The rise of the medical scribe industry: implications for the advancement of electronic health records.

With federal meaningful-use incentives driving adoption of electronic health records (EHRs), physicians are increasingly concerned about the time spent documenting patient information and managing orders via computerized patient order entry (CPOE). Many perceive that the inefficiencies of EHRs are adversely affecting the quality of care, and because physicians see fewer patients per day, income may decline.1 Although physicians approve of EHRs in concept and appreciate their future promise, the current state of EHR technology has increased physician dissatisfaction.1 Poor EHR usability, time-consuming data entry, reduced patient care time, inability to exchange health information, and templated notes are central concerns. Physicians emphasize that EHR technology—especially user interfaces— must improve,1 and a new industry has emerged nationally to provide physicians with medical scribes. Use of medical scribes—unlicensed individuals hired to enter information into the EHR under clinician supervision—has increased substantially.2 Scribes reportedly enable physicians to see more patients; generate more revenue; and improve productivity, efficiency, accuracy of clinical documentation and billing, and patient satisfaction.2 At least 22 companies provide scribe services across 44 states (eTable in the Supplement). Organizations, mostly scribe service vendors, train and certify scribes, and there are dedicated medical scribe training programs. The American College of Medical Scribe Specialists (ACMSS), a tax-exempt nonprofit organization representing more than 3000 scribes and 300 hospitals nationwide, offers a Medical Scribe Certification and Aptitude Test (MSCAT) for certification and publishes the Medical Scribe Journal.3 Certification requires that candidates pass a 90-day employment probation period and record 200 hours of clinical work.3 The ACMSS, according to its executive director, “protects the medical scribe industry.”3 The organization’s president envisions ACMSS as a “brain lab...where companies can come together to work on national scribing standards and lobby regulators on behalf of the industry.”3 The ACMSS, whose leading financial sponsor is ScribeAmerica,4 states on its web page that “the process of selecting a potential Certified Medical Scribe is complex” and that “ACMSS provides the groundwork for excellence throughout the industry.” Yet it also stipulates that “minimum requirements include a high school diploma or G.E.D. [and that] each company sets their [sic] own criteria for hiring and selection process.”3 ScribeAmerica’s training program involves a 2-week orientation, a supervisory period under a “highly experienced” medical scribe, and periodic reassessment of the scribe’s effectiveness.4 PhysAssist Scribes emphasizes that “great scribes aren’t just born—they’re made,” so it established a “scribe university...a five-day training program unlike any other in the industry.”5 PhysAssist was recently acquired by TeamHealth, one of the nation’s largest providers of hospital-based clinical outsourcing. Estimates on growth of the medical scribe industry, its constituent companies, or of its principal service are anecdotal. No agency of state or federal government currently monitors—or regulates—the growth or activities of this new health care industry. Many smaller local companies either do not have websites or advertise only as medical staffing agencies. The 22 companies listed in the eTable (in the Supplement), likely an underestimate of the industry’s breadth, offer services in 1058 locations. The chief executive officer of ScribeAmerica, the largest US scribe company, estimates that 10 000 scribes are working in hospitals and medical practices around the country.6 According to the ACMSS, the number of medical scribes has been doubling annually, with about 20 000 expected to be working by the end of 2014.7 The industry “expects [its] ranks to swell to 100,000 by 2020.”7 If accurate, in 6 years, there will be 1 medical scribe for every 9 physicians in the country. One company, Medical Scribe Systems, currently operates in 100 hospitals nationwide and employs more than 2000 scribes.8 The company was cited by Inc. magazine as one of the fastest growing private companies in the United States in 2014.8 ScribeAmerica is purportedly the most successful US medical scribe company, with more than 5000 scribes in more than 570 health care facilities across 44 states.4 The Joint Commission neither endorses nor prohibits the use of scribes, noting that scribes may not act independently when documenting dictation or other activities determined by a physician. Although scribes can assist practitioners with EHR navigation, retrieval of diagnostic results, documentation, and coding, allowing scribes to enter orders in the patient’s electronic record is prohibited “due to the additional risk added to the process.”9 The Centers for Medicare & Medicaid Services stated, “We disagree ... that anyone should be allowed to enter orders using CPOE. This potentially removes the possibility of clinical decision support and advance interaction alerts being presented to someone with clinical judgment, which negates many of the benefits of CPOE.”10 With problems associated with EHRs so substantial— and physicians’ experiences using medical scribes so positive—are there any risks engendered by the rise of a medical scribe industry and its potential for becoming inVIEWPOINT