By Adele Field, ZyDoc Marketing & Communications Director
Disclaimer: ZyDoc’s core business is providing secure web-based medical transcription and EHR data insertion services. ZyDoc also offers remote scribing.
Transcriptionists and scribes share a common Latin word origin, scribere, “to write,” and can trace their roots back to antiquity. They have been around since the days of committing words and transactions to papyrus for philosophers and kings. In the current era of electronic health records, employing elite corps of language specialists is still the go-to solution for navigating the complexities of documentation. Both transcriptionists and scribes generate clinical documentation under the guidance of physicians for inclusion in the EHR. Both reduce the time-consuming, unnecessary cognitive overload imposed on clinicians by suboptimal EHR user interfaces that require counter-intuitive data entry by keyboard and mouse. Both solve the same problem, but they do it differently.
Medical transcription, once considered "old-school," is now typically cloud-based, using secure cutting-edge technologies such as smartphone dictation, remote EHR connectivity, and natural language processing (NLP) to extract structured data elements from narrative. Scribes are enjoying a new wave of popularity among clinicians who want to offload basic data entry and other non-medical tasks for completion in near real-time during patient encounters.
While the efficacy of scribes vs. transcriptionists is debatable, and seemingly a matter of individual physician preference, there are advantages to each but some serious risks to take into account.
Pro’s: Documentation captured and entered in the EHR in near real-time. Physicians gain more meaningful time with patients, and improve their own work-life balance when they can untether from their computers.
Cons: No certification or training standards. No background for understanding medical and legal issues. Hiring challenges such as expense and turnover. Risks associated with errors may affect patient safety.
Scribes can work onsite or remotely (virtual scribes). They may be in-house employees with the ensuing overhead of salaries, benefits, and training; or they may be provided by a staffing agency. Scribe companies charge an average of around $15/hour per scribe, and may require a long-term contract and/or setup fees. On the plus side, physicians who use scribes may be able to offer patients more undivided attention, see more patients on a daily basis, bill more accurately, and have a better work-life balance when they are able to reduce screen and typing time, and confidently hand off EHR-related charting tasks.
That confidence has to be individually earned and maintained however. Various organizations and commercial entities offer training and accreditation programs, but there is no standardized certification for scribes. A high school diploma may be all that is required, with limited formal training if any. It’s very unlikely that a typical scribe will have a background sufficient to understand the medical and legal issues associated with patient health information, after perfunctory (if any) training in HIPAA and OSHA compliance. On the other end of the spectrum are pre-med and other healthcare students who are initially better qualified but see the job as a temporary stepping stone to their real career goals, resulting in high (and expensive) turnover. Recruiting an existing in-house medical assistant for scribe duties avoids the longevity issue, but often to the detriment of normal office operations.
If the first challenge is finding and keeping competent scribes, the second is acclimating to their physical presence and effectively utilizing their strengths. Some patients will reject the idea of a third party in the examination room, and the physician must handle those encounters without a scribe, but typically, scribes develop a strong rapport with and closely shadow their physicians. Breaks and, certainly, longer absences then become a problem, so multiple scribes may be necessary.
Risks related to over-documentation, patient safety, and malpractice represent the greatest challenges associated with the use of scribes. Although virtual scribes sometimes work from recordings, most scribes enter data into the EHR during patient encounters, with some pre-encounter data gathering, and post-encounter notes-processing. Without a strong background in medical terminology or pharmacology, or experience in a clinical setting, scribes struggle to keep up with their physicians to do the best they can. A 2017 research study published in JMIR Medical Informatics, “Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study,”1 showed wide variability between scribes in accuracy and length of notes, reflecting errors of omission and commission (elements not present in the control note, and thus assumed inaccurate). While entries must be attested by the scribe and then the physician before inclusion in the official health record, the physician may be saving neither time nor money if close review and extensive corrections are needed. Scribes are prohibited by CMS and Joint Commission guidelines from ordering prescriptions, but they may enter an order pending final signoff by the physician. If serious errors are not caught, the physician’s liability and patient safety are at stake.
