Health data collection at hospitals is a responsibility of the health information department and performed by Health Information Management (HIM) / Medical Records (MR) practitioners. It is common for hospitals to generate monthly and annual reports that describe the number of patients treated and the types of services delivered. The data to generate the monthly and annual reports are typically based on patient data relating to a single patient, such as his/her diagnosis, name, age, earlier medical history etc. from a single patient-health care worker interaction.
For instance, when a patient visits a hospital, a variety of details may be recorded, such as the patient’s temperature, their weight, and various blood tests. Should this patient be diagnosed as having “Vitamin B 12 deficiency anaemia, unspecified”, HIM/MR practitioners are all too familiar to code the diagnosis as corresponding to ICD-10 code D51.9, this particular interaction might eventually get recorded as an instance of “Anaemia” in an aggregate based system, that is reported in the monthly morbidity report, for example.
Patient based data is important when you want to track longitudinally i.e concerned with the development of patients over time. For example, if we want to track how a patient is adhering to and responding to the process of TB treatment in Malaysia (typically taking place over 6-9 months), we would need patient based data.
Aggregated data differs from patient based data.
It is the consolidation of data relating to multiple patients, and therefore cannot be traced back to a specific patient. They are merely counts, such as incidences of Malaria, TB, or other diseases. Typically, the routine data that a hospital deals with is this kind of aggregated statistics, and is used for the generation of routine reports and indicators, and most importantly, strategic planning within the health system. Aggregate data cannot provide the type of detailed information which patient level data can, but is crucial for planning and guidance of the performance of health systems.
HIM/MR practitioners know very well that patient data is highly confidential and therefore must be protected so that no one other than doctors can get it. For HIM/MR practitionerswho continue to work with paper-based medical records, they are very aware that it must be properly stored in a secure place. For HIM/MR practitionerswho choose to work with computers (EMRs/EHRs), they are aware that patient data needs secure systems with passwords and restrained access.
With the kind of introduction above laid out before you, I am going to write about the Joint Commission International (JCI) Standard MCI.20.1 which states that “The organization has a process to aggregate data and has determined which data and information are to be regularly aggregated to meet the needs of clinical and managerial staff in the organization and agencies outside the organization.”
JCI Standard MCI.201. has specific requirements.
The first requirement for JCI Standard MCI.20.1 is to ensure that hospitals as “The organization has a process to aggregate data in response to identified user needs.”
The second requirement is when the hospital as “The organization provides needed data to agencies outside the organization.”
Given the wide issues of concern for the above two requirements I shall not rush to complete writing about JCI Standard MCI.20.1 for the sake of publishing on the web in a hurry while compromising the quality of the posts.
I like to say once again that what I am blogging about in posts like this one is simply a collection of my experiences and working knowledge accrued over the long years. I hope the posts I bring you in this blog convey best practices in HIM/MR which I hope young HIM/MR practitioners can learn to improve and the senior ones to compare, re-learn and adapt to bring HIM/MR practices to a higher level.
However, I am not implying what I am blogging here is all the gospel truth about standards to maintain or processes and procedures which need to be followed, as what I have written about are not carved in stone.
I ask you as the reader to make meaningful comments on posts I bring. I wish to continue to learn in the process and grow.
I shall post about the first requirement of the two requirements for this standard in my next post for this standard.
References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
When devising a plan of anaesthesia care, the anaesthesia planning process includes educating the patient, his or her family, or decision maker on the risks, benefits, and alternatives related to the planned anaesthesia and postoperative analgesia.
Educating the patient, his or her family, or decision maker on the risks include the following factors to consider when formulating a planned anaesthetic, usually hampered by individual patient variability:
persuading patients who may express a fear of dying during anesthesia that anaesthesia is very safe (Ronald & Manuel, 2011)
certain prescription drugs (antihypertensive, tranquilisers, steroids, and diuretics) and over-the-counter (OTC) medications and herbal preparations, can increase (Sue & Patricia, 2011) the patient’s anaesthesia risks. Surgical patients with chronic diseases at risk taking numerous medications can cause complications during the perioperative period and also increase the patient’s anaesthesia risks. The anaesthesiologistwill advise the patient, family, and decision makers which medication(s) must be stopped at least 2 weeks prior to surgery, or the surgery may be canceled.
the patient’s co-morbid conditions i.e coexisting diseases
other risks include peripheral nerve damage, brain damage, airway trauma (most often caused by difficult tracheal intubation), intraoperative awareness, eye injury, fetal/newborn injury, and aspiration.
