Friday, April 11, 2014

Medical Scribes, an Evolving Threat to Patient Privacy

by Joel Sherman MD


Medical scribes are a burgeoning field with many institutions and practices exploring their use while the many commercial enterprises who lease out scribes are pushing for their widespread acceptance.  There is no accepted definition of what scribes do or what their background or training should be.  There is no mechanism for licensure of them in any state.  They are poorly defined medical assistants.  The field is in its infancy and its ultimate role in our healthcare system is unclear.

The usual use of a medical scribe is to follow a provider around in their clinical tasks for the purpose of data entry.  This may or may not involve being present for the history and physical exam.  Most commonly they are physically present in the room and witness the entire encounter.  The need they fill is a function of our ever increasing mandates for electronic medical records (EMR).   Before EMRs, the use of data processors in examining rooms was quite rare.  Thus federal mandates have created another whole class of employees who are placed in the middle of health care interactions increasing the potential cost and complexity for all.   Some practices will clearly be tempted to use the scribes for as many uses as possible including assisting with minor procedures which I’ve seen advertised and acting as chaperones, which I know happens. This can help to ameliorate some of the extra cost involved in their employment.

The background of scribes is not standardized.  The minimum requirement appears to be competent data entry ability which translates into typing speed at a terminal.  Some advertisements require applicants to have a high school diploma or a year or two of college.  Many make no mention of education at all.  Some commercial sites train the scribe for a period varying from a few weeks to months.  At the high end, some advertisers require an existing knowledge of medical terminology with the preferred candidate being a medical student or premed student.  This is more often the case when the scribes are being used by academic institutions that have much greater access to people with these qualifications.  The majority of practices will not have access to premed or med students.  The scribes are mostly young and it is likely that few will choose this as a permanent career.  Thus they constantly have to train new ones.  The advertised pay rates vary from a minimum wage of about $8/hr up to about $20-25/hr.  The work may be full time but often is part time.

The touted benefits of scribes are to increase the efficiency of the practice by allowing the physician to see more patients while having a more personal interaction as they are freed from data entry.   It is advertised as a money saving strategy though a practice I discussed this with wasn’t at all sure that it saved money in their practice.  Scribes are a possible solution to the imposition of EMRs whose benefit to the patient and practice are frequently unclear or negative to begin with.  The dangers to patient privacy are clear but not often emphasized.  How much of a concern this is depends on the practice.  My ophthalmologist uses them without difficulty.  Few would object to an assistant hearing your ophthalmological history.  But many patients of general practitioners or internists would be inhibited from giving an intimate history by the presence of an assistant.  A few have the assistant outside the room for this perhaps making the patient more comfortable.  The presence of scribes during intimate physical exams is a further situation where many patients would be uncomfortable.  One article by urologists studied this and found no problems with acceptance, but the study had many caveats which the authors document[1].  This took place in an academic setting with medical students used as scribes.  The majority of the scribes were in fact men.  The one female urologist in the practice with a predominately female following refused to be part of the study.  I think the results would have been different in a urology practice in a private non academic setting where scribes were predominately young women without a medical background.   The routine use of opposite gender scribes would certainly make many patients uncomfortable in a private urology practice.  The most common use of scribes to date is in emergency departments where there are certainly many issues of patient privacy.  But in emergency settings patients are less likely to be concerned about their privacy.


The accuracy of scribes has not been studied to my knowledge.  The results would depend greatly on the background and training of the personnel.  But I do not see how anyone with a high school background and a few months of training could possibly understand all the medical conditions covered in a general practice.  The physician is responsible for signing off all records of course, but if the record is full of errors, it would be of limited use.  If premed or med students are being used, the results should be better, but this is partially mitigated by the fact that there would be immense turn over and new people would always need to be trained.

