GHS Virtual Scribe Program
The Guardian Health Services Virtual Scribe Program was developed in compliance with the guidelines established by the American Health Information Management Association (AHIMA) and the Joint Commission for Medical Scribes, and the mandates of the Health Insurance Portability and Accountability Act (HIPAA). The Program is designed to:
- Enhance the time and opportunity for physicians and/or NPs or PAs to focus on hands-on, attentive, face-to-face patient care as opposed to EHR data entry.
- Increase patient volume and revenue.
- Improve clinical documentation, including medical risk adjustment coding and HCC capture.
- Facilitate timely identification closure of quality performance gaps at point of care.
- Assist practice in MIPS measures.
- Improve office workflow and reduce stress.
- Increase provider and patient satisfaction; and
Guardian Virtual Scribes are formally trained on medical terminology, anatomy and physiology, electronic health records, medico-legal rules and regulations (including HIPAA), the basics of me dical billing and coding, Merit-Based Incentive Payment System (MIPS) performance categories and composite score, and medical risk adjustment and HCC capture; and Under the program dedicated Guardian Scribes are remote and listen in real-time to the patient visit (encounter), and navigate the Practice EHR entering information as directed by the physician. Correspondingly, Practice use a desktop or portable device (mobile phone or tablet) to communicate with the Guardian Virtual Scribe as documentation is entered into their EMR. Guardian Virtual Scribes are responsible for capturing an accurate and detailed description of a patient encounter in the provider’s words. The Scribes are clerical in nature and do not interview or have direct contact with the patient. They do not perform clinical services, administer medication, or perform treatments and procedures. The Scribes remotely listen in real-time to the patient encounter, or a portion of the encounter, and enters information into the EMR as directed by the provider (physician, PA or NP). All interactions and recordings of the Guardian Virtual Scribes are managed through Health Insurance Portability and Accountability Act (HIPAA) compliant screen sharing technology. Client practices utilize a desktop or portable device (mobile phone or tablet) to communicate with the Guardian Virtual Scribe as documentation is entered into the native EMR.
The general Scope of Work of the Guardian Virtual Scribe is as follows:
Prior to Face-To-Face Interaction between Patient and Provider
1. Practice office clinical staff obtain from the patient verbal consent for the use of a virtual scribe during the patient encounter. Consent can be given verbally or in writing by the patient. Consent must be obtained from the patient (or the patient’s caregiver) either prior to the patient’s face-to-face interaction with the provider or as the first action item of the provider in the encounter. NOTE: The Guardian Virtual Scribe cannot be remotely connected until the patient consent is established.
2. Practice clinical staff direct patient to exam room and enter history and vitals into the patient’s EMR.
3. Guardian Virtual Scribe connects to the exam room remotely through a secure, HIPAA compliant VOIP and RDP/VPN connections, reviews the patient’s file.
4. Provider (physician, NP or PA) enters the exam room for face-to-face visit.
During Patient and Provider Face-To-Face Encounter
5. Guardian Virtual Scribe listens to and documents the provider-patient encounter in real time (i.e., enters notes, CPT and IDC-10 codes, eRx, order, and other relevant data/information into the patient’s EMR).
6. Guardian Virtual Scribe identifies for provider gaps in MIPS performance measures and/or other
quality measures that need to be addressed.
Post Patient and Provider Encounter
7. Provider reviews day’s patient medical records with the Guardian Virtual Scribe via a secure VOIP Connection, identifies any edits, and signs off.