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Utilizing comments from teachers, professionals, college and high school students, this report is derived from the 5th Ned Hatathli Seminar, sponsored by the Navajo Health Authority, and presents factual information relative to American Indian participation in Indian Health careers. The following major speeches are presented: (1) "The Practice of Medicine in the Indian Community"; (2) "Papago Welcome" (emphasis on cultural responsiveness); (3) "American Indian and Health" (numerous problems defined); (4) "The Challenge of Indian Health Careers"; (5) "The Need for American Indians in Health Career Fields". Also presented are definitive summaries which detail the orientational and educational requirements of the following health careers: (1) Physical Therapy; (2) Speech and Hearing; (3) Occupational Therapist; (4) Vocational Evaluation in Rehabilitation; (5) Rehabilitation Counselor; (6) Alcohol Studies; (7) Allied Health Careers; (8) Social Work; (9) Medical Librarian; (10) Nutrition; (11) Gerontology; (12) Community Health Representative; (13) State Committees on Health Issues; (14) Pharmacy; (15) Nursing; (16) Veterinary Medicine; and (17) Medicine, Osteopathy, and Dentistry. The Seminar Evaluation is appended. (JC)

The manual provides major topics, objectives, activities and, procedures, references and materials, and assignments for the training program. The topics covered are hospital organization and community role, organization and management of a medical records department, international classification of diseases and operations, medical terminology, legal aspects, standards, education and training, and data processing. (The Instructor's Guide for the training program is available as LI 003097). (AB)

A program of education including training materials is presented to improve the technical proficiency of medical record clerks in small, rural hospitals. The program is planned for fifteen days of instruction or approximately 120 hours including evaluation, orientation and discussion sessions. Students are expected to have a high school diploma and no training beyond that received on the job. The material in the manual is organized in a unit plan to allow the instructor to fit the material to his teaching situation. (The student manual for the program is available as LI 003096.) (AB)

An exploratory study was conducted to obtain information regarding staff requirements in small tumor registry centers, involving a brief analysis of existing tumor registry centers and exploration of training and organizational factors that might be associated with establishing new centers. Activities performed by tumor registry personnel were defined as: (1) selecting medical records for registry purposes. (2) abstracting records, (3) coding records for data processing purposes, (4) initiating follow-up for cases within the registry, (5) maintaining registry files, (6) preparing reports, (7) activating a registry, and (8) supervising personnel and operations. It was found that various kinds of guidance and reference materials did exist for the eight activities but there were no formal training programs and there was a need for improving existing materials. The development of a self-instructional package for teaching medical terminology appeared to be particularly desirable. Study findings are discussed under the headings: (1) objectives, services, and procedures for a state-wide tumor registry system, (2) centralization of activities, (3) alternative systems, (4) relation between procedural alternatives and physician involvement in record abstracting, (5) training implications, and (6) research projects. (JK)

Describes the role of the clinical librarian in establishing information flow within clinical teams at teaching hospitals. (KP)

A practical approach to the improvement of medical information systems in small hospitals is described. This plan combines the training of library managers through a preceptorship experience with the loan of a demonstration collection of basic books and indexes to the journal literature and a vigorous on-site consultation program. (5 references) (Author/SJ)

The trial distribution of a specialized abstracting service, using the publication "Current References," to physicians practicing in rural communities in western Missouri is reported. The service was developed by clinical medical librarians who regularly leave the library setting to work with a docent team in the patient care setting. (LBH)

This study uses electronic health record data to evaluate medical record closure outcomes before and after the use of medical scribes at a large academic medical center.

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.

Background: It is essential that clinical documentation and clinical coding be of high quality for the production of healthcare data. Objective: This study assessed qualitatively the strengths and barriers regarding clinical coding quality from the perspective of health information managers. Method: Ten health information managers and clinical coding quality coordinators who oversee clinical coders (CCs) were identified and recruited from nine provinces across Canada. Semi-structured interviews were conducted, which included questions on data quality, costs of clinical coding, education for health information management, suggestions for quality improvement and barriers to quality improvement. Interviews were recorded, transcribed and analysed using directed content analysis and informed by institutional ethnography. Results: Common barriers to clinical coding quality included incomplete and unorganised chart documentation, and lack of communication with physicians for clarification. Further, clinical coding quality suffered as a result of limited resources (e.g. staffing and budget) being available to health information management departments. Managers unanimously reported that clinical coding quality improvements can be made by (i) offering interactive training programmes to CCs and (ii) streamlining sources of information from charts. Conclusion: Although clinical coding quality is generally regarded as high across Canada, clinical coding managers perceived quality to be limited by incomplete and inconsistent chart documentation, and increasing expectations for data collection without equal resources allocated to clinical coding professionals. Implications: This study presents novel evidence for clinical coding quality improvement across Canada.

