Patient Access and Amendment to Medical Records

Hello readers. I am not a writer but I just maintain and write blog posts for this website / blog as its rightful owner.

Like most writers, I too have become an inveterate procrastinator. In the course of writing for this website / blog, I had actually dumped my gold standard and writing policy to make sure that I have at least written frequently something that someone would actually want to read over the past months.

As 2015 is fading away, here I have now this new post and hope to endeavour with more posts into 2016 and also take a moment to breathe and probably as psyched as you may have watched Kylo Ren in Star Wars: The Force Awakens who has the following dialogue, “Nothing will stand in our way. I will finish what you started.”, and now say to myself and tell you readers that “Nothing will stand in my way. I will finish what I started.”, by finishing some unfinished blog posts in the course of 2015 and continue to write in MRPALSMY.

Paper-based medical record practitioners, doctors and healthcare management have been influenced for example after attending healthcare conferences and lured by vendors of the promise that Electronic Medical Records (EMRs) were supposed to improve patient care and make doctors’ lives easier, do away with paper documents, and provide greater governance and stewardship for medical records practitioners.

Unfortunately, the promise of how EMRs are supposed to be in theory, haven’t worked out as well in practice as they were to be.

A detailed report in the Chicago Tribune, laments how doctors in the U.S. are even looking forward to retiring because these doctors are crying out in pain over an increasing  “burnout“ to the demands of clicking through page after page of records.

Their predicament was compounded from the findings of a new 2015 survey by Accenture PLC which found that fewer U.S. doctors believe that the EMR has improved treatment decisions, reduced medical errors or improved health outcomes. This is compared to a similar study conducted in 2012.

Headquartered in Dublin, Ireland¸ Accenture PLC is the world’s largest consulting firm and as the world’s most admired Information Technology Services Company – providing multinational management consulting, technology services, and outsourcing.

Accenture PLC had commissioned a six-country online survey of 2,619 doctors to assess their adoption and attitudes toward electronic health records and healthcare IT. The survey conducted by Nielsen between December 2014 and January 2015 included doctors across six countries, which included neighboring Singapore (200 respondents) and the U.S. (601 respondents).

Another recent study by Mayo Clinic researchers, working with the American Medical Association, further strengthened the case against the use of EMRs which found that more than half of physicians felt emotionally exhausted. Heavier workloads and “increased clerical responsibilities.” were among the chief complains.

But all is not bad for EMRs.

There is evidence that EMRs are helping patients to get more access to their medical information.

In Malaysia, a patient’s medical record on which the paper it was printed on belongs to the medical practitioner and the healthcare facility and its services. Thus, the medical practitioner and the healthcare facility and its services hold all rights associated with ownership of the physical medical record.

Nonetheless, the contents of a medical record jointly belong morally and ethically between the practitioner and the patient, simply because the practitioner who wrote the medical record holds the intellectual property right over the medical record while the patient who confided with the practitioner considers his or her “confidential” information therein contained in the medical record as “private” in observance of the on-going ethical doctor-patient relationship.

This longstanding Malaysian, almost a decade old guideline on medical records by the Malaysian Medical Council concurs well with the universal and traditionally accepted view that the information contained within the health / medical record belonged to the individual patient, and the paper it was printed on belonged to the healthcare facility.

This guideline further acknowledges and asserts that since the patient views that all the information contained in his/her medical records (i) is about him/her, (ii) that he/she should have access to records containing information about his/her medical condition for legitimate purpose and in good faith between the practitioner and him/her, (iii) he/she has a right to know what personal information is recorded, (iv) rightfully expects the records are accurate, and (v) also knows who has access to his/her personal information.

The patient’s views that all the information contained in his/her medical records (i) is about him/her, (ii) that he/she should have access to records containing information about his/her medical condition for legitimate purpose and in good faith between the practitioner and him/her, is supported by the findings from the 2015 Accenture study which shows there is evidence in the U.S. in particular, that increased access to online medical records in particular has provided patients (55 percent) with better understanding of their illness as well as having a positive impact on patient-doctor relationship.

While patients have right of such access to their medical records, the Malaysian guideline does not say if patients may be permitted to make their own changes to the mostly paper-based medical record systems available in Malaysia, and stops at proclaiming that the Malaysian patient rightfully expects the records are accurate.

The 2015 Accenture study also does not report if patients are allowed to alter medical records in the U.S., but reports that patients there do monitor their medical records and inform the practitioner of any factual errors in their personal patient information and seek to change any entries made by the practitioner in the course of consultation, diagnosis and management, thus increasing the accuracy of their medical records (60 percent).

