Podiatrist Dr. Mark Lewis greets his first patient of the morning in his suburban Seattle exam room and points to a tiny video camera mounted on the right rim of his glasses. “This is my scribe, Jacqueline,” he says. “She can see us and hear us.”
Jacqueline is watching the appointment on her computer screen after the sun has set, 8,000 miles away in Mysore, a southern Indian city known for its palaces and jasmine flowers. She documents the details of each visit copiously and enters them into the patient’s electronic health record, or EHR.
Before COVID-19, most scribes—typically young, aspiring health professionals—worked in the exam room a few paces away from the doctor and patient. This year, as the pandemic led patients to shun clinics and hospitals, many scribes were laid off or furloughed. Many have returned, but scribes are increasingly working online—even from the other side of the world.
Remote scribes are patched into the exam room’s sound via a tablet or speaker, or through a video connection. Some create doctors’ notes in real-time; others annotate after visits. And some have help from speech-recognition software programs that grow more accurate with use.
While many remote scribes are based in the United States, others are abroad, primarily in India. Chanchal Toor was a dental school graduate facing limited job opportunities in India when a subcontractor to Augmedix hired her in 2015. Some of her scribe colleagues also trained or aspired to become dentists or other health professionals, she said. Now she’s a manager for Augmedix in San Francisco, and she said scribing, even remotely, makes her feel like part of a health care team.
Augmedix recruits people who have a bachelor’s degree or the equivalent, and screens for proficiency in English reading, listening comprehension, and writing, the company said. Once onboard, scribes undergo about three months of training. The curriculum includes medical terminology, anatomy, physiology, and mock visits.
Remote scribe “Edwin” gives internist Dr. Susan Fesmire more time, freeing her from having to finish 20 charts at the end of every day. “It was like constantly having homework that you don’t finish,” she said. With the help of Edwin (Fesmire said he declined 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 scribes in India. Fesmire pays $14 an hour for Edwin’s services.
Doctors with foreign scribes say notes may need minor editing for dialectal differences, and scribes may be unfamiliar with local vocabulary. “I had a patient from Louisiana,” said Fesmire, “and Edwin said afterward, ‘What is chicory, doctor?’” But she also praised his notes as more accurate and complete than her own.
Only 1 percent of patients refuse a remote scribe when asked by physicians at Massachusetts General Physicians Organization, said Dr. David Ting, the practice’s chief medical information officer. His group, an IKS Health client, always seeks patient consent, Ting said.
Scribes aren’t for everyone, though. Janis Ulevich, a retiree in Palo Alto, California, declines her primary care doctor’s remote scribe. “Conversations with your doctor can be intimate,” said Ulevich. “I don’t like other people listening in.”
Some patients may not have the opportunity to decline. With limited exceptions, federal laws such as HIPAA, the Health Insurance Portability and Accountability Act of 1996, don’t require doctors to seek a patient’s consent before sharing their health information with a company that supports the practice’s work (like a scribe firm), as long as that company signed a contract agreeing to protect the patient’s data, said Chris Apgar, a former HIPAA compliance officer.