The use of regional anaesthesia has significant benefits for patients and facilities. For example, regional anaesthesia for patients undergoing orthopedic procedures decreases (Ronald & Manuel, 2011) overall anaesthesia when compared to general anaesthesia and postanaesthesia care unit (PACU) discharge time can be shortened and the immediate postoperative period made more pleasant for the patient.
The patient, his or her family, or decision maker will be educated on the choice of anaesthesia, whether it is to be either general, or regional or sedation and will be influenced by (Ronald & Manuel, 2011):
site of the surgery
position of the patient during surgery
risk of aspiration
age of the patient
patient cooperation
anticipated ease of airway management
coagulation status
previous response to anaesthesia
preference of the patient
This discussion on the risks, benefits, and alternatives related to the planned anaesthesia and postoperative analgesia occurs as part of the process to obtain consent for anaesthesia (including moderate and deep sedation) as required in PFR.6.4, ME 2, which I have already blogged about in the post Informed Consents – 5 required documentation in the medical record providing information to patient and family (this link will open in a new link of your current window).
An anaesthesiologist or a qualified individual provides this education.
If a hospital has been accredited for Joint Commission International (JCI) accreditation status or already enjoying JCI accreditation status or because a hospital is going for a re-survey by JCI surveyors for another new term of JCI accredited status, then a Health Information Management (HIM) / Medical Records (MR) practitioner is likely to be part of a team using the Medical Records Review Tool form during any one Medical Records Review session which contains the JCI Standard ASC.5.1 to test for conformance to its requirement which states that “The risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.”
Although this standard does not require any form of documentation in the medical record, HIM/MR practitioners must take note that risks, benefits, and alternatives that are discussed with the patient, his or her family, or those who make decisions for the patient are normally recorded by the surgeon or anaesthetistin the Preanaesthesia Evaluation Note.
References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
Ronald, DM & Manuel, CP Jr 2011, Basics Of Anesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA
Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA
I fist read about – from reading the September issue of CHIP Malaysia, an IT magazine I purchase from time to time, a move to streamline medical records into a centralised system utilising virtualisation technology supplied by VMware, the market leader in virtualisation at the University of Malaya Specialist Centre (UMSC). This article was too short and hard for me to understand about ‘virtualisation’. I decided to find out more, prepare a post on this blog, and here is what I like to share with you readers. In this post I shall focus a little on virtualisation techonlogy – hoping you and I can understand it better, and how UMSC hopes to decentralise medical records, and its benefits.
The UMSC is a private medical centre within a publicly funded, 1,300-bed teaching hospital called the University of Malaya Medical Centre (UMMC), both operated by the University of Malaya. UMSC provides the public access to world-class specialist clinical services with the support from about 200 clinicians and another 250 nursing and support staff.
Image credit : http://sprouti.com/
The VMware website explains that virtualisation is about how “today’s x86 computer hardware was designed to run a single operating system and a single application, leaving most machines vastly underutilized. Virtualization lets you running multiple virtual machines on a single physical machine, with each virtual machine sharing the resources of that one physical computer across multiple environments. Different virtual machines can run different operating systems and multiple applications on the same physical computer. “
You can watch this video and learn how virtualisation works.
Source of the video above : http://www.vmware.com/virtualization/
I am sure many of you readers out there will feel intimidated watching and understanding all the IT jargon in this video.
Allow me to describe a little about virtualisation, and tell you how servers we know about can be transformed into virtual machines, which is what basically virtualisation is all about.
Most of you will know and surely heard of servers and networks. A server is a physical computer dedicated to running one or more services to serve the needs of the users of other computers on the network, the “clients”. Servers usually run a single operating system and a single application. You would have heard the IT guy talking about a database server, file server, mail server, print server, web server, gaming server. Each of these kind of named serves run a single operating system and a single application, depending on the computing service that each of these servers offer. This is the traditional way servers are managed, in a simple way of understanding You would have noticed several servers (computers) all located in a server room. Since servers are designed to run a single operating system and a single application, these leaves most of such computers (machines) vastly underutilised. This is when the virtualisation technology steps in.
Virtualisation converts any one server which is a single physical machine, into mutliple virtual machines inside it, with each virtual machine sharing the resources – including the CPU, RAM, hard disk and network controller of that one physical computer across multiple environments. Different virtual machines inside any one server can run different operating systems including Windows, Linux and more and multiple applications, for example Oracle, Exchange, SQL Server, Sharepoint and SAP, on the same physical computer. Thus, the old “one server, one application” model is eliminated. This frees IT admins from spending so much time managing servers.
