George A. Gellert

An Outbreak of Acute Gastroenteritis Caused by a Small Round Structured Virus in a Geriatric Convalescent Facility

An outbreak of acute gastroenteritis (AGE) occurred in a 201-bed geriatric convalescent facility in Los Angeles County during December 1988 through January 1989. The attack rate was 55% among residents and 25% among employees. Illnesses were characterized by vomiting and diarrhea to a lesser extent, and the absence of fever. Bacterial and parasitic tests in a sample of patients were negative. A 27 nm small round structured virus (SRSV) was identified in one of 30 stools studied by immune electron microscopy (IEM). While rotavirus and influenza A and B were found in three, one and three cases, respectively, no alternative etiologic agent could be demonstrated for most cases. The outbreak met Centers for Disease Control (CDC) clinical and epidemiologic criteria for Norwalk-like gastroenteritis. The death rate of residents was not elevated beyond baseline during the outbreak; however, one healthy employee had diarrhea and dehydration and died after developing an arrhythmia. An autopsy showed moderate, diffuse lymphocytic and neutrophilic myocarditis, and viral studies found influenza A in left ventricular tissue. Fourteen (25%) of 57 employee cases worked in occupations without routine stool or patient contact. At least nine of these employees lacked evidence of direct fecal contact, and transmission of infection in these cases may have been airborne.

The Rise of the Medical Scribe Industry: Implications for the Advancement of Electronic Health Records

With federal meaningful-use incentives driving adoption of electronic health records (EHRs), physicians are increasingly concerned about the time spent documenting patient information and managing orders via computerized patient order entry (CPOE). Many perceive that the inefficiencies of EHRs are adversely affecting the quality of care, and because physicians see fewer patients per day, income may decline.1 Although physicians approve of EHRs in concept and appreciate their future promise, the current state of EHR technology has increased physician dissatisfaction.1 Poor EHR usability, time-consuming data entry, reduced patient care time, inability to exchange health information, and templated notes are central concerns. Physicians emphasize that EHR technology—especially user interfaces— must improve,1 and a new industry has emerged nationally to provide physicians with medical scribes. Use of medical scribes—unlicensed individuals hired to enter information into the EHR under clinician supervision—has increased substantially.2 Scribes reportedly enable physicians to see more patients; generate more revenue; and improve productivity, efficiency, accuracy of clinical documentation and billing, and patient satisfaction.2 At least 22 companies provide scribe services across 44 states (eTable in the Supplement). Organizations, mostly scribe service vendors, train and certify scribes, and there are dedicated medical scribe training programs. The American College of Medical Scribe Specialists (ACMSS), a tax-exempt nonprofit organization representing more than 3000 scribes and 300 hospitals nationwide, offers a Medical Scribe Certification and Aptitude Test (MSCAT) for certification and publishes the Medical Scribe Journal.3 Certification requires that candidates pass a 90-day employment probation period and record 200 hours of clinical work.3 The ACMSS, according to its executive director, “protects the medical scribe industry.”3 The organization’s president envisions ACMSS as a “brain lab...where companies can come together to work on national scribing standards and lobby regulators on behalf of the industry.”3 The ACMSS, whose leading financial sponsor is ScribeAmerica,4 states on its web page that “the process of selecting a potential Certified Medical Scribe is complex” and that “ACMSS provides the groundwork for excellence throughout the industry.” Yet it also stipulates that “minimum requirements include a high school diploma or G.E.D. [and that] each company sets their [sic] own criteria for hiring and selection process.”3 ScribeAmerica’s training program involves a 2-week orientation, a supervisory period under a “highly experienced” medical scribe, and periodic reassessment of the scribe’s effectiveness.4 PhysAssist Scribes emphasizes that “great scribes aren’t just born—they’re made,” so it established a “scribe university...a five-day training program unlike any other in the industry.”5 PhysAssist was recently acquired by TeamHealth, one of the nation’s largest providers of hospital-based clinical outsourcing. Estimates on growth of the medical scribe industry, its constituent companies, or of its principal service are anecdotal. No agency of state or federal government currently monitors—or regulates—the growth or activities of this new health care industry. Many smaller local companies either do not have websites or advertise only as medical staffing agencies. The 22 companies listed in the eTable (in the Supplement), likely an underestimate of the industry’s breadth, offer services in 1058 locations. The chief executive officer of ScribeAmerica, the largest US scribe company, estimates that 10 000 scribes are working in hospitals and medical practices around the country.6 According to the ACMSS, the number of medical scribes has been doubling annually, with about 20 000 expected to be working by the end of 2014.7 The industry “expects [its] ranks to swell to 100,000 by 2020.”7 If accurate, in 6 years, there will be 1 medical scribe for every 9 physicians in the country. One company, Medical Scribe Systems, currently operates in 100 hospitals nationwide and employs more than 2000 scribes.8 The company was cited by Inc. magazine as one of the fastest growing private companies in the United States in 2014.8 ScribeAmerica is purportedly the most successful US medical scribe company, with more than 5000 scribes in more than 570 health care facilities across 44 states.4 The Joint Commission neither endorses nor prohibits the use of scribes, noting that scribes may not act independently when documenting dictation or other activities determined by a physician. Although scribes can assist practitioners with EHR navigation, retrieval of diagnostic results, documentation, and coding, allowing scribes to enter orders in the patient’s electronic record is prohibited “due to the additional risk added to the process.”9 The Centers for Medicare & Medicaid Services stated, “We disagree ... that anyone should be allowed to enter orders using CPOE. This potentially removes the possibility of clinical decision support and advance interaction alerts being presented to someone with clinical judgment, which negates many of the benefits of CPOE.”10 With problems associated with EHRs so substantial— and physicians’ experiences using medical scribes so positive—are there any risks engendered by the rise of a medical scribe industry and its potential for becoming inVIEWPOINT