In summary, the routine use of scribes in a general practice has many potential problems of privacy and accuracy.   I don’t see how scribes without a medical background could ever be competent to understand a general medical history.  It would be far more accurate to have patients fill out detailed questionnaires on the initial visit and then have data entry performed on this later by scribes.  This would also permit a far greater feeling of patient privacy.   Patients have always understood that their medical records may be processed for administrative purposes.  The presence of scribes during intimate histories and exams should be very limited and only done with the express permission of the patient.  They should not be used as chaperones or multipurpose medical assistants without further special training.  In the long run the use of scribes is likely to be a temporary answer to a cumbersome system of mandated EMR which can still cause as many problems as it solves.  There is no intrinsic reason why EMRs need be so intrusive that their use requires a staff of intermediaries.  This makes it increasingly impossible for solo physicians and small groups to stay in practice.




[1] Koshy S et al, J. Urol. Vol 184, 258-262, July 2010.

This article has been re-published on KevinMD.com.

18 comments:

Anonymous said...

I know that scribes in many regards are being used
as chaperones which is in contrast to the intention
that a chaperone should be a partial observer. It
makes no sense to have a scribe present during
any intimate procedure. Furthermore as I recall a
chaperone should never be privy to the initial
history taking and this is exactly what scribes are
being used for. I have heard ed physicians refer
to scribes as their assistants, unethical and
unprofessional.

PT

Maurice Bernstein, M.D. said...

I agree. Scribes contribute nothing but foul up any proper doctor-patient relationship and foul up any true documentation of the facts of te history or physical by their own immediate interpretations of what was said and done. I am sure that inspection of what was documented later by the physician does nothing much to establish reliability regarding the documentation. ..Maurice.

StayingFit said...

NPR did a story on medical scribes today. They only devoted one sentence to the issue of privacy, which surprises me a bit, since it is the first thing that I thought of when I first heard about scribes. Also, I noticed that at least one person in the comments section was adamantly opposed to the presence of a scribe.

Unfortunately, a lot of people seemed to be just fine with the concept. Of course, those people may change their minds when they are faced with this in real life.

Also, no one has brought up the gender issue yet. I suppose that is predictable, given the listener demographics for NPR.

There are a lot of comments already, and the number keeps growing. Here is the story.

Joel Sherman MD said...

Thanks. The subject is very topical right now. The Wall Street Journal has also published a recent story. Much of this is a coordinated commercial push. But there is a need to lighten the always increasing burden on physicians. Best cure would be to do away with all EMR and ICD mandates until they come up with a system that is easy to use AND time saving.
My article should soon be published elsewhere.

Doug Capra said...

Here's an interesting NPR piece about scribes.

http://www.npr.org/blogs/health/2014/04/21/303406306/scribes-are-back-helping-doctors-tackle-electronic-medical-records?utm_medium=facebook&utm_source=npr&utm_campaign=nprnews&utm_content=03032014

And here's the comment I added to the article:

People are different and have different views of privacy, respect and modesty. Some people may not mind scribes in the room even for the most personal exams. Others might. Both types of patients have the right to their personal views of privacy. Very clear and specific policies need to be created about scribes.
-- Who can become scribes and what training do they need? Right now most hospitals are turning over all this to agencies and basically putting control of all this into profit-making organizations. Medical or nursing students as scribes are one thing. Minimum wage non medical professionals are quite another.
-- Under what specific conditions can scribes be used and under what specific conditions will they NOT be used.
-- The use of scribes MUST be acknowledged to patients and patient permission MUST be obtained to have a scribe in the room. Scribes must be identified as scribes, not as "This is Joe who will be working with me today."
-- If patients agree to a scribes, the scribe MUST be introduced to the patient. Scribes are not flies on the wall -- the are an extra set of eyes in the room. They are not potted plants. They represent another observer.
-- Scribes are NOT chaperones and should not be used as such. If they are, the patient should be clearly informed of this and permissions obtained.
These are just a few of the issues that must be addressed in policies about scribes. And hospitals should obtain patient input in creating these policies.
Scribes can be useful under the right conditions. But patients have a right to refuse scribes. And this isn't just about what's convenient for hospitals. Patient privacy, modesty and comfort concerns are just as important and need to be regarded as such.

ray said...