Healthcare IT infrastructure in healthcare settings in many places as it was at UMSC, is a very traditional environment of complex, device-centric computing made up of autonomous content factories or “silos” with inherently incompatible technologies, product-specific workflows, uncoordinated content development, efforts resulting in overlapping content, linear workflows to produce multiple deliverables from each product’s content.
Medical records in most hospitals in Malaysia are still not centralised, scattered across departments often keeping their own documents making it diffiucult to collate them. This often leads to long delays in patients getting treatment.
In the pursuit of a new strategy for content ubiquity (that is to say the state or capacity of the contents of medical records being everywhere, especially at the same time), UMSC seeked solutions to change its fragmented, legacy IT systems of a decentralised medical records system into cost-effective, agile computing infrastructure environments. UMSC wanted to concentrate the data and make it readily available for their medical personnel to access.
According to Leon Jackson, Head of IT, UMSC, in the past doctors could end up using as many as three terminals simultaneously to access the necessary information to treat a patient. Jackson was hired in 2009 to help develop UMSC’s IT system for its new premises in 2016. He started the hospital on a journey which would see the digitisation of existing workflow and adopting virtualisation to drive efficiency and making a move toward a unified virtualised IT environment. Jackson believes this is one of the easiest ways to gain a competitive edge in the medical industry.
The solution process faced a specialised set of infrastructure and end-user requirements to support the digitisation of biomedical imaging and other medical information, to enable/ease basic clinical processes via electronic workflows, and to provide personal desktop environments that could be accessed on mobile devices, and via terminals throughout UMSC including in sterile and electronically sensitive areas such as operating theaters which allow for more “sterile” equipment through the deployment of thin-client touchscreens with washable mice and keyboard.
UMSC wanted to deliver a more user-centric (that is to say in which the needs, wants, and limitations of end users of a product are given extensive attention) connected care computing infrastructure environment to boost the availability of systems needed to treat patients effectively, the encouragement of clinicians to embrace digitisation, and meet demand for new medical services applications.
After evaluating options, UMSC decided on VMware. VMware claims that VMware virtualisation solutions have been chosen by over 250,000 customers, including 100% of the Fortune 100.
VMware’s solution to UMSC was for a more user-centric computing infrastructure environment which enables higher quality on-demand experience which allows new ways for clinicians to collaborate across applications and data from any device, where and when they need. In this way, more clinicians and healthcare consumers were expected to leverage hybrid cloud resources, while maintaining a managed, secure environment to use their applications and services, through which healthcare providers will be able to deliver better services at lower costs.
We know for a fact that patient care happens everywhere – bedsides, remote offices, homes, labs and these days in the cloud. These varied locations require providers to manage a variety of unique desktop environments, ranging from workstations on wheels to high-traffic nursing stations to inpatient room computers.
UMSC hopes to benefit from this automated and efficient ubiquitous IT system in the following ways:
speeding up clinicians’ access to various clinical information systems across different devices, including mobile and fixed terminals providing the continuous availability necessary to clinicians delivering tertiary care, and to all delivery units using IT to improve patient management.
provides better decision support to clinicians and increases efficiency that will lead to reduced waiting times and UMSC being able to see more patients
cutting server hardware and infrastructure spending to 60 percent of the cost of an all-physical infrastructure; vendors that could not adapt to its new infrastructure were gradually phased out
a system that responds quickly to clinicians’ requirements and helps provide a better service to patients; minimising unplanned downtime; and redirects IT spending to support new application delivery
deploy new virtual machines in minutes to support staff requirements, rather than waiting weeks or months to procure and implement new physical servers
VMware View desktop virtualisation provides the surgical team with a ”follow-me desktop’ that helps them access the same data from multiple devices within the private network; surgical work is considered to be typically not conducive to carrying mobile devices, so for surgeons a ‘follow me’ desktop accessible from fixed terminals anywhere within the UMSC buildings is ideal
clinicians will be able to consume and contribute information to and from the patients records at the point of care, improving efficiency, reducing errors and the need for clerical support plus time wasted treasure hunting for information; for example, that if a doctor was giving a lecture on campus and received a call from a nurse, he would be able to remotely access his files and provide the required information for a particular patient
For your information, UMSC is currently running about 100 VMware View desktops, and expects to increase this over the following year to 300 concurrent users. Jackson revealed that to support this migration, UMSC had invested up to 4 percent of its revenue each year for the last three years on IT.
Also on the pipeline by the end of Q3 2012, is when all clinicans will use iPads to access a virtual Windows 7 desktop incorporating legacy thick-client (thick-client meaning, “intelligent” regular Windows applications installed on the local machine i.e the client machine, capable to processing more data locally on the client) applications together with new mobile applications for its hospital information systems.