Fatalities assessed by the Orange County child death review team, 1989 to 1991

Interagency child death review teams have emerged in response to the increasing awareness of severe violence perpetrated against children in the United States. Child death review involves a systematic, multidisciplinary, and multiagency process to coordinate data and resources from the coroner, law enforcement, the courts, child protective services, and health care providers. The Orange County, CA team reviews all coroners cases (unattended death or questionable cause of death) for children 12 years old and younger. This paper describes the interagency review in Orange County and provides data on the demographics of cases reviewed by the team (N = 637) compared to unreviewed deaths (N = 1,463) for the period 1989 to 1991. Trends were analyzed to assess differences in: (1) age distribution; (2) gender; (3) ethnicity; (4) cause of death (non-SIDS natural; non-natural including traffic deaths, SIDS, other injuries; homicide; and undetermined); and (5) cause of death by age, gender, and ethnicity. Implications of the data for other jurisdictions with child death review teams are discussed.

International migration and control of communicable diseases.

The epidemiology and policy implications of communicable disease (CD) transmission associated with international migration have received little systematic study. This is a review of clinical and epidemiological reports in search of strategies to assess and manage the impact of international migration on the transmission of CDs. The economics and demography of migration from less developed to industrialized nations is considered. Migration-related transmission should differentiate between actual transmission as opposed to geographic relocation of disease. Limitations of current screening and disease prevention strategies are discussed. Social and ecological processes through which migration can contribute to increased CD transmission are described, including placement in refugee camps, unclear legal status of migrants in recipient nations, and temporary return migration. Strategies for non-discriminatory and non-punitive control of migration-related CDs, needed changes in clinical practice, and complexities presented by CDs of long latency (such as HIV infection) are reviewed.

The Obsolescence of Distinct Domestic and International Health Sectors

yas HE traditional and historic bases for differentiating domestic and international health in Western nations have, as a result of profoundly changing epidemiology and demographics, lost meaning. International health F has been viewed as independent and unrelated to the >c X* domestic health sector as a legacy of colonialization, and as a result of distinctive economic development issues, cultural backgrounds, and regionalism of health problems. Four phenomena have contributed to an unprecedented internationalization of domestic health: i) the re-emergence of a deadly infectious disease pandemic with the human immunodeficiency virus (i); 2) health effects anticipated from environmental exploitation and decay (global warming, ozone depletion, toxic and radioactive waste disposal, deteriorating air and water quality, deforestation and desertification) (2, 3); 3) a shift in immigration patterns such that developing world peoples comprise a majority of immigrants to Western nations (84% of 64,3000 immigrants to the United States in 1988 were of Latin American or Asian origin) (4), and are often foci of endemic and epidemic diseases, both infectious and noninfectious; 4) an emerging global economic interdependence, independent of but heightened by the facts that the United States is now a debtor nation, and that Japan leads in international health funding. The consequences of these trends are that the infrastructures of developed nations face qualitatively new and intense pressures from developing world peoples. Furthermore, the global village concept has never more aptly described the status of world health. We suggest that there exists a mutuality and parallelism of domestic-international public health research, practice and interest which must be nurtured. Mutual areas of

A cluster of coagulase-negative staphylococcal bacteremias associated with peripheral vascular catheter colonization in a neonatal intensive care unit

