe included:
- Assisting a healthcare provider (physician, nurse or physician’s assistant) with navigating the EHR
- Responding to messages as directed by a provider
- Locating records such as notes, reports, test results and lab results for review
- Entering data into the EHR
- Conducting research as directed by a provider.
The Joint Commission guidelines made clear that there are limitations on what scribes, who are not licensed medical professionals, can and cannot do. Entering personal information such as family history, a tentative diagnosis and symptoms is acceptable, but a scribe should not place written orders for X-rays, prescriptions or other tests.
How to become a medical scribe
As a relatively new position in healthcare, the role of a medical scribe is still evolving. One emerging benefit is that the position offers an opportunity for pre-med students to gain exposure to the day-to-day work of licensed medical professionals in a clinical setting.
No licensing is required, although the American College of Medical Scribe Specialists offers training, accreditation and evaluation for medical scribes. According to research published on PayScale.com, the median salary for medical scribes was $27,075 as of late 2016.
In most cases, physicians are responsible for hiring their own medical scribes, often through an agency. There are more than 20 agencies around the country, and most of them do more than act as an intermediary during the hiring process.
Agencies often recruit, train, manage and evaluate the performance of their associated medical scribes. In general, a college degree is not necessary to become a medical scribe, although some agencies only hire someone with at least some college experience.
Regardless of the level of formal education, a medical scribe is expected to possess a working knowledge in the following areas, according to the AHIMA guidelines:
- Basic human anatomy
- Basic medical coding
- HIPAA (Health Insurance Portability and Accountability Act)compliance
- Medical terminology and spelling
- Computer skills
- EHR and health informatics
- General roles and responsibilities of physicians, nurses and physician’s assistants.
Every healthcare practitioner defines the role of medical scribes to suit the hospital, clinic or practice’s needs.
Some physicians rely extensively on their scribes to produce error-free records, requiring only minimal review and revision. Others ask scribes to perform extensive research. One emerging benefit is that the position offers an opportunity for pre-med or Health Informatics students to gain exposure to working with information and data in a clinical setting.
No matter what duties a medical scribe is expected to fulfill, all responsibilities, policies and legal limitations should be defined clearly in writing.