Medical scribes lack consensus on training, certification

Certification of medical scribes does not satisfy concerns about whether scribes should be allowed to use computerized order entry as part of the meaningful-use program for electronic health records, the federal government says.

Meanwhile, the growing medical scribe industry has yet to come together on a single broadly accepted training and certification process, though industry leaders say they will eventually do so.

In a response to comments about who is qualified to use computerized physician order entry, or CPOE—a Stage 2 requirement under the American Recovery and Reinvestment Act's EHR incentive program—federal rule writers said CPOE users should not be medical scribes, partly because “as there is no licensing or credentialing of scribes, there is no guarantee of their qualifications.”

“The healthcare community is very conflicted over who should do computerized provider order entry,” said Peter Ashkenaz, spokesman for HHS' Office of National Coordinator for Health Information Technology. “We received many public comments that only the ordering provider should be entering the order into the EHR just as we received many comments that it didn't matter at all who entered the order into the EHR,” he said.

“We also received many comments supporting only licensed healthcare professionals and other comments supporting our current policy of licensed healthcare professionals plus credentialed medical assistants.”

A first stab at a national scribe-certification program has been attempted by the American College of Clinical Information Managers, based in Irvine, Calif., which has tested about 300 medical scribes and certified about 250, said Kristin Hagen, ACCIM executive director. The organization was founded in November 2010 by ScribeAmerica, Aventura, Fla., a medical scribe provider.

The testing and certification program was launched in February 2012 and the first scribe received certification in April 2012, Hagen said.

“ACCIM is a relatively new organization pioneering the credentialing of scribes,” Ashkenaz said. Certification is a “first step to establishing a scope of practice for scribes” and that will “go a long way to giving us the information necessary to evaluate in the future whether their established scope of practice includes the ability to evaluate clinical decision support and/or accurately convey clinical decision support interventions to the ordering provider,” he said.

The use of scribes is growing throughout the healthcare industry, as physicians outside of hospital emergency departments, where scribes were first deployed, look to scribes as a means to regain speed and restore bedside manners lost to the advent and distractions of EHR systems.

The ACCIM offers a training manual and study guide, but doesn't operate training programs. It focuses instead on recruiting certified academic partners—training organizations that have submitted curricula for ACCIM approval and provide training, Hagen said.

Three partners are signed up—American Healthcare Documentation Professionals Group, Shrewsbury, Mass.; and Medical Document Services, Wichita, Kansas; both medical transcription service and online training organizations; and Trident Technical College, a 17,000-student community college in North Charleston, S.C. More schools are “in the pipeline,” she said.

Dr. Luis Moreno, cofounder and president of ScribeAmerica and cofounder and president of ACCIM, said the testing and certification program was launched in response to rapid growth in the number of companies offering scribe services, compounded by concerns over variations in industry practices. Moreno said he and his partner, ScribeAmerica CEO and ACCIM Vice President Dr. Michael Murphy, worried their company might be “lumped in the same bucket” as others that didn't share their values.

“One thing that we heard was that a scribe would enter a room by themselves without the accompaniment of a doctor, which is an inappropriate use of scribes,” said Moreno, who is board certified in emergency medicine. “We felt when you start to separate the scribe from the doctor, that's when you're going to run into the ground.”

“We can't go to the other companies and tell them what to do,” Moreno said. But certification and promotion of minimum performance standards was a way to differentiate both scribes and the companies that employ them, he said.

In addition to training, candidates for certification must have 200 hours of relevant experience and must pass a 90-minute Medical Scribe Certification and Aptitude Test, covering knowledge of medical terminology, technical spelling, how a physician-patient encounter is documented, risk mitigation and compliance with the federal privacy and security rules under the Health Insurance Portability and Accountability Act and other requirements. Certification also obliges scribes “to sign affidavits that they work the minimum number of hours and they work a certain way,” Moreno said.

Because the ACCIM was founded by a scribe company, there has been skepticism among competing scribe services providers, he said. So far, Moreno said, “none of our competitors in the scribe vendor market have trusted that the nonprofit is really at arm's length from ScribeAmerica.” But he said the founders have promised to hold open elections for the organization's board of directors and are optimistic that skepticism will abate.

“It does take a lot of time and it does seem like we're carrying the torch by ourselves,” Moreno said. But “it is a torch that needs to be carried. We hope to see it be a voice for the industry.”

The organization is changing its name to the American College of Medical Scribe Specialists to better reflect its purpose, Moreno said.

“It's a new industry that's discovering itself and evolving every year,” said Dr. Kathleen Myers, founder and CEO of ScribeSTAT, a Portland, Ore.-based scribe services provider. “It takes a while to develop a standardized body of knowledge.”

Each company has its own training program, Myers said. “Our training evolves every single year.”

Working together as an industry to develop a consensus on training and certification “sounds like a good concept,” Myers said. One of the stumbling blocks with the ACCIM has been cost, she said.

“There was a substantial fee to join the organization and that buys a board seat,” Myers said. “That's why nobody joined. I think we will get there as an industry and develop a national standardizing body, but we're not there yet.”

Regarding scribes and order entry, Moreno said the Joint Commission in 2010 first recognized scribes in a guidance and said it was OK for scribes to enter orders. But in 2012, the commission reversed itself and said scribes entering orders is not a supported function, he said.

Some EHR systems enable scribes to log in and access a limited set of functions, while locking them out of CPOE, with clinical decision supports—such as drug allergy warnings—firing only for the clinician.

At least one EHR developer allows scribes to enter pending orders. But in that system, it is the scribe who sees the CDS support prompt or alert, not the physician who reviews and completes the order, Moreno said.

Moreno said he believes EHRs should allow scribes to create pending orders and receive alerts, but any orders entered up by scribes must be confirmed by a physician, who also should receive any alerts or other CDS information.

“The vendor would develop into their systems pending functions—not all of them have pending functions (today)—and add double alert functions, where it would happen at the pending phase and the execution phase,” Moreno said. “That would be the ideal solution.”

Follow Joseph Conn on Twitter: @MHJConn