References:
Avanti, K 2012, How VMware is helping to ‘free’ Malaysian healthcare, Computerworld Malaysia, viewed 22 September 2012, <http://www.computerworld.com.my/resource/applications/how-vmware-is-helping-to-free-malaysian-healthcare/>
CHIP Malaysia, Making Sense of Medicine, September 2012, Online Dynamics (M) Sdn. Bhd., Petaling Jaya, Selangor Malaysia
Farhan, G 2012, 01/08/2012, Cloud medicine at UMSC, PC.com Malaysia, viewed 25 September 2012, < https://www.liveatpc.com/cloud-medicine-at-umsc>
Ryan, H 2012, M’sia hospital prescribes virtualization for healthcare sector, ZDNet, viewed 25 September 2012, <http://www.zdnet.com/my/msia-hospital-prescribes-virtualization-for-healthcare-sector-7000002976/>
VMware, viewed 22 September 2012, <http://www.vmware.com/>
VMware Customer Case Study, Medical Center’s Virtualization Journey Boosts Patient Care and Transforms Medical Systems, VMware, viewed 26 September 2012,<http://www.vmware.com/files/pdf/customers/
VMware_University_Malaya_Specialist_Centre_12Q2_EN_Case_Study.pdf>
Previous posts about patient informed consent on this blog provided insight into required documentation in a medical record, and they were built upon requirements on:
how a process defined by the hospital and carried out by trained staff in a language the patient can understand, facilitates acquiring patient informed consent
how patients and families can make care decisions after they receive adequate information about the illness, proposed treatment(s), and about health care practitioners who have primary responsibility for the patient’s care or who is authorised to perform procedures or treatment(s)
informed consent which is obtained before surgery, anaesthesia, use of blood and blood products, and other high-risk treatments and procedures
Image credit : http://www.eidohealthcare.com/
In this post I shall discuss about a hospital process within the context of existing law, culture, and custom when others can grant informed consent as the last required documentation in the medical record for patient informed consent.
Informed consent is based (Michelle & Mary, 2011) upon the principle of autonomy which refers to an individual’s right to choose and the ability to act on that choice. The individuality of a patient as an individual with a right to decide for them is respected when autonomy is maintained.
A frequently occurring ethical dilemma confronting autonomy is when informed consent for care sometimes requires that people other than (or in addition to) the patient be involved in decisions about the patient’s care. This is especially true when the patient does not have the mental or physical capacity to make care decisions, when culture or custom requires that others make care decisions, or when the patient is a child. It should not be surprising that the process of seeking informed consent when informed consent for care sometimes requires that people other than (or in addition to) the patient be involved in decisions about the patient’s care presents doctors and other health professionals with difficult ethical issues.
When the patient is a child, parental or guardian consent should be obtained before treatment is initiated on a minor. If a patient is a minor and the parents or legal guardian deny a lifesaving treatment, a court may be obtained by the hospital authorities to overrule the decision.
When a patient is either comatose or near death, there is usually knowledgeable concurrence by the prescribing doctor who writes a do not resuscitate (DNR) order and the patient’s family or guardian about actions to prolong the patient’s life. The principles of informed consent must be respected by the prescribing doctor. A hospital will have policies in place that provide a mechanism (process) that respects local law, culture, and custom for reaching a DNR decision as well as for resolving conflicts in decision-making.
At a later time, if a patient with dementia is unable to give informed consent for procedures and thus unable to make decisions competently, responsibility for decision-making often falls on the family. The family can make decisions on behalf of the patient, using the patient’s expressed preferences from an advance directive stating the his or hers preferences for caregiver procedures, treatments, and life-sustaining measures, completed while he or she was still mentally competent to understand and make health decisions.
Parents and guardians will be required to provide informed consent to disclose to those who need to know a minor’s human immunodeficiency virus (HIV) status to provide medical care and services care. Such confidential HIV related information will indicate that the minor had an HIV-related test; or has HIV infection, HIV-related illness, or Acquired Immunodeficiency Syndrome (AIDS) or any information that could indicate that the minor has been potentially exposed to HIV.
The Joint Commission International (JCI) requires that a hospital “establishes a process, within the context of existing law and culture, for when others can grant consent” and “individuals, other than the patient, granting consent are noted in the patient’s record” through its Standard PFR.6.2 (JCI, 2011).
