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In Practice
Neurologists Rewrite the Script on EHR as Medical Scribes Step In



MORE THAN 17,000 scribes are working in some 1,800 medical institutions, and more than 20 companies are currently training and placing scribes in physician offices.

Some neurology practices are using medical scribes to record and document data from patient visits into electronic medical records. Practice managers say that having scribes enables neurologists to interact more with their patients and maintain more normal work hours.

Since Waleed El-Feky, MD, a partner in Texas Neurology in Dallas, began using a medical scribe last June, he said he has increased his efficiency because he spends so much less time working in the practice's electronic health record (EHR) system.

More importantly, he is talking with patients face-to-face rather than typing at a keyboard while they discuss their symptoms.

“This gives me a much better interaction with the patients and improves the overall patient relationship because they are getting all my attention,” said Dr. El-Feky, director of the Texas Neurology Sleep Disorders Center.

Dr. El-Feky is one of an increasing number of neurologists who are turning to medical scribes to help offset the burdens associated with entering data into EHRs, capturing an increasing amount of information needed for quality measurement, and documenting patient visits with a high level of specificity to support the ICD-10 coding system.

Medical scribes enter information into the EHR under the direction of a physician or other licensed clinician. The scribe industry has emerged as EHRs have become ubiquitous in medical practice, requiring an ever-growing amount of detailed data entry that was uncommon a decade ago.

The American College of Medical Scribe Specialists, a non-profit professional society, represents more than 17,000 scribes working in some 1,800 medical institutions, and more than 20 companies are currently training and placing scribes in physician offices. The largest of these companies — ScribeAmerica — has been recognized on Inc. magazine's list of America's fastest-growing private companies for each of the past six years.

That likely reflects physicians' growing frustration with changing documentation standards and the cumbersome nature of EHR technology.


Dent Neurologic Institute, a practice of about 65 neurologists and mid-level providers based in Buffalo, NY, experimented with scribes about four years ago and determined that their services were not useful enough to continue.

“Back then, the perspective was that the role of the neurologist in documentation is to use their expertise to pull together all sorts of facts and turn that into a gestalt that fully represents what's going on with this patient,” said Joseph V. Fritz, PhD, the Institute's chief executive officer. “A scribe in neurology is not able to do that type of formulation, and just collecting the pieces of information and getting them entered did not seem helpful enough.”

But a lot has changed in four years, including Dent Institute's participation in the Academy's Axon clinical quality registry. That involves pulling data from EHR systems and entering those data points consistently so they can be pulled into the registry, allowing a physician's or a practice's performance to be tracked longitudinally and benchmarked against others.


DR. WALEED EL-FEKY said he is talking with patients face-to-face rather than typing at a keyboard while they discuss their symptoms. “This gives me a much better interaction with the patients and improves the overall patient relationship because they are getting all my attention.”

Participation in the registry is why Dent Institute will experiment with medical scribes again in 2017. “With the need for the more structured detail required in the documentation, this really becomes attractive again,” Dr. Fritz said.


Noran Neurological Clinic, a Minneapolis practice with 58 neurologists and mid-level providers, hired a medical scribe about seven years ago to support a physician who was having trouble keeping up with documentation. Since then, five other neurologists have followed suit.

That includes a young physician who had the opportunity to use his partner's scribe when the partner was out of the office for a month.

“He realized that he was more productive enough to pay for the scribe while also making his life less complicated so he could get home at night,” said Brad Montgomery, the practice's chief executive officer. “My guess is we'll have another couple physicians start using a scribe over the next year.”

As in most medical practices, the physician who uses a scribe is responsible for paying that person's salary and benefits. Each scribe's duties vary a bit, based on the physician's preferences, but the basic task is to prepare each patient's EHR chart before an appointment by verifying that all information is current and to use an appointment template during the visit to enter information as directed by the physician.

“The scribe sits in on the appointment with the patient and the doctor and, at the end, the physician reviews the notes and signs the record,” Montgomery said.

Raleigh Neurology Associates, a 28-physician practice in Raleigh, NC, has used medical scribes for more than three years. Currently, about 10 physicians are employing scribes, said Steve Smith, the practice's chief executive officer.

The practice pays $12 an hour to start with a raise to $14 an hour in the second year. At that rate, a neurologist needs to see an average of 1.2 more patients per day to break even.

The efficiency gained by using a medical scribe makes that doable, and dramatically improves the quality of life for physicians who get overwhelmed with documentation duties. Smith noted that one of his doctors used to stay at the office until 7:30 pm and continue working on charts at home later in the evening.

“Now she's leaving at 5:30 every night, completely done,” he said.

Indeed, most of the neurologists in the group practice who use scribes are able to answer their phone calls during the workday rather than using every spare moment to enter documentation into the EHR and returning calls in the evening. Moreover, the service has increased patient satisfaction, Smith said.

“We didn't have scribes the first couple of years after we started with the electronic medical record system, and since we hired them, many patients have remarked, ‘I like you better with that person in the room because you're looking at me,’” he said.


Most medical scribes are current students or recent graduates who are waiting to be admitted to medical school, a physician assistant program, or another higher education for a career in medicine.

Dr. El-Feky's first scribe had recently completed a bachelor's degree in neuroscience, and she recruited another scribe who is in the last year of her degree program.

“They are already very fluent in medical terminology because that is what they study at school, so the training for this is very easy for them,” he said.

Meanwhile, the students and recent grads think the experience helps their applications for medical school, Montgomery said.

“They are highly motivated to learn and very excited to be in a physician practice,” Montgomery said.

And the on-the-job experience helps the scribes that move on to medical school.

“They already know how to conduct a medical exam, for example,” Smith said. “When they come back to visit, they tell us that, for the first six months of medical school, they are ahead of everyone else.”


Scribes are not right for all neurologists, so they should only be used if the physician is enthusiastic about the benefits.

“The scribe becomes your shadow in a way,” El-Feky said. “So this is not for someone who is bothered by another person following you all over the place.”

Matching the right scribe with the right physician is the key to success with medical scribes, in Smith's view.

“They have to be able to communicate very well together,” he said. “You can't just hire the smartest people and hope that it works. You've got to match up personalities.”


Among other strategies, El-Feky recommends fine-tuning a visit template that allows the scribe to easily capture information in the right format and train the scribe thoroughly. “You really need to spend plenty of time to make sure that that scribe is writing exactly what you want them to write, and they're just conforming to the way that you want the medical record to be completed,” El-Feky said.

At Raleigh Neurology, Smith hired an intern to develop a training module that all scribes use. It includes intensive training to thoroughly learn the EHR system and documentation standards. “Then they go through a training process with the head scribe to see how she and her doctor interact — and then they start shadowing their doctor,” he said.


Because most scribes are waiting to start another phase of their education, turnover is high. “If you become very dependent on them and they quit, that becomes a problem,” El-Feky said. He addressed that by asking his scribe to recruit and help train another scribe to work on an as-needed basis.

Smith of Raleigh Neurology suggests having a two-week overlap between the time one scribe leaves and the next one takes over. That gives the new person time to see how the physician works with the scribe.

Although the practice now recruits and hires its own scribes, Raleigh Neurology initially contracted with a service. Smith liked the company's expertise at matching the right scribe to each physician, which allowed his practice's scribe program to get off to a good start.


• The American College of Medical Scribe Specialists.
    • ScribeAmerica.