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Professional burnout has reached epidemic levels among U.S. medical providers. One key driver is the burden of clinical documentation in the electronic health record, which has given rise to medical scribes. Despite the demonstrated benefits of scribes, many providers-especially those in academic health systems-have been unable to make an economic case for them. With the aim of creating a cost-effective scribe program in which premedical students gain skills that better position them for professional schooling, while providers at risk of burnout obtain documentation support, the authors launched the Clinical Observation and Medical Transcription (COMET) Program in June 2015 at Stanford University School of Medicine. COMET is a new type of postbaccalaureate premedical program that combines an apprenticeship-like scribing experience and a package of teaching, advising, application support, and mentored scholarship that is supported by student tuition. Driven by strong demand from both participants and faculty, the program grew rapidly during its first 5 years (2015-2020). Program evaluations indicated high levels of satisfaction among participants and faculty with their mentors and mentees, respectively; that participants felt the experience better positioned them for professional schooling; and that faculty reported improved joy of practice. In summary, tuition-supported medical scribe programs, like COMET, appear to be feasible and cost-effective. The COMET model may have the potential to help shape future health professions students, while simultaneously combating provider burnout. While scalability and generalizability remain uncertain, this model may be worth exploring at other institutions.

On September 30, 2014, the US health care system is to assign the last International Classification of Diseases, Ninth Revision, Clinical Modification code. The new system, International Classification of Diseases, 10th Revision (ICD-10), Clinical Modification/Procedure Coding System, will become effective on October 1, 2014. We are embracing one of the largest health care changes in the past 30 years. This article describes the steps in setting up and implementing an efficient and effective ICD-10 training workshop. A 2-day North Carolina ICD-10 workshop is used as a case study. Following the initial workshop, 11 additional workshops were conducted throughout North Carolina.

On September 30, 2014, the US health care system will assign the last International Classification of Diseases, Ninth Revision, Clinical Modification code. The new system, International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System, will become effective on October 1, 2014. A 3-question prepresentation and postpresentation survey was completed by attendants at 11 workshops on the new system; this article discusses the results of the surveys, revealing what coders and billing staff are saying about the new International Classification of Diseases, 10th Revision system.

The increasing use of electronic medical records during the clinical encounter brings not only benefits but also barriers that may affect the doctor-patient relationship and increase the work burden of the physician. We evaluated whether the use of an electronic medical record scribe in an academic urology program would ameliorate these problems.We randomly assigned electronic medical record scribes to the office hours of 5 academic urologists, and using surveys we evaluated patient and physician acceptance and satisfaction.Patients were accepting of an electronic medical record scribe and satisfaction rates were high (93% vs 87% in the absence of a scribe, p = 0.36). Patients were comfortable disclosing urological information in the presence of the scribe. Physicians were dramatically more satisfied with office hours when a scribe was present (69% vs 19%, p0.001). We were unable to determine whether the presence of a scribe improves productivity.Electronic medical record scribes in a urology practice may be a practical solution to provide documentation while maintaining or improving the doctor-patient relationship because they increase physician satisfaction and do not detract from patient satisfaction.

The migration of Kaiser-Permanente (KP), a large managed care organization, to the management of health care information in a paperless environment is presented from the viewpoint of Health Information Management (HIM) professionals. The author conducted an informal survey of these professionals and presents a synopsis of their recommendations in the context of KP's efforts to develop an enterprise Electronic Medical Record. Their consensus is that physicians are primarily information managers and that successful health care organizations will be those who most effectively manage their information.

Objective: To determine whether hospital discharge diagnoses can be used for intensive care unit (ICU)-related activities. Design: Comparison between the diagnoses coded by physicians at the time of ICU admission and those diagnoses coded by medical records personnel. Setting: University hospital adult surgical ICU. Patients: Consecutive ICU admissions (n = 622). Interventions: None. Measurements and Main Results: The ICU admission and hospital discharge codes were compared in two ways. Initially, each discharge code was subtracted from the corresponding ICU admission code. There was no difference in 150 (24%) cases. In 216 (35%) patients, the codes differed by ±10. In 221 (36%) instances, the codes differed by >200. The secondary discharge diagnoses were also compared with the ICU admission diagnoses. In 56 patients, the ICU admission diagnosis was one of the secondary diagnoses. The second comparison involved having two physicians not associated with the study examine each pair of codes to determine if the two diagnoses were medically different. Review of the codes by physicians not involved in the study found that in 318 (48%) patients, the two diagnoses were not different, i.e., the codes were either the same or the codes were so similar as not to functionally change the actual diagnosis. Conclusions: The primary discharge diagnosis often failed to reflect the reason for ICU admission, making it impossible to consistently establish the reason for ICU admission from the discharge data. The reason for ICU admission was also frequently not included among the secondary discharge diagnoses. Administrative data are therefore not useful for ICU quality management and other functions. Intensivists need to establish their own databases.

Given the wide usage and proven value of the Abbreviated Injury Scale (AIS) in rating severity of trauma, it is essential that certain reliability issues concerning its application be resolved. This article describes a study designed to address these reliability issues. Each of 15 raters with varying qualifications was asked to identify AIS code injuries sustained by 375 trauma patients admitted to four Baltimore area hospitals. Results showed that as a group, physicians and nurses tend to be more reliable in their ratings than either emergency medical technicians (EMTs) or nonclinical technicians, although a research assistant who is well trained in AIS coding and is a diligent worker can use the AIS to code severity as reliably as the physicians when sufficient information is provided in the medical chart. Reliability of AIS scoring was somewhat higher for blunt (vehicular and nonvehicular) versus penetrating injuries.

A standardized system for recording patient care data for medical audit was developed and implemented in six community hospitals' coronary care units. It utilized the principles of predefining the data base and having both nurses and physicians participate. This system was compared with conventional retrospective record abstraction as a source of information for medical audit. The results suggest that the proposed system produces slightly more clinical data relevant to diagnostic impressions. Accuracy is comparable to that achieved by standard computerized abstraction procedures. Such an approach is readily adaptable for implementing medical audit to meet the requirements currently imposed upon community hospitals. EVERY HOSPITAL STAFF now faces the problem of operating a quality assurance program which will meet accreditation and legislative requirements. Consequently, medical audit programs are undergoing intensive development and implementation. The JCAH-recommended Quality Assurance Program and most other available systems require physicians of a hospital staff to set standards for the delivery of quality health care in their institution, measure the level of care given by retrospectively reviewing the records of discharged patients, and compare the standards with measured performance.3 Computerized data systems such as the Professional Activity Study (PAS) and Hospital Utilization Project (HUP) collect and report information which has been ab