In all circumstances irrespective if the hospital is JCI accredited or not, Health Information Management (HIM) / Medical Records (MR) practitioners must look out for relevant informed consent form documentation that must be available in the medical record for a (i) minor, (ii) mentally incompetent patients, (iii) DNR patients, (iv) patients with dementia, and (v) minors diagnosed or suspected as HIV infected.
HIM/MR practitionersmust be aware that informed consent will not be present in the medical record for patients in certain extreme emergencies such as when an unconscious patient is admitted to an emergency room and procedures may be performed without specific written or verbal consent, as no one may be available to give consent. HIM/MR p can update their awareness by checking out specific protocols in documentation maintained for example from their hospital Quality Department that must be followed for example, (i) that allow for two doctors to sign an emergency consent, and (ii) a court order to administer treatment is obtained for cases of extreme emergencies.
A hospital policy usually contains clauses to the above exceptions for informed consent when others can grant consent within the context of existing law and culture. I like to advise HIM/MR practitionersto also check out relevant hospital policy to reference and formulate a section on informed consent HIM/MR best practices including circumstances when other can give consent on behalf of patients, in the Medical Records Policy.
References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA
A hospital’s primary purpose is to provide patient care and to work to improve patient care outcomes over time by applying quality improvement principles. To reach conclusions and to make decisions on how to work to improve patient care outcomes over time, requires access to a wide range of information from varying sources.
Each time patients receive health care, a record is generated to document the patient’s current symptoms,medical history, results of examination, treatments rendered along with outcomes, ancillary report results (e.g., laboratory), diagnoses, and plans for treatment. This patient data is organised, analysed, and maintained by Health Information Management (HIM) / Medical Records (MR) practitioners working in hospital settings to ensure the delivery of quality health care.
Data collection and analysis processes entail combining patient care data from various sources and transformed into useful information. But the ability to collect and analyse data within and across hospitals is hampered by different information systems and processes, and by the highly complex and fragmented nature of health care systems.
Converting data into meaningful information for decision making calls for the expertise of trained and qualified professionals. The data analysis process involves individuals who will be among medical, nursing, and other departmental heads who participate in relevant quality improvement and patient safety processes. These indivuals must understand information management, have skills in data aggregation methods, and know how to use various statistical tools and techniques when suitable, and participate in the process.
Understanding statistical techniques is helpful in data analysis, especially in interpreting variation and deciding where improvement needs to occur. Every system has variation; some of this is due to the system itself, known as common cause variation; some of it is due to singular incidents or special situations; this is special cause variation. 94 percent of problems (or possibilities for improvement) lie with the system as common-cause variation; 6 percent are special causes (Deming, 1982). In understanding trends and variation in health care, statistical tools for example run charts, control charts, histograms, and Pareto charts can prove to be useful statistical tools to know. Examining data over a period of time and making decisions based on trends or other patterns, will save time, energy, and other resources.
HIM/MR practitioners are trained in managing patient health information and medical records, administering computer information systems, and coding diagnoses and procedures for health care services provided to patients, and have an understanding of statistical techniques as part of their training and education. I believe their unique knowledge and expertise in hospital management information systems will enable strong partnerships beween them and with clinical and management teams to advance the quality and safety of patient care delivery.
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Data analysis must provide continuous feedback of quality management information to help those individuals make decisions and providing continuous quality improvement, and allocating limited resources to optimise quality and effectiveness. Thus, results of data analysis need to be reported to those individuals responsible for the process or outcome being measured and who are accountable for taking action of the results.
Hospitals which have adopted the Joint Commission International (JCI) hospital accreditation program, and who are already JCI acredited or hospitals seeking JCI accreditation status or hospitals that are seeking for a re-survey for JCI accreditation status, have to comply with JCI Standard QPS.4, which specifically requires that individuals in a hospital with appropriate experience, knowledge, and skills systematically aggregate and analyze data using statistical tools and techniques when suitable and transform the data into useful information. This standard also requires that “Results of analysis are reported to those accountable for taking action.”
It is imperative from the above that HIM/MR practitioners practicing in hosptitals with a quality improvement and patient safety program such as hospital accreditation are likely individuals who will be among medical, nursing, and other departmental heads who participate in relevant quality improvement and patient safety processes. HIM/MR practitioners as trained individuals to understand healthcare information management, have skills in data aggregation methods, and know how to use various statistical tools and techniques, and thus I believe they will be best suited for this role.
References : American Health Information Management Association (AHIMA) 2011, HIM Functions in Healthcare Quality and Patient Safety, Viewed 15 September 2012 < http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049122.hcsp?dDocName=bok1_049122>
Deming, WE 1982, Out of the Crisis, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
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