Background: Information technology has the potential to streamline processes in healthcare for improved efficiency, quality and safety, while reducing costs. Computer-assisted clinical coding (CAC) has made it possible to automate the clinical coding process by assigning diagnoses and procedures from electronic sources of clinical documentation. Implementation of CAC requires both investigation of the clinical coding workflow and exploration of how the clinical coding professional’s role might change and evolve as a result of this technology. Objective: To examine the benefits and limitations of CAC technology; best practices for CAC adoption; the impact of CAC on traditional coding practices and roles in the inpatient setting. Method: This narrative review explores the current literature available on CAC. Literature indexed in ProQuest, Medline and other relevant sources between January 2006 and June 2017 was considered. Results: A total of 38 journal articles, published dissertations and case studies revealed that CAC has demonstrated value in improving clinical coding accuracy and quality, which can be missed during the manual clinical coding process. Conclusion: Clinical coding professionals should view CAC as an opportunity not a threat. CAC will allow clinical coding professionals to further develop their clinical coding skills and knowledge for future career progression into new roles such as clinical coding editors and clinical coding analysts. Sound change management strategies are essential for successful restructuring of the clinical coding workflows during the implementation of CAC.

Background Advanced primary care models emphasize patient-centered care, including self-management support (SMS). This study aimed to promote the translation of SMS into primary care practices and reported on key baseline practice characteristics that may impact SMS implementation. Methods Thirty-six practices in Colorado and California participated in the study from December 2013 to March 2017. Practice administrators completed a Practice Information Form describing practice characteristics. Clinicians and staff (n = 716) completed the Practice Culture Assessment and the Patient-Centered Medical Home (PCMH) Monitor. Descriptive statistics were computed to determine practice characteristics related to culture, quality improvement, level of PCMH, and SMS implementation. Field notes and key informant interviews provided contextual details about practices. Iterative qualitative analyses identified important facilitators and barriers and change capabilities around SMS implementation. Results In bivariate analyses, rural locations, fewer uncontrolled patients with diabetes, higher Medicaid or uninsured populations, underserved designation, and higher level of "PCMHness" were associated with greater reported implementation of patient SMS (all P Conclusions Careful attention-and action-on key practice characteristics and context may create more favorable initial conditions for practice change efforts to improve SMS in primary care practices.

Purpose of Review In the ever-changing healthcare system, along with new advancements in the field of allergy, the workflow for the allergist continues to evolve requiring more time spent doing non-clinical duties such as documentation and reviewing reimbursement challenges in the midst of busy clinics. The use of electronic medical records and medical scribes has emerged as tactics to aid the clinic’s workflow and efficiency in the modern allergy and immunology clinic. Recent Findings The practicing allergist can implement various additional strategies in their office workflow to maximize and synthesize good medicine and good business. Optimal use of office staff, electronic health records, and various workflow efficiencies has been shown to improve job satisfaction and reduce physician burnout. Summary By utilizing these methods and integrating them into their practices, allergists will be able to meet the demands of the healthcare system and still provide patients with evidence based, compassionate, and cost-effective care.

Objectives To understand how medical scribes’ work may contribute to alleviating clinician burnout attributable directly or indirectly to the use of health IT. Materials and Methods Qualitative analysis of semistructured interviews with 32 participants who had scribing experience in a variety of clinical settings. Results We identified 7 categories of clinical tasks that clinicians commonly choose to offload to medical scribes, many of which involve delegated use of health IT. These range from notes-taking and computerized data entry to foraging, assembling, and tracking information scattered across multiple clinical information systems. Some common characteristics shared among these tasks include: (1) time-consuming to perform; (2) difficult to remember or keep track of; (3) disruptive to clinical workflow, clinicians’ cognitive processes, or patient–provider interactions; (4) perceived to be low-skill “clerical” work; and (5) deemed as adding no value to direct patient care. Discussion The fact that clinicians opt to “outsource” certain clinical tasks to medical scribes is a strong indication that performing these tasks is not perceived to be the best use of their time. Given that a vast majority of healthcare practices in the US do not have the luxury of affording medical scribes, the burden would inevitably fall onto clinicians’ shoulders, which could be a major source for clinician burnout. Conclusions Medical scribes help to offload a substantial amount of burden from clinicians—particularly with tasks that involve onerous interactions with health IT. Developing a better understanding of medical scribes’ work provides useful insights into the sources of clinician burnout and potential solutions to it.