I rest the case for EMRs that promises better patient care, which is accentuated by findings from the Accenture survey that a high percentage (82 percent of respondents) of U.S. patients when allowed by their doctors to update their own medical records, it increases their engagement in their own health as well as improves patient satisfaction, boosts understanding of their health conditions, increases patient and physician communication.

Readers can view an infographic below which summarises the 2015 Accenture study.

2015 Healthcare IT Check-Up Shows Progress (And Some Pain)

Infographic credit: Accenture PLC

In Malaysia, since we do not have specific laws or regulations that address how amendments should be processed in medical records, I think it is about time healthcare organisations in Malaysia structure their practices to comply with the greater awareness and requirements of patients’ rights and the promise of better health care in Malaysia through both paper-based and electronic medical records.

References:

  1. Accenture, 2015, Accenture doctors survey 2015: Healthcare IT pain and progress, Accenture PLC, [https://www.accenture.com/us-en/insight-accenture-doctors-survey-2015-healthcare-it-pain-progress.aspx]
  2. John, R 2015, Beleaguered by electronic record mandates, some doctors burning out, Chicago Tribune, [http://www.chicagotribune.com/business/ct-doctors-hate-records-mandate-1213-biz-20151211-story.html#]
  3. Malaysian Medical Council , 2006, Medical Records And Medical Reports, Guideline Of The Malaysian Medical Council, http://mmc.gov.my/v1/docs/Medical%20Records%20&%20Medical%20Reports.pdf]
  4. Patricia, C 2011, Patient Access and Amendment to Health Records (Updated), American Health Information Management Association (AHIMA), [http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048587.hcsp?dDocName=bok1_048587\]

EHR-related Safety Events

Hospitals around the globe are fast implementing or are now expanding on the use of Electronic Health Records (EHRs). The notion is that hospitals are able to provide better quality of care and at the same time, ensure improved productivity for providers with computer equipment hosting the EHRs.

While we watch the whole world marching onwards in implementation and expansion of EHRs, readers are reminded of the aspects of patient safety as defined by the World Health Organisation, which is to prevent errors and adverse effects to patients that are associated with health care.  Safety is what patients, families, staff, and the public are likely to expect when they are at hospitals. Thus the safety net must not only safeguard patients but staff caring for the patients and visitors to hospitals. As such, safety controls from hazards or risks posed by buildings, grounds, and equipment (JCI 2013) such as computers and EHRs to patients, families, staff, and the public must be in place at hospitals to prevent safety related events.

In this post I have summarised graphically into three (3) charts contributing factors for EHR-related Safety Events and on how to prevent, mitigate, and react to them. The facts presented in the charts are based on the opinions given by three (3) Joint Commission Resources (JCR) and JCI consultants on the ever-increasing EHR lawsuits in the United States between 2013 and 2014, as was reported recently in Becker’s Health IT and CIO Review.

The Charts 1 and 2 show eight (8) common causes of EHR-related safety events as follows:

  1. user error
  2. EHR builds
  3. workflows
  4. limited EHR interoperability across all three levels of health information technology interoperability i.e. foundational, structural and semantic levels
  5. deficient provider EHR education
  6. poor post-deployment vendor or institutional support
  7. losing sight of EHR best practices
  8. organisations that do not have a well-organised paper medical record cannot describe what they want in an EHR thus leading to work arounds 

EHR-related-Safety-Events-1

EHR-related-Safety-Events-2Chart 3 presents six (6) ideas on what can be done to decrease the number of EHR-related safety mistakes which are:

  1. need to make end users aware of the potential this technology has to contribute to safety events
  2. encourage the reporting of events that may be related to EHRs
  3. if an EHR-related safety event occurs, the event should be analysed
  4. resources should be available to address post go-live optimization
  5. third party consultants
  6. use patient safety and standards and processes as the structure for appraisal and guidance

EHR-related-Safety-Events-3As we in this part of the world are implementing quality standards from the JCI, appraisal and guidance to focus on and prevent EHR-related Safety Events can be found in the Leadership chapter and the Management of Information chapter found in Joint Commission International Standards for Hospitals, as recommended by these three (3) Consultants.

I like to conclude that while hospitals worldwide are riding the wave of implementing or now expanding on the use of EHRs, it is best to be aware of whatever the contributing factors to EHR-related Safety Events maybe including those identified in this post, and to be accountable to prevent or minimise such events with awareness and the necessary knowledge as outlined by the above mentioned Consultants.

