Do Physicians Need Patients' Consent to Use Medical Scribes?

virtual medical scribe cost

Feb 23, 2023

Do Physicians Need Patients' Consent to Use Medical Scribes?

Generally clinical encounters involve serious health conversations between the patient and physician. Patients discuss their ailments, symptoms, lifestyles, fears, worries, and much more. Medical scribes have been around for decades, seen sitting in the corner of the exam room typing notes while the physician treats the patient. This is a scenario that most patients are aware of as physicians try to keep pace with the demands of EHRs. Today, virtual medical scribes are seen listening into patient encounters through an audio device and taking notes from afar. But how does it feel when someone is listening to and observing from another corner of the room or from afar? Won't this make patients feel uncomfortable? Won't they feel embarrassed divulging personal health information? Well, having an unknown or anonymous person sitting inside the exam room or perhaps on the other side of the world may feel like violating their boundaries. With this said, is it required to obtain the consent of the patient about the presence of the scribe? Read on to learn more.

Should the patient be notified of the scribe's presence and what experts have to say?

For patients, studies suggest that the use of scribes has been shown to have a favorable or neutral impact on their satisfaction. While some may have privacy concerns, state laws vary as to whether the patient must be notified about the presence of the scribe listening from miles away.

Dr. David Y Ting, chief medical information officer and a practicing physician at Massachusetts General Physicians Organization said that only 1% of patients declined the use of virtual scribes listening in during their visit. However, some patients do not have a say in this regard.

Chris Apgar, a former HIPAA compliance officer, says that that the federal laws like HIPAA does not necessarily require physicians to obtain the patients permission before sharing their health information with a company that provides documentation assistance to the practice, in this case a scribe firm, provided the company has signed a contract to protect patients' healthcare data. However, one-quarter of US states require physicians to obtain prior consent from patients to have a scribe present in the exam room in-person or virtually. They should clearly communicate the role of the scribe while also respecting the patient's right to refuse the presence of a scribe.

Matthew Fisher, a partner at Mirick O'Connell and a specialist in healthcare law, says some states have some special provisions. For e.g. some states have special privacy and confidentiality laws for people with HIV/AIDS or strict regulations requiring informed consent.

What does the US laws say on getting patient consent for using a scribe

If physicians prefer to take the help of scribes to reduce their documentation burden, does the law require them to obtain patient consent? Does the patient have the right to decline? The answer to these questions depends on where the patient lives and the physician's preferences. The state laws vary on whether the physician has to get patient consent or not. However, for most of the states, the US federal laws like the HIPAA doesn't mandate that physicians should obtain permission prior to using a scribe or share patient data, provided the third-party company, (a scribe firm) signs a contract agreeing to protect sensitive patient data. However, most US states are 'one-party consent' states - meaning it does not require consent from all parties involved in recording the conversation, even those that happen between a physician and a patient. Thirteen 'two-party consent' (all party consent) states demand unanimous consent from both parties. Although not all physicians are required to obtain approval before using a scribe to document patient encounters, most of the physicians opt to do so.

Security and privacy are major concerns, especially when using remote scribes. Hence, if you are opting to take the help of scribes for documentation support it's important to check whether the scribe service provider adheres to strict security and data protection measures. Look for a HIPAA compliant service provider. Scribe4Me is a 100% HIPAA compliant virtual scribing company which has invested in the technology, process and the people to protect patient-sensitive data. All our virtual scribes work in a HIPAA secure facility and a Business Associate Agreement (BAA) is also issued. Simply put, with virtual scribes you can rest easy knowing that patient data is in safe hands. What more do you need? If you are a physician considering the use of virtual medical scribes get in touch with us, today!

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