OBJECTIVES/HYPOTHESIS Electronic health records have brought many advantages but also placed a documentation burden on the provider during and after the clinic visit. Some otolaryngologists have countered this challenge by employing clinical scribes. This project aimed to better understand the influence of scribes on patient experience in the otolaryngology clinic. STUDY DESIGN Retrospective cohort survey study. METHODS Patients presenting to the otolaryngology clinic for new and follow-up appointments were recruited to complete surveys about their experience. RESULTS A total of 153 patients completed the survey, and 96 of those patients (62.7%) interacted with a scribe. Patient satisfaction was not significantly associated with participation of the scribe (P = .668). Similarly, patient rating of their physician on a scale of 1 to 10 was not associated with scribe involvement (P = .851). The patients who did interact with a scribe responded that the scribe positively impacted the visit 77.1% of the time. Participation of a resident, primary language other than English, and use of interpreter were associated with lower satisfaction (P = .004, P

Background: Health records are the basis of clinical coding. In Portugal, relevant diagnoses and procedures are abstracted and categorised using an internationally accepted classification system and the resulting codes, together with the administrative data, are then grouped into diagnosis-related groups (DRGs). Hospital reimbursement is partially calculated from the DRGs. Moreover, the administrative database generated with these data is widely used in research and epidemiology, among other purposes. Objective: To explore the perceptions of medical coders (medical doctors) regarding possible problems with health records that may affect the quality of coded data. Method: A qualitative design using four focus groups sessions with 10 medical coders was undertaken between October and November 2017. The convenience sample was obtained from four public hospitals in Portugal. Questions related to problems with the coding process were developed from the literature and authors’ expertise. The focus groups sessions were taped, transcribed and analysed to elicit themes. Results: There are several problems, identified by the focus groups, in health records that influence the coded data: the lack of or unclear documented information; the variability in diagnosis description; “copy & paste”; and the lack of solutions to solve these problems. Conclusion and implications: The use of standards in health records, audits and physician awareness could increase the quality of health records, contributing to improvements in the quality of coded data, and in the fulfilment of its purposes (e.g. more accurate payments and more reliable research).

Background Bronchiolitis is a common respiratory disorder in children. Although there are specific ICD-9-CM diagnosis codes for bronchiolitis, the illness is often coded using broader diagnosis codes. This creates the potential for subject misclassification if researchers rely on specific diagnosis codes when assembling retrospective cohorts. Here we challenge the common research practice of relying on specific diagnosis codes for bronchiolitis. Methods We examined the use of diagnosis codes for the first episode of bronchiolitis, bronchitis, acute asthma, and bronchospasm and wheezing, in children younger than six and 24 months in the State of California Medic-Aid database. We categorized codes as narrow or broad diagnosis codes. We compared patient, geographic, and temporal characteristics of the different diagnoses codes. Results We identified visits from 48,732 children for first episode of wheezing illness. We retained 48,269 who had the diagnosis codes and data of interest. Diagnosis codes for acute asthma were widely used, even in children younger than six months in whom a diagnosis code for bronchiolitis would have been anticipated. The temporal pattern was similar across all diagnoses. Antipyretics were prescribed more often in those with diagnosis codes for bronchiolitis and bronchitis. Other statistically significant differences were too small to usefully distinguish the groups. There was substantial geographic variability in the diagnosis codes selected. Conclusion Users of Medic-Aid administrative data should generally favor broad rather than narrow definitions of bronchiolitis and should perform sensitivity analysis comparing broad and narrow definitions. Electronic supplementary material The online version of this article (10.1186/s12874-018-0589-4) contains supplementary material, which is available to authorized users.

Scribe use throughout health care is becoming more common. There is limited peer-reviewed literature supporting this emerging role in health care despite rapid uptake of the role.Our study assesses impact of scribes on relative value units (RVUs) in adult and pediatric emergency departments (EDs).A prospective cohort study was developed in a tertiary academic ED. Charts were coded by an external billing and coding company, then returned and mapped by International Classification of Diseases, 9th revision diagnostic codes. After training by a staff member with significant experience in implementing scribe programs, scribes provided 1-to-1 support to a provider as staffing allowed. Comparisons were made between scribed and nonscribed visits.There were 49,389 patient visits during the study period (39,926 adult [80.84%] and 9463 pediatric [19.16%] visits), of which 7865 (15.9%) were scribed. For adults, scribed visits produced 0.20 additional RVUs per patient (p 0.001). Scribes generated additional RVUs in Emergency Severity Index (ESI) 2 (p 0.001) and 3 (p 0.001) patients. There were variable effects of scribes on RVUs by diagnostic codes. For pediatric patients, scribed encounters generated 0.08 fewer RVUs per patient (p = 0.007). ESI score had no effect on RVUs. The impact of scribes on pediatric diagnostic groupings was inconsistent.Scribes had a positive impact on RVUs in adult but not pediatric patients. Among adults, scribes led to higher RVUs in ESI 2 and 3 but not 4 and 5 patients, perhaps suggesting a limitation to improve revenue capture on lower-acuity patients.