References:

  1. Healthcare Information and Management Systems Society(HIMSS) 2015, What is Interoperability?, viewed 18 June 2015, < http://www.himss.org/library/interoperability-standards/what-is-interoperability>
  2. HealthITInteroperability 2015, HealthITInteroperability Definitions, viewed 18 June 2015, <http://healthitinteroperability.com/glossary>
  3. James,  S., The Book on Healthcare IT: Volume 2, 2015
  4. Joint Commission International 2015, JCR and JCI Consultants on Reducing and Preventing EHR-related Safety Events, viewed 18 June 2015, <http://www.jointcommissioninternational.org/jcr-and-jci-consultants-on-reducing-and-preventing-ehr-related-safety-events/>
  5. Joint Commission International 2013, Joint Commission International Accreditation Standards For Hospitals, 5th edn, JCI, USA
  6. Margret, A., Process Improvement with Electronic Health Records A Stepwise Approach to Workflow and Process Management, 2012, CRC Press, Florida, United States of America
  7. World Health Organisation 2015, Patient safety, viewed 18 June 2015, <http://www.who.int/patientsafety/about/en/>

8 strange ICD codes

Sometimes we encounter morbidity and mortality conditions that are amusingly unconventional and idiosyncratic to apply the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) code or the 2015 American International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.

Let’s delve into the infographic below (click on the infographic to view a larger image in a new tab of your current window) from Healthcare IT News  (a publication of  HIMSS Media which is a media organisation serving today’s healthcare industry, including all major healthcare organisations), and hope to find appropriate ICD-10 codes for them.

On verifying the codes given in the infographic, I found them to have similar variations in ICD-10 when compared to the ICD-10-CM codes. Let’s look in detail each of these 8 zaniest codes using the ICD-10-CM and how the differ when using ICD-10.

The first code from the infographic is Z63.1

It was not quiet easy to find an equivalent code for Z63.1 in ICD-10. In ICD-10 there is Z63 but you will need to cross reference with other codes to find hints for lead terms found among other codes belonging under a three-digit category. For example, Z63.1 is one of the several four-digit categories belonging under the three-digit category Z63.

Since “Family discord NOS” is classified to “Other specified problems related to primary support group” with code Z63.8; but when a family discord in relation to or with parents and in-laws is the situation with a presenting patient, then Z63.1 is the appropriate code.

Another example would be when the patient is a “Dependent relative needing care at home”. If the dependent relative is a parent and in-law(s), then code Z63.1 is the appropriate code since this code qualifies with specificity who the dependent relative is, since the parent or the in-law would be an elder or aged. So rather than using code Z63.6 which is for “Dependent relative needing care at home”, use Z63.1 when the dependent relative is a parent or an in-law.

Asphyxiation due to being trapped in a (discarded) refrigerator, accidental has the ICD-10-CM Diagnosis Code T71.231D, which differs from ICD-10.

ICD-10 differs from ICD-10-CM when two codes for asphyxiation due to being trapped in a refrigerator which may be accidental, one from Chapter IX Injury, poisoning and certain other consequences of external causes  and the other from the Chapter XX External causes of morbidity and mortality.

The ICD-10 code T71 from Chapter IX is used for the asphyxiation from systemic oxygen deficiency due to low oxygen content in ambient air. The ICD-10 code W81 from Chapter XX  is used fo describe the circumstances when the patient was found confined to or trapped in a low-oxygen environment including accidentally shut in or trapped in refrigerator. No mention of “discarded” is found for the ICD-10 code W81 if the refrigerator was indeed discarded.

ICD-10 code V97.3 only specifies if the person on ground injured in air transport got sucked into jet unlike ICD-10-CM which has a unique code when person sucked into jet engine with code V97.33XD, “engine” as the addition qualifying term used here.

The exclusion note for “Falls“ includes falls into water (with drowning or submersion) in ICD-10 is classifiable to codes ranging from W65 to W74 which are conditions due to accidental drowning and submersion. There is no code found for accidental drowning and submersion from a fall into a bucket under codes W65 to W74. So we are left only with using the code W74 “Unspecified drowning and submersion” which includes “fall into water NOS”.

This differs greatly from the ICD-10-CM code W16.221 which is for “Fall in (into) bucket of water causing drowning and submersion”, which could happen if the patient was a toddler.

