AHDI Series: "Let's Talk About...Medical Scribes"

Recently TRSi partnered with ScribeAmerica to jointly form an online distance learning educational training program for the allied healthcare documentation sector.  The partnership is an industry's first, complimenting the greater healthcare system in tandem with other healthcare professionals.  I have included some common questions and answers to better understand the quickly emerging and developing career opportunity geared to evolving and transitioning medical transcriptionists, pre-medical students, seekers of second careers, the unemployed, and those interested in working clinically alongside a physician through the mainstream of healthcare. You will see a preview into this growing career field.  Enclosed is the open letter, "Let's Talk About...Medical Scribes," authored by myself.

What is the background of a medical scribe?

Scribes have been around since the early biblical days. Today scribes are commonly referred to as Clinical Information Managers. The primary function of a scribe is the creation and maintenance of the patient’s medical record, which is created under the supervision of the attending physician. The scribe documents the patient’s history and story through the physician’s interaction with the patient, procedures performed, the results of laboratory studies, and other ancillary information gathered at the point of care. Scribes follow the workflow of the patient(s) under the direct care of the physician.

What are current scribing trends and models?

Medical scribes have commonly been deployed into emergency departments to provide real-time supportive services to busy emergency room physicians by documenting clinical patient encounters as they occur through direct data entry into the EHR. They serve as a right hand to the ER physician in capturing the care encounter while also coordinating the presentation of diagnostic data to assist the physician with clinical decision-making.

There are various levels of scribe training programs from local to national organizations, designed to create efficiencies within the US healthcare system. The demand has traditionally been filled with eager pre-medical students, learning first-hand about the workflow patterns and patient care they will deliver in the future. As a medical scribe, the role is focused on creating comprehensive and complete medical records and eliminating some duplication of tests. The base education has been set around medical scenarios, case management, disease processes, medical terminology, anatomy and physiology, coding, and other biological processes. Scribes are pre-screened for the selection process.

What are the skill set requirements and training required to become a medical scribe?

Medical scribes may be trained on site or through affordable online distance education programs. Skill sets include strong English grammar, a compelling interest in healthcare and patient improvement, a strong desire to work in a clinical setting, superior analytical and resource skills, understanding and training in enabling technologies (with computer and keyboarding skills), an understanding of information workflow, attention to detail, keen listening skills, and strong multi-tasking abilities. A scribe, by design, is a self-starter who works well in a variety of different settings and paces and follows directions well. The medical scribe is the physician’s assistant and is continuously utilizing a strategic thought process. The individual also has a desire to work within a team of allied healthcare personnel. Together the physician and the scribe partner to create a comprehensive and meaningful care encounter record. Scribes are also expected to be well-versed in HIPAA and regulatory compliance, and like MTs, scribes have a steep learning curve, with clinical shadowing required in the post training phase.

How does medical scribing connect to the broader documentation spectrum and other health information management (HIM) roles?

Medical scribes are a central liaison within any healthcare facility, surgical center, or emergency department. They uniquely interact and collaborate with other members of the healthcare team, tracking patient information, including ancillary departments of laboratory and radiology departments. Medical scribes adapt to technological needs of the facility, understand the basis of electronic record systems, coding practices and levels, medical decision-making, and the disposition of the patient. Medical scribes fill a need identified by market demands. Physicians focus on the patient, documentation is tracked and delivered in real time, and documentation is available at the point of care, as defined by our healthcare system.

Could this be a stepping stone for medical transcriptionists and others in the medical transcription field? Is this an alternate career path for medical transcriptionists?

There are similarities and distinct differences between medical transcriptionist and medical scribes, as are there in comparing these roles with any other health information management role. Just as medical scribes would need additional training to transition to the unique application of a traditional transcription skill, with some additional training in specialized applications, medical transcriptionists would also be uniquely qualified to fill the roles open in the emerging and growing field of scribes. One thing is certain. National mandates and incentives will increase the adoption of electronic medical records. Healthcare will need professionals who have a flexible resume of contributory skills applicable to an EHR-centric documentation setting. Scribing is a potential alternate documentation setting for medical transcriptionists. All allied healthcare personnel and career fields will continue to adapt, evolve, and emerge alongside medical transcriptionists, medical insurance specialists, health information managers, medical informatics, and other quality documentation analysts to blend roles and skill sets forming a sophisticated electronic network globally. Like all medical professions, continuing education is imperative for the well-being of the allied healthcare system.

Similar to medical transcription, medical scribing provides another career pathway, or stepping stone, to the broader healthcare system. Utilizing knowledge and skill sets through a variety of roles, the medical scribe is focused clinically, observing the patient’s encounter, documenting alongside a team on site under the physician’s care. Healthcare career opportunities are anticipated to grow, and these career fields offer a springboarding opportunity to other roles, as desired. The market will continue to adapt, evolve, and innovate, and we need to be prepared to do the same.

As a close observer of the scribe profession through new training programs, I can tell you that transcribing and scribing are neither competing nor complementary. They are quite unique, with some overlapping fundamental training but with divergent connection to technology and practical application. They are simply two of many current and evolving roles for those who desire a role in documenting healthcare encounters. It’s a matter of choice and options – and depend greatly on the individual in terms of personal choice for role, setting, and training.

The AHDI Lounge has setup a place for positive discussion and welcomes all to attend the Town Hall series to discuss emerging roles and other top-of-the-mind industry topics in greater detail.