Pro’s: Extensive training in medical terminology and HIPAA compliance, and if relevant to their specialty, OSHA regulations. Standardized, accepted certification standards. Longevity of transcription as a career, not a stopgap. Most transcription is outsourced, reducing HR expenses and problems. Completeness and quality of notes. Physician’s full narrative captured from dictation to document the rich, nuanced patient health story. Automatic insertion into specific EHR sections reduces physicians’ keyboard and mouse usage. Accuracy easier to achieve because dictation is typed verbatim and reviewed by the doctor who will catch discrepancies between what was said and what was typed.
Cons: Documentation not accomplished real-time, although delay is minimal with typical 24hr or less, or optional STAT, turnaround. Other EHR-related clinical tasks are not performed, such as helping the doctor find previously stored information, or collecting pre-exam patient history in person.
Transcription is enjoying a resurgence as a response to the poor usability of most EHR systems. Doctors need to document extensively to meet government mandates and payer requirements, but they shouldn’t spend a disproportionate amount of time navigating the EHR with keyboard and mouse to accomplish clerical tasks that can be delegated to others. Transcriptionists, like scribes, fill the bill. Transcriptionists are less intrusive because they are not in the exam room during the patient encounter. Often they are not in-house at all; many work remotely under the auspices of a medical transcription service organization (MTSO) which charges the healthcare practitioner on a per-line or per-minute basis. No overhead, no HR headaches, no scheduling difficulties, non-impactful turnover if any. Transcriptionists choose their profession because they are detail-oriented medical language specialists who take pride in their role in the healthcare ecosystem by accurately and quickly transcribing doctor dictation for the primary purpose of patient care and for documentation in the EHR. While they may get to know a particular doctor by working with the doctor’s narrative style and learning frequently dictated phrases or prescribed drugs and tests over time, transcriptionists who demonstrate their excellence but never actually meet their doctors in person still become trusted, integral partners in the documentation process.
From a medical and legal standpoint, the use of transcriptionists may be less risky than using scribes. One, transcriptionists are generally better trained in medical terminology and thus apt to understand and transcribe exactly what the doctor says and means. (If they have questions, they can leave blanks or ask for clarification.) Two, transcriptionists’ responsibilities are limited to documenting encounters and reports as dictated. Transcriptionists do not also work independently in the EHR or support doctors with other aspects of patient engagement. They do not interpret a real-time doctor-patient interaction from their own perspective, which could result not only in individual variations (see above reference to the study, “Use of Simulation Based on an Electronic Health Records Environment ...” 1), but also in errors of omission or commission (elements not present in the control note, and thus assumed inaccurate).
Transcription in the 21st century is largely web-based, requiring sophisticated, ultra-secure technology for recorded and transcribed data in transmission and at rest. Patient safety is paramount; HIPAA and PHI breaches incur serious penalties, and EHRs have their own security issues to factor in. The days of an individual typing on an unsecured computer a report from a cassette and delivering a paper printout or file on CD are gone, not just because digital processing is more efficient, but also because it can be made more secure. A good cloud-based MTSO, with stringent, verifiable security protocols in place, as well as a rigorous quality assurance program, significantly reduces provider risk. A full and accurate transcript also affords protection against claim denials, inadvertent over-billing, and audits. To achieve these benefits and comply with government mandates for reporting and information exchange (interoperability), an MTSO must employ state-of-the-art technology that can interface with EHRs in order to extract and insert the requisite data from transcriptions into the correct EHR sections.
An MTSO that has invested in highly trained specialized transcriptionists, strict quality assurance measures, and state-of-the-art secure cloud-based technology should be considered the gold standard for producing accurate, complete, and compliant clinical documentation. Can a scribe ensure the same level of trust and results? Weigh the pro’s and cons carefully, and give one or both methods a try. The right answer is the one that works best for your practice.
1 Pranaat R, Mohan V, O'Reilly M, Hirsh M, McGrath K, Scholl G, Woodcock D, Gold JA. Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study. JMIR Med Inform 2017;5(3):e30.
DOI: 10.2196/medinform.7883. PMID: 28931497. PMCID: 5628287