V91.7 applying the fourth-character subdivision “.7” is the most likely ICD-10 code to use for an accident to watercraft for example a burn to water-skis (which is a watercraft) causing other injury (in this case a burn), when compared to ICD-10-CM V91.07XD for a burn due to water-skis on fire.

Walking into a stationary object is to say “striking against or struck by other objects” describing the ICD-10 code W22. From the infographic, the stationary object is a lamp post. ICD-10-CM uses the code W22.02XD in this instance.

Hair causing external constriction is the cause when an item like hair is causing the external constriction. The ICD-10-CM code W49.01XD is for a subsequent encounter when hair is causing an external constriction. In ICD-10, the equivalent would be to use the code W49 for “Exposure to other and unspecified inanimate mechanical forces”. Here the inanimate mechanical force (the constriction) is from the hair.

Animal-rider injured in collision with streetcar or trolley uses the ICD-10-CM code V80.730A for an initial encounter. I think the ICD-10 code V80 Animal-rider or occupant of animal-drawn vehicle injured in transport accident best describes a similar accident. You will also need to find a ICD-10 code for the injury as a consequence of the external cause.

8 Strange-Codes

Infographic credit: http://himt.wisconsin.edu/blog/6-health-information-technology-infographics-need-see-right-now/

Now we have seen how weird some 8 conditions can be, and how we will know exactly which ICD-10 or ICD-10-CM code to use.

References:

  1. World Health Organization 2011, Volume 1 Tabular list, International Statistical Classification of Diseases and Related Health Problems 10th Revision, 2010 edn, Geneva, Switzerland
  2. 8 zaniest ICD-10 codes, 25 July 2013, Healthcare IT news, viewed 28 February 2015, <http://www.healthcareitnews.com/infographic/infographic-top-zaniest-icd-10-codes>

Tracking the Ebola outbreak (if any) in Malaysia

Ebola virus disease (EVD) – formerly known as Ebola haemorrhagic fever, its outbreak in West Africa with the first case notified in March 2014, and its effects around the world, continues to get news coverage.

As I write this article, the World Health Organisation (WHO) is investigating reports according to three media outlets that an undisclosed number of Islamic State of Iraq and Syria (ISIS) militants displaying signs of Ebola have been showing up at an Iraqi hospital in the ISIS-held city of Mosul, 250 miles north of Baghdad. Thus, Malaysians who are fighting there alongside other ISIS militants – and when they return, are likely to pose a real danger of exposing the Malaysian public with Ebola. Fortunately, the Ministry of Health Malaysia has in place a comprehensive “Guideline on Ebola Viral Disease (EVD) Management In Malaysia” which includes guidelines for healthcare providers to stay alert for and evaluate any probable case,  for example known persons who are returning from ISIS controlled regions. The guidelines ensures screening of an such an individual as a Person Under Investigation (PUI) since he or she was a contact of an EVD case with either a high or low risk.

The World Health Organisation (WHO) warns that the Ebola virus causes an acute, serious illness which is often fatal if untreated. EVD first appeared in 1976 in two African states, and takes its name when the second case occurred in a village near the Ebola River, in the Democratic Republic of Congo.

The International Classification of Diseases (ICD) Ninth Revision i.e. ICD-9 for morbidity and mortality coding was adopted by Malaysia by 1978. Since the Ebola virus was first discovered in 1976, Health Information Management (HIM) / Medical Records (MR) practitioners in Malaysia who had just started morbidity and mortality coding using ICD-9, would have coded any probable case of Ebola as “078.89, other specified diseases due to viruses”.

As the Ebola outbreak heightened after the West African outbreak in 2014, any eventuality of an outbreak in Malaysia will not impede our ability to track and respond to the virus within its own borders and makes it easier to share information with the rest of the world. Malaysia’s ability to immediately track and respond to the Ebola outbreak from a public health perspective will be possible with the specificity in patient data morbidity and mortality coding for EVD using the Tenth Revision of ICD i.e. ICD 10, as Malaysia would be able to use the ICD-10 code for the Ebola virus – A98.4 to assess the efficacy of treatment and outcomes. Malaysia adopted ICD-10 by 1 January 1999 in our morbidity and mortality reporting systems.

The infographic by the Coalition for ICD-10 below (click to enlarge the infographic which will open in a new tab of your current browser window), presents the public health benefits of using ICD-10 in the fight against Ebola.