In the photo we see a male scribe and a female patient. I don`t know anything about the use of scribes in the US (fortunately, they don`t seem to exist in Germany), but I would be very surprised if this wasn't another field dominated by females which is another blow to male patients' privacy.

GaryM said...

Dr Sherman,

I agree that the use of scribes is an affront to patient privacy and can interfere with open and honest communication between doctor and patient. But I have another question that I hope is not too off topic regarding this particular post.

It is one thing to introduce chaperones, scribes and assistants into a medical exam/setting which infringes on the patient's right to privacy. However, I have recently come across some disturbing information where medical care providers (think doctors and nurses) are concerned that is appalling enough even without the introduction of chaperones, assistants and scribes.

The medical profession has long been associated with morals, mercy, and other good character traits and qualities. That's why when a doctor, nurse or any medical care giver acts in ways that are considered unethical, immoral, or just plain illegal, we as a society gasp as if to say "How can that be? They are "professionals."

Dr Sherman, you may remember some of my posts where I spoke at length about the chaperone issue.

I know that doctors and nurses are people, too. And as individuals their life outside of the hospital is their own business as long as it doesn't interfere with their duties and their ability to do their job while at their places of employment.

What surprises me is the seemingly high use of pornography and lewd behavior among medical personnel.

While I believe that behavior can be compartmentalized, a person's morals and their conscience cannot. And eventually what is on the inside will come to the outside.

I get it that medical professionals are taught to de-sexualize the nudity that they see--even objectify it so as not to look upon the patient in a sexual way but in a "clinical" way.

A good question would be. "how can a medical professional imbibe pornography and all of the attendant consequences, and then go to work and see patients in their nakedness and treat in a totally clinical way?"

I understand that context plays a big role but I find it hard to believe that a nurse, for instance, can look at sexually-charged nude images off the clock and then magically transform themselves into an angel of mercy who has a totally clinical view of nudity as soon as they walk into the hospital.

Wouldn't the viewing of porn make them more likely to sexualize any encounter at the hospital instead of the opposite?

I have read where a husband and wife nurse team were fired for operating a porn web site which featured nude images of the wife and some of the husband, They said it was only to make a little extra money on the side. They stated that nursing was their chosen profession. But how could they even view nudity in a clinical context when they participate in this kind of activity? If they do not value their own modesty and privacy, how could they value the modesty and privacy of a patient?

Also, I came across posts where nurses were uploading nude pictures of themselves at their places of employment. Again, how can these people be trusted to view our nudity professionally when they don't even have a high regard for their own?

Anonymous said...

GaryM

Where did you read that "medical professionals" are taught to desexualize the nudity? I have never seen it written, nor have I ever heard it said. Are you assuming it's just picked up via the curriculum.

I know of a radiologist who went to prison for
5 years for money laundering and being a pimp. After
prison his probation was that he could not step into
a strip club for 3 years. Personally, I doubt even the
judge thought this condition of his probation would
ever quell his thirst for porn.

I have seen full nude foldouts from playgirl
magazine posted in the female nurses restroom
of an intensive care unit. Apparently, they were
never taught to "desexualize" nudity of their male
patients since it was so important that they needed
to see this at work.

PT

GaryM said...

Hi PT,

I've enjoyed your contributions to the modesty discussion. Thanks for replying here...

I saw somewhere (forgive me as there are so many places I have visited online) where a blogger--maybe Doug Capra--I can't be sure, said that the nurses and doctors are taught to look at clinical nudity in a nonsexual way--or at least they learn to deal with it so they are comfortable in doing their jobs. Even so as to objectify the patient for the sake of boundaries.

I believe Doug Capra said something to this effect on his blog posting about "Not Just Bodies" article.