Objectives Assess the impact of scribes on an academic emergency department's (ED) throughput one year after implementation. Methods A prospective cohort design compared throughput metrics of patients managed when scribes were and were not a part of the treatment team during pre-defined study hours in a tertiary academic ED with both an adult and pediatric ED. An alternating-day pattern one year following scribe implementation ensured balance between the scribe and non-scribe groups in time of day, day of week, and patient complexity. Results Adult : Overall length of stay (LOS) was essentially the same in both groups (214 vs. 215min, p=0.34). In area A where staffing includes an attending and residents, scribes made a significant impact in treatment room time in the afternoon (190 vs 179min, p=0.021) with an increase in patients seen per hour on scribed days (2.00 vs. 2.13). There was no statistically significant changes in throughput metrics in area B staffed by an attending and a nurse practitioner/physician assistant, however scribed days did average more patients per hour (2.01 vs. 2.14). Pediatric : All throughput measurements were significantly longer when the treatment team had a scribe; however, patients per hour increased from 2.33 to 2.49 on scribed days. Conclusions Overall patient throughput was not enhanced by scribes. Certain areas and staffing combinations yielded improvements in treatment room and door to provider time, however, scribes appear to have enabled attending physicians to see more patients per hour. This effect varied across treatment areas and times of day.

Background: This study examined: (a) whether medical record administrators (MRAs) properly understand and apply a cancer registration manual; (b) weaknesses in cancer registration: and (c) factors influencing the accuracy of cancer registration. Methods: MRAs dealing with cancer registration in 81 national member hospitals were asked by mail to answer 17 questions about cancer information among registration items. After calculating rates of correct and incorrect answers to each question, an analysis was conducted of whether they were related to particular factors (hospital type, hospital location, number of hospital beds, experience of cancer registration, and experience of consulting cancer registration). Results: A total of 45.7% of the participants gave approximately 90% correct answers. The rates for correct answers about general rules were under 90% for objectives of cancer registration and treatment. The rate concerning histologic type was over 90%, while few correct answers exceeded 50% to questions concerning newly revised rules for the colorectal system. For questions about initial treatment, date of diagnosis, and method of final diagnosis, as well as four questions on checking the validity of registered data, the correct answer rates were 70-90%. Regarding the features of hospitals and respondents, number of hospital beds and prior experience in cancer registration questions were found to contribute to the high rate of correct answers. Conclusion: To improve the accuracy of cancer registration, the manual needs to be supplemented in areas demonstrating low correct answer rates. Education opportunities and methods for MRAs should be diversified.

Background This study examined the agreement between patient-reported chronic diseases and hospital administrative records in hip or knee arthroplasty patients in England. Methods Survey data reported by 676,428 patients for the English Patient Reported Outcome Measures (PROMs) programme was linked to hospital administrative data. Sensitivity and specificity of 11 patient-reported chronic diseases were estimated with hospital administrative data as reference standard. Results Specificity was high (> 90%) for all 11 chronic diseases. However, sensitivity varied by disease with the highest found for ‘diabetes’ (87.5%) and ‘high blood pressure’ (74.3%) and lowest for ‘kidney disease’ (18.8%) and ‘leg pain due to poor circulation’ (26.1%). Sensitivity was increased for diseases that were given as specific examples in the questionnaire (e.g. ‘parkinson’s disease’ (65.6%) and ‘multiple sclerosis’ (69.5%), compared to ‘diseases of the nervous system’ (20.9%)). Conclusions Patients can give information about the presence of chronic diseases that is consistent with chronic diseases derived from hospital administrative data if the description in the patient questionnaire is precise and if the disease is familiar to most patients and has significant impact on their life. Such patient questionnaires need to be validated before they are used for research and service evaluation projects. Electronic supplementary material The online version of this article (10.1186/s12874-019-0729-5) contains supplementary material, which is available to authorized users.