By Sarah Kwon, Kaiser Health News
The podiatrist Dr. Mark Lewis greets his first patient of the morning in his Seattle suburb exam room and points to a tiny video camera attached to the right edge of his glasses. “This is my scribe, Jacqueline,” he says. “She can see and hear us.”
Jacqueline watches the appointment on her computer screen after the sun goes down, 13,000 kilometers away in Mysore, a south Indian city known for its palaces and jasmine flowers. She documents the details of each visit in detail and enters them in the patient’s electronic patient record (EHR).
Jacqueline (her real first name according to her employer) works for Augmedix in San Francisco, a startup with 1,000 medical professionals in South Asia and the USA. The company is part of a growing industry that is benefiting from a confluence of healthcare trends – including the pandemic – that are spreading patient care around the world.
Medical scribes first appeared in the 1970s as note-makers for emergency doctors. However, the practice began after 2009 when the HITECH federal law encouraged health care providers to introduce EHRs. These were supposed to simplify the patient record, but scribes were needed instead. Doctors find it tedious and time consuming to enter notes and data into poorly designed EHR software. Writing is a rapidly growing field in the United States. The workforce will grow from 15,000 in 2015 to an estimated 100,000 this year.
A 2016 study found that doctors spent 37% of a patient visit at the computer and an average of two extra hours after working on EHR tasks. The use of EHR contributes to physician burnout, which is increasingly viewed as a public health crisis in and of itself.
Before COVID-19, most scribes – usually young, aspiring health professionals – worked in the exam room a few steps away from the doctor and patient. That year, as the pandemic caused patients to avoid clinics and hospitals, many scribes were laid off or on leave. Many have returned, but scribes are increasingly working online – even from across the world.
Remote writers are patched into the sound of the exam room through a tablet or speaker, or through a video link. Some take physician notes in real time; others comment after visits. Some have help from speech recognition software programs which become more accurate with use.
While many remote writers are based in the US, others are overseas, mostly in India. Chanchal Toor was a graduate of a dental school with limited job opportunities in India when she was hired by an Augmedix subcontractor in 2015. Some of her fellow writers also trained or aspired to become dentists or other health professionals, she said. Toor, who is now a manager at Augmedix in San Francisco, said that writing made her feel like part of a health team even from a distance.
Augmedix recruits people with a bachelor’s degree or equivalent and verifies their English skills in reading, listening and writing. Once the clerks are on board, they are trained for about three months. The curriculum includes medical terminology, anatomy, physiology, and mock visits.
Sales have increased this year and its sales team has grown from four to 14 members, said Augmedix CEO Manny Krakaris. Sachin Gupta, CEO of IKS Health, which employs Indian doctors to teletype its US counterparts, is forecasting 50% sales growth for its typing business this year. He said the company had 4,000 employees but declined to reveal the number of scribes.
The teletype “Edwin” gives the internist Dr. Susan Fesmire more time and frees her from completing 20 charts at the end of each day. “It was like you always had homework that you weren’t doing,” she said. With the help of “Edwin” – Fesmire said he refuses to use his real name – she had the time and energy to become chief operating officer of her small Dallas practice. Edwin works for Physicians Angels, which employs 500 remote writers in India. Fesmire pays $ 14 an hour for its services.
Doctors with overseas scribes say that dialectal differences may require minor editing of notes and scribes may not be familiar with local vocabulary. “I had a patient from Louisiana,” said Fesmire, “and Edwin said afterwards,” What is chicory, Doctor? “But she also praised his notes as being more accurate and complete than her own.
Kevin Brady, president of Physicians Angels, said their scribes start at $ 500 to $ 600 a month plus health and retirement benefits, while senior scribes make $ 1,000 to $ 1,500 – a middle class family income in India. Employers are required to offer health insurance to their workers, even though many scribes are contractors, and construction site Indeed.com states that the average salary for a clerk in India is $ 500 a month. Scribes in the United States are paid approximately $ 2,500.
Remote scribing is still a small part of the market. Craig Newman, chief strategy officer of HealthChannels, parent company of ScribeAmerica, the largest typing company in the US, said the company’s teletype business has tripled since the pandemic began, but that “a large majority” of the company’s 26,000 US writers remain still work personally.
It’s a heavily unregulated industry that doesn’t require training and certification. The service typically costs doctors $ 12 to $ 25 an hour. Studies show that using scribers is linked to less patient documentation time, higher job satisfaction, and more patients – which can mean more sales.
Studies suggest that scribes have a positive or neutral influence on patient satisfaction. However, some have privacy concerns and state laws vary as to whether or not a patient needs to be notified that someone is watching and listening many miles away.
Only 1% of patients refuse to use teletype when asked by doctors at the Massachusetts General Physicians Organization, said Dr. David Ting, the practice’s chief medical information officer. His group, an IKS Health client, always seeks patient approval, Ting said.
However, scribes are not for everyone. Janis Ulevich, a retiree in Palo Alto, California, turns down her GP’s teletype. “Conversations with your doctor can be intimate,” said Ulevich. “I don’t like it when other people listen.”
Some patients may not have the option to refuse. With limited exceptions, federal laws like HIPAA, the Health Insurance Portability and Accountability Act of 1996, don’t require doctors to obtain a patient’s consent before sharing their health information with a company that supports the practice (such as a clerk company) as long as that company has signed a contract to protect patient data, said Chris Apgar, a former HIPAA compliance officer.
About a quarter of the US states require all interlocutors to agree to the recording, which means they need a patient’s permission. Some states also have specific privacy policies for specific groups, like people living with HIV / AIDS or very strict informed consent or privacy laws, said Matt Fisher, a partner at Mirick O’Connell law firm in Massachusetts.
Remote scribing also raises cybersecurity concerns. Reported data breaches are rare, but some recorder companies have sloppy security, said Cliff Baker, CEO of healthcare cybersecurity company Corl Technologies.
The next step in the trend might not be any human scribes at all. Tech giants like Google, EHR companies, and venture capital development startups are already developing or marketing artificial intelligence tools to reduce or eliminate the need for people to document visits.
AI and scribes will not eradicate the doctor burnout that comes with the nature of the health system, said Dr. Rebekah Gardner, an associate professor of medicine at Brown University, who is studying the problem. Neither of them can do burnout-inducing EHR duties, such as filing applications for approval of procedures, drugs, and tests by insurance companies, she said.
This KHN story was first published on California Healthline, a service of the California Health Care Foundation.
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KHN (Kaiser Health News) is a non-profit health news service. It is an editorially independent program of the KFF (Kaiser Family Foundation) that is not affiliated with Kaiser Permanente.