BACKGROUND A cluster of six neonatal cases of coagulase-negative staphylococcal bacteremias occurred in a Los Angeles County neonatal intensive care unit in March 1989. METHODS A retrospective cohort study assessed the impact of host-and delivery-related variables, length of hospitalization, duration of antibiotic treatment, performance or duration of invasive procedures, and staffing variables on risk of coagulase-negative staphylococcal bacteremia. RESULTS Unstratified analyses yielded eight risk factors with risk ratios greater than 2. After stratification by gestational age (less than 29 weeks) and low birth weight (less than 1500 gm), frequency of blood transfusions, duration of respiratory therapy, heparin lock and central vascular line placement, and hyperalimentation remained associated with elevated risk. Two species were identified, arguing against a common source of infection. Of four cohort months with more than 15 very low birth weight infants in the neonatal intensive care unit, an elevation of coagulase-negative staphylococcus-positive blood cultures and diagnosed bacteremias occurred in only two. CONCLUSIONS This cluster of coagulase-negative staphylococcal bacteremia was probably caused by frequent manipulation of catheters in neonates who were at heightened risk because of low birth weight and prematurity.

HIV/AIDS knowledge and high risk sexual practices among southern California Vietnamese.

OBJECTIVES--Vietnamese immigration to the U.S. since the conclusion of the Vietnam war has been substantial and in Orange County, CA, Vietnamese Americans comprise 3% of the population (the largest community in the US). Our objective was to collect data on the HIV/AIDS knowledge, attitudes and self-reported high risk behaviours within this community. METHODS--A survey instrument was administered anonymously in Vietnamese to 532 respondents in their homes. Individuals from three population strata were randomly sampled: men 18 to 35 years old (N = 193); men 36 to 45 years old (N = 137); and women 18 to 35 years old (N = 202). Data were gathered on: (1) degree of acculturation; (2) knowledge and attitudes towards HIV/AIDS; and (3) self-reported sexual and other high risk practices. RESULTS--Survey data indicated that 38% of respondents were very worried about themselves and 83% were worried about a family member getting AIDS. Knowledge about actual modes of HIV transmission was generally accurate, but a substantial minority still believed that HIV can be transmitted through casual contact, and 68% from needles used in hospitals. Women demonstrated less accurate knowledge than men on five key items. Quarantine of the HIV infected was agreed to by 45%. Twenty-nine percent did not believe that the epidemic would affect them personally, and 49% stated that they did not have enough information about AIDS to protect themselves. Regarding sexual practices, 31% reported never having had sex. Of the others, 8% had two or more sexual partners in the prior 12 months. No same sex behaviour was reported. Six percent of men had visited a female prostitute; of these, 24% had visited 2 or more in the prior 12 months; half of encounters in this time period were outside the US. Substantial percentages of sexually active, unmarried respondents indicated that they never use (17-40%) or only sometimes use (10-32%) condoms. Less than 1% had used injection drugs. CONCLUSIONS--Education should be targeted at the Vietnamese community of southern California to improve knowledge that HIV cannot be contracted through casual contact, to convey information about methods for self-protection, and to reduce high risk sexual practices such as unprotected sex, sex with multiple partners and sex with prostitutes.

Improving the cost-effectiveness of AIDS health care in San Juan, Puerto Rico

In an era of decreasing availability of funds and increasing demand, the AIDS epidemic threatens to overwhelm health-care services in some countries. We describe a comprehensive model for the treatment of AIDS in San Juan, Puerto Rico, and compare it with traditional hospital-based services. Given the existing allocation of funds, the comprehensive model emphasised prevention, education, surveillance, early detection, and outpatient care to reduce hospital care. In 1987, the last year of the traditional system, there were 95 admissions of AIDS patients to hospital, and in 1988, the first year of the comprehensive model, there were 100 admissions. The mean length of stay of AIDS inpatients was reduced from 22.3 days in 1987 to 11.3 days in 1988, a 46.8% reduction (p = 0.001). The annual mean (SE) cost of inpatient care per AIDS patient fell from

Barriers to health care access and utilization among vietnamese Americans in Southern California

15,118 (1699) in 1987 to

AIDS and prehospital personnel: knowledge and prevention of occupational exposure.

3869 (659) in 1988. Savings were used to improve non-hospital services, including outreach, education, emergency and outpatient care, laboratory and epidemiological services, and research, and to introduce an employee incentive scheme. Management strategies that reduce the length of inpatient care and provide less costly treatment alternatives can improve AIDS health care in developing nations.