I know many nurses who have a "seen one seen em all" view of body parts. And I do believe that most medical personnel are desensitized to a lot of the nudity that they see otherwise they would have a difficult time of doing their job and behaving themselves.

Here is a quote from that blog article I spoke about... it's entitled DEAR DOCTOR AND NURSE: WE’RE NOT JUST BODIES

By Doug Capra © 2010


"But -- the big difference between these medical professionals and most patients is the years of experience they have had dealing with naked bodies. Nudity becomes routine to them. They may still have the feelings and attitudes they began their professional experience with, but the report “Not Just Bodies” found that “With few exceptions, the men and women in this study reported that they were uncomfortable performing examinations in the early part of their training but that they became more comfortable as they progressed through their careers.” The report goes on: “Several physicians and nurses noted that they ‘see 20 patients a day and everybody looks the same’ and that they ‘have been doing this for so long’ that they never get uncomfortable.”

This was my point by using the word "de-sexualize" to refer to how they view the nudity in a clinical setting.

I am not so naive so as to think that some nurses and doctors still let their minds wander and their behavior suffer and they do unprofessional things.

I just don't understand how the ones that do continue to do their job in a seemingly professional manner while living a sort of "double life" outside their places of employment.

GaryM said...

PT,

One more thing...

There are instances where nurses and doctors have behaved unprofessionally.

We know this.

And as taken back as I was to learn what some of these people have done and still do both in and outside of their places of employment (Activities you would not normally associate with someone in medicine), I wasn't really surprised after all. They are fallible people, and anywhere you have people, you have the potential for problems.

Even in the medical arena...

With all that I have said and observed I still believe it is wrong to take the few examples of bad behavior and paint the whole profession with a broad brush.

I still want to believe most professionals view themselves as such, and really want to make a difference in the lives of their patients. And do their jobs professionally with respect to the patient.

While we can advocate for equal treatment for both genders to protect privacy as has been advocated by Dr Sherman and others, until the hiring practices and logistics are worked out to reflect this change, we are stuck with the current state of things.

Like Dr Sherman, I do not have a problem with exposure to any medical professional--be they male or female, doctor, nurse or technician--as long as said personnel are an integral part of my healthcare (not just an observer), respect my dignity and privacy as a patient, and behave in a professional manner.

Even with all I have discovered, I still will approach my medical care the same as I have always done.

I will always trust the nurse/doctor who greets me for a procedure or whatever, and give them the benefit of the doubt as to their training, professionalism and such like.

In the end, as patients, all we can ask is to be treated with dignity and our privacy respected. As patients, we should, in turn, respect our medical provider.

We as patients do not and cannot know what is in a medical provider's heart. Nor the kinds of activities they are into outside their places of employment. Nor do we know their moral character.

All we can do is ask for the basic common courtesies expected of the medical profession and, assuming we get them, we can consider our visit and our medical care as adequate and acceptable.

Other than this, what else can a person ask for? You can't change a person's heart/character; you CAN ask that their behavior reflect professionalism and that they conduct themselves according to the law and the guidelines established by the various medical licensing boards, etc.

Anonymous said...

GaryM

Nowhere in nursing curriculum is there a
class offered called looking at clinical nudity in a
non-sexual way. There is no such class offered
to pre-med students or med students nor to any
health care employee for that matter. If there were
wouldn't you think patients wouldn't mind if males
in this country performed mammography. The
female healthcare industry ensured no males
work in that industry. Why? They don't want males
looking at them like they look at their male patients.

Same scenario in L & D, female patients were
never asked about the gender makeup, hospital
department directors assured this. I'm sure if you
worked in healthcare you would have a different
perspective on this subject and by the way Gary,
if you are so positive of the all encompassing
professional behavior of everyone in healthcare,
then why are you posting on this site.

PT

M Banterings said...

Good points, everybody.

Here is a solution: Wit all the cell phone, bluetooth, and wireless technology today, why can't the provider simply wear a headset that wirelessly connects to a scribe in another location in the facility?

