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Thinking of using a scribe? What you need to know

25 January 2019 | Kate Gillman, BA, LLB, Head of the Medico-legal Advisory Service and Georgie Haysom, BSc LLB (Hons), LLM (Bioethics), GAICD, Head of Advocacy, Education and Research, Avant

Doctor burnout, higher patient volumes and electronic health records (EHR) adoption, has seen some Australian doctors follow a USA trend and turn to medical scribes to assist with administrative tasks.

In recent years, the use of scribes in the USA has increased in popularity. There are currently 20,000 scribes nationwide and by 2020, it is estimated there will be 100,000 scribes.1

Scribes can have many benefits including easing doctors’ administrative burden and increasing efficiency, doctor and patient satisfaction and income. A recent one-year crossover study published in JAMA Internal Medicine, including 18 primary care doctors randomised to three months with scribe assistance and three months without, found use of scribes was associated with less self-reported after-hours EHR documentation. Sixty-nine percent of doctors in non-scribed periods reported performing EHR documentation during the week and 77% on weekends. These rates decreased to 17% and 40% respectively, with a scribe.

Results showed scribe use was associated with a significantly higher perceived patient interaction time in office visits. Of the 735 patients surveyed, 61.2 % reported scribes had a positive bearing on their visits.

However, these benefits come with some potential risks. Our medico-legal experts outline some of the medico-legal issues associated with scribe use to enable you to make an informed decision.

Onsite and remote scribes

Scribes are typically medical students who have received training in privacy legislation, medical terminology and coding. They help doctors by performing administrative tasks including documenting patient information in EHR, consultations with other providers, discharge instructions and writing referral letters.

Onsite scribes accompany doctors on their shifts using mobile carts connected to the hospital EHR. Alternatively, remote scribes, who may sometimes be based overseas, connect with doctors via platforms including Voice over Internet Protocol connections and tablet, smartphone and computer video-conferencing applications. The scribe documents the consultation with the patient in real-time before the doctor reviews and approves it for inclusion in the EHR.

Use of scribes in Australia

While the use of scribes is relatively new in Australia, a few hospitals are using onsite scribes. A qualitative pilot study led by Melbourne’s Cabrini Health researchers, analysed the use of onsite scribes in its Emergency Department. The study involved interviews with 13 emergency physicians, 11 of whom had used scribes and two who declined to use them. The study concluded:

  • Scribes were most helpful in capturing initial consultations and completing discharge tasks.
  • Scribes captured more detail than most physicians, but editing was required for omissions, misunderstandings and rearranging information order.
  • All of the physicians who used scribes wanted to continue to use them and reported improvement in productivity, enjoyment at work, stress levels and the ability to multi-task.
  • Physicians who declined to use scribes felt uncomfortable with the concept of a constant observer and one thought complex nuances in consultations would be missed. They also felt that for them writing notes allowed “cognitive processing” and reinforced their memory of a patient.

Medico-legal issues to consider

Patient consent

If you decide to use a scribe, the patient must consent to the scribe being involved in their consultation. If a scribe is based overseas, under Australian Privacy Principle 8, patients generally need to consent to the disclosure of their information to the overseas location. Some patients may object to having a third party overseas transcribing their conversation. Therefore, it’s prudent to inform patients where the scribe is based and that they are recording a transcript of the consultation.

Medical records

Doctors have a responsibility to take reasonable care and skill in maintaining clear and accurate medical records that assist with the continuity of patient care. This includes complying with The Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia section on medical records. Good medical practice involves:

  1. Keeping accurate, up-to-date and legible records that report relevant details of clinical history and findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners.
  2. Ensuring your medical records are held securely and not subject to unauthorised access.
  3. Ensuring your records show respect for your patients and do not include demeaning or derogatory remarks.
  4. Ensuring the records are sufficient to facilitate continuity of patient care.
  5. Making records at the time of the events, or as soon as possible afterwards.
  6. Recognising patients’ right to access information contained in their records and facilitating that access.
  7. Promptly facilitating the transfer of health information when requested by the patient.

The notes also need to comply with Medicare’s requirements for MBS billings.

You are also required to take reasonable steps to protect health information from unauthorised access or disclosure. Therefore, you will be accountable to the patient and regulatory agencies if records are not properly stored and retained.

Privacy

Privacy and security are significant issues, particularly when using remote scribes. It’s important to check with the scribe service about the security of the connection and any records.

It’s also important to check what notification you will receive if the video/audio link is lost and what local support you can access if this happens.

Remote scribes

Use of remote scribes can pose some unique challenges. It’s important to check whether the scribe is trained in Australian privacy legislation.

Language and terminology differences may also impact the accuracy of the medical notes and result in having to spend longer correcting notes. Time differences are another consideration and could become an issue if you require remote scribes to perform additional follow-up work.

Liability for errors

When using scribes, you bear the responsibility for approving the medical notes. This means you are responsible if there is an error in the transcribed notes and this subsequently results in harm to the patient. This reinforces the need to be satisfied the scribe is properly trained in order to minimise the risk of errors.

Any claims made against you by patients and/or scribes in the USA will not be covered under your Avant policy.

Key lessons

  • Patients must consent to the use of a scribe and generally need to consent to the disclosure of their information overseas.
  • Carefully review and correct the medical records prepared by the scribe, as they will be deemed to be yours. You are responsible for ensuring the records accurately reflect the relevant aspects of the consultation.

It is not a defence to any future complaint or claim to say the records were prepared by a scribe and therefore do not accurately reflect the consultation.

More information

For more information on the APP 8 and cross-border disclosure of personal information, view the Office of the Australian Information Commissioner’s guidelines.

Read the article, ‘Five lessons for working with a scribe’ and an article by Dr Atul Gawande, a general and endocrine surgeon, Brigham and Women’s Hospital, Boston and a Harvard professor, on whether digitalization makes medical care easier and more efficient?

Reference

1JAMA.2015;313(13):1315-1316.

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