Health Information Compliance Alert

Published on Fri Jul 08, 2022 PDF

Understand how HIPAA weighs in on this type of documenting process.

Clinicians may find virtual scribes especially appealing with the COVID numbers trending upward again, as the virtual connection removes one additional source of exposure. If your practice is evaluating whether to use a virtual scribe, consider these points before you dive in.

Don’t Forget About HIPAA

If you’re considering hiring a virtual scribe, you don’t necessarily have to advertise and hire an individual. Companies exist to connect practices with such services; you can research and contract with a company rather than a “freelance” individual. Plus, an established company that is reputable has the benefit of ensuring compliance with the Health Insurance Portability and Accountability Act (HIPAA).

“Using virtual scribes can be 100 percent compliant, provided it is being properly used. There are many companies that offer this service, and they do it in a variety of different ways,” says Christine M. Speroni, CPC, administrative office manager at NHPP Gynecologic Oncology in Ronkonkoma, New York.

“Typically, it is not recorded, but there is someone on the other end of a microphone who is not present in the room listening in on everything. I think some even do it with AI, so it’s a computer program (like a smart dictation) listening, not a human. Any reputable company providing this service will be HIPAA-compliant,” she says.

Prioritize the Patient’s Perspective

During the pandemic, some patients may be especially worried about “unnecessary” sources of exposure and may view an in-person scribe with skepticism or outright distrust.

However, patients may also be skeptical of a virtual scribe, wondering who is listening to their appointment, where the person is located, whether the encounter is being recorded or simply streamed live, and whether their privacy is maintained.

“I will say, personally, from a patient standpoint, if a scribe is being used, I would vastly prefer an in-person scribe. To me, it just seems creepy that there’s an open microphone either on the computer, or a phone line and someone or something, somewhere else in the world is listening in. Depending on exactly how embarrassing my reason for the visit is, my level of comfort with that process could vary,” Speroni notes.

Whomever is making the call on hiring a scribe needs to weigh these variables carefully before deciding whether an in-person or virtual scribe makes more sense for the practice, especially during the pandemic.

Aim for Transparency

Transparency builds and maintains trust, and patients probably want to know who can access their health information. Consent and informed consent are crucial aspects of any clinician-patient interaction, and making sure the patient feels comfortable with everyone in the room (literally or figuratively) is important.

Technically, physicians may not have to tell patients that they’re relying on transcription, rather than personally taking notes.

“For example, if a physician uses a transcription program or person, the patient does not need to consent to this. The company providing the service (if not an employee) needs to have a business contract with the health care provider. Some providers or companies might have internal policies to inform the patient, but it is likely not required by law,” Speroni says.

Once you sort out the nitty-gritty details of transparency surrounding the encounter itself, you’ve done the hard work; you don’t need to worry about the documentation itself.

“From a coding standpoint, as long as it is signed by the clinician, it doesn’t really matter who or how the information is there,” Speroni says.