The scribe does not need to see anything. This preserves privacy and dignity.

What will change this will be when scribes start to secretly video record attractive patients or situations that may be awkward and may have the potential for humor to some. Once these begin showing up on the internet, then change will come (eventually).

For many years I have proposed that providers be in the same state of exposure as the patients because procedures and protocols would be radically different.

-- Banterings

Deborah said...

Why aren't more medical transcriptionists who are being phased out by EMR being hired as scribes? They are familiar with anatomy, medications, medical conditions, etc. and are more familiar entering such data than doctors, nurses, etc. They also understand HIPAA and confidentiality. They could sit with their back to the patient for patient privacy, with the doctor speaking just loud enough that the scribe can hear what to enter, sort of a "live" dictation.

Joel Sherman MD said...

I don't really have any data on that question. Do you know how many transcriptionists have lost their jobs due to the change over to EMR?

Joel Sherman MD said...

Here's a brief joint commission statement on scribes:
JCAH guidelines on scribes

dartmusic said...

For the first time, I experienced medical scribes at an appointment earlier this month with a dermatologist. I was stunned that two girls were admitted to the exam room, with laptops, and who remained for the entire appointment. When they entered behind the doctor, he said quickly, "I hope this is ok?" but it wasn't presented as a question requiring an answer. I frowned and said "Well.." but should have been much clearer and more specific, because they just sat down and began typing.
I have psoriasis on my arm and leg and even though these are not considered intimate areas, I found the presence of these two girls extremely off-putting and my entire interaction with the doctor was quite different than it would have been with the doctor alone.
I'm interested to learn that the patient can object to the presence of a scribe (why I had two, I have no idea). I'll be objecting at the next appointment.
I understand how valuable a scribe is to a physician but, as a patient, I intensely dislike the practice.

Biker in Vermont said...

I came across this blog and in reading the comments I did go to the NPR article that StayingFit posted on 4/21/14. In the discussion that followed in the comments area, supporters of scribes kept trying to emphasize their training and how scribes are bound of HIPAA etc. Maybe if they are medical students or working towards being a medical student they would have incentive to take HIPAA seriously, but if they just did a quick training because they needed a job I'm not convinced they'd take it seriously in the manner that say a doctor or RN who have a lot to lose would. I'm not saying they'd divulge patient info either, just that not all scribes have a whole lot to lose if they aren't confidential.

What gives me pause here is that a few years ago I was in the emergency room of the local hospital because I had very carelessly cut a finger badly while working outside. I was kind of embarrassed for having been so stupid and wasn't planning on saying anything at work. The next day I go to work and one of my friends knew I been in the emergency room and what I had done. I hadn't seen anyone in the emergency room that I knew but clearly one of the staff made a connection and quickly blabbed about my visit. Not all medical "professionals" take HIPAA seriously, and scribes aren't even at that level.

The privacy issue for me is both my unclothed body and what is discussed with the doctor.

Anonymous said...

My husband and I were first introduced to a scribe in ER with him. No introduction, no consent. Just thrown there. Bad. We had no idea who this person was. I then was exposed to a scribe when visiting my clinic on my doctors request to see an specialist. Again no permission, no consent, no introductioneed. On my part no talking about what my doctor wanted me seen for. Next time for my husband and I for gastroenterology. Neither of us told pro less we were having except what our doctor sent us for. So he is not having endoscopy and I am not having colonoscopy. As if either of us want to go ahead with either side cell in our area our request for same gender caregivers falls on deaf ears. When I told the one office no scribe no observers I was told he had to have a scribe by law. They have no education and are secretaries. The problem with our countryou pertaining to our health care is 1. Doctors who are trained to the hilt being given replaced but PASS and NPS, Nurses are being replaced by off the street trained (?) Cna'so and ma'staff. We do not have quality care and no rights anymore. Men have no chance and would enjoy either.