EVD Infographic

References :

  1. Ebola virus disease, Fact sheet N°103 Updated September 2014, World Health Organisation (WHO),viewed 3 January 2015, ,< http://www.who.int/mediacentre/factsheets/fs103/en/ >
  2. Guidelines On Ebola, Ministry of Health Malaysia, viewed 3 January 2015, ,< http://www.moh.gov.my/english.php/pages/view/606 >
  3. ICD-10: A Common Language for Public Health, The Coalition for ICD-10,viewed 3 January 2015, ,< http://coalitionforicd10.org/2014/09/04/icd-10-a-common-language-for-public-health/ >
  4. ISIS fighters ‘have contracted Ebola’: World Health Organisation investigating reports militants showed up at Iraqi hospital with lethal disease, Mail Online, Saturday, Jan 3rd 2015, viewed 3 January 2015, < http://www.dailymail.co.uk/news/article-2894154/ISIS-fighters-contracted-Ebola-World-Health-Organisation-investigating-reports-Islamist-militants-disease-showed-Iraqi-hospital.html >

Patient in one system is the same patient in another system, The Master Patient Index, Introduction

health-information-analytics-series-posts-logoOne forum in a regional eHealth Information Network of which I am a subscribed member, has been actively having an open discussion of a subject of public interest in health Information Technology (IT) analytics in their public ListServ lists, this time around about the Master Patient Index (MPI).

It seems appropriate to me to talk about MPI and share what is in that forum that I can blog here, in a new series of blog posts named Health Information Analytics Series (HIAS), on MPI for the benefit of Medical Records PALS Malaysia readers outside that forum.

In getting the complete story on MPI, let’s start entering this post to know who is it about, when it takes place, what happens with it, where does it take place, why it happens, and how it happens.

The MPI is about the patient in a healthcare environment who attends an Emergency Department or an Outpatient Department or who gets admitted to the hospital. As the patient enters the healthcare environment, a medical record is started that according to Huffman (1990) “must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at the health care facility, justify the treatment and accurately document the results of that treatment”. As we are aware, since the medical record is a written collection of information about a patient’s health and treatment, they are used essentially for the present and continuing care of the patient. Individuals managing an individual patient’s data may be providers, or members of a health plan. For an efficient and effective medical record system, correct identification is needed to positively identify the patient and ensure that each patient has one medical record number and one medical record ONLY.

Many countries still do not combine outpatient attendance at the Emergency Department (ED) or an Out-Patient Department (OPD) or a Consultant (Specialist) Clinic (CC) together with admission as an inpatient. A separate numbering system is used for the ED or an OPD or a CC attendance. If the ED or an OPD or CC attendance is combined with admission as an inpatient, then the medical record begins with the patient’s first admission as an inpatient or attendance as an outpatient to the health care facility. Thus, a unit record is created during his or her stays at the health facility, visits to the ED and other facilities at a hospital (Margaret 2003).

The collection of identification information from the patient is the first stage in adding to the MPI found at a single electronic system level or the facility level. MPI can extend to enterprise or health information exchange (HIE) levels. Most health facilities worldwide have electronic systems while many still maintain MPI in paper format. In either format, the MPI is the single most important resource in a healthcare setting that links the patient’s activity within this setting and across the continuum of care, since the unit record never always stays in one domain of the care provider (Margaret 2003).

I shall not dwell too much into the basics of a MPI but will continue in the following post of these series of posts, to talk about the pitfalls as each provider tends to have its own way of assigning a unique numeric or alphanumeric medical record number in the absence of a local, or regional or a national patient identifier to a patient during the creation of a new patient file. I think I will also cover the essential building blocks for a clean, reliable and workable MPI, and how important is it to have one and much more, leading to trends in MPI development as discussed in the ListServ mentioned right at the beginning of this post.

References:

  1. Huffman, EK, 1990, Medical Record Management, 9th edn, Physicians’ Record Company, Berwyn. Illinois.
  2. International Federation of Health Information Management Associations (IFHIMA), Education Module for Health Record Practice, Paper 1, Module 2 – Patient Identification, Registration and the Master Patient Index, IFHIMA, 2014, viewed 18 August 2014, < http://ifhima.files.wordpress.com/2014/08/module2-patient-identification-registration-and-the-master-patient-index.pdf>
  3. Medical Records Manual: A Guide for Developing Countries, 2006, World Health Organisation, Western Pacific Region, Manila, Philippines
  4. Margaret, AS (ed.) 2003, Health Information Management: principles and organisation for health information services, 5th edn, Jossey-Bass, San Francisco