Monthly Archives: November 2022

My back hurts

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Paper documents have carried the medical industry for centuries.

Not too long ago before the rise of technology, paper medical records were the standard, and when managing medical records was a straightforward process of storing thick, color-coded paper charts in filing cabinets or on office shelves.

Even though paper medical records have enlivened the medical sector and brought about a quantum leap in patient care, they still have some shortcomings that cannot be overlooked.

However, for a lot of hospitals worldwide, paper records are all they’ve ever known.

Thus, it was a common scene when bundles of medical records were transported internally by Medical Records or other approved hospital staff. Although this practice has not gone away, it can still be seen happening in hospitals, especially in developing and less developed countries.

In the healthcare field, change is the only constant—something that we cannot avoid.

As practices have evolved and diagnostics and analytical tools have advanced, medical records management has also rapidly changed. Hospitals are now generating and retaining more patient information than ever before, including paper and electronic records.

In these situations, the barriers to switching to an Electronic Medical Record(EMR) are significant, like migrating archives that normally date back decades and hospital practices that would need to learn about EMRs, before they can start evaluating potential products.

All that to say, sticking with tried-and-true paper methods is appealing to a lot of providers.

Nonetheless, the EMR phenomenon has revolutionised healthcare. Healthcare providers are all too busy making a shift from dealing with mountains of paperwork to, for example, using touch panel PCs to maintain EMRs using the mobility of medical carts, which allows doctors to access and update patient records at the point of care with ease, instead of spending time digging through stacks of paper or staff carrying around paper-based medical records to reach the bedside.

Although we see change, I dare say that to this day, paper-based records aren’t completely obsolete, and many healthcare facilities worldwide are still using paper-based records only.

Many still are using a combination of paper-based and digital documentation using EMRs.

Policies and Procedures 

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A policies and procedures document is just not needed to comply with certain privacy and information security frameworks, and hospital accreditation but also to inform employees in a hospital setting of both the acceptable and unacceptable methods of performing their work duties.

Without these documents, employees would have no idea what practices the organisation prohibits or what they consider the best way to perform a certain job function.

Nonetheless, the majority of staff in a hospital setting rather yawn and dread work they perceive to be boring and tiresome when the words “policies and procedures” is stated.

That’s okay, they are correct; creating these documents can be time-consuming and tedious.

However, staff must become aware and take into account the ROI of developing, putting into practice, and consistently referring to rules and procedures.

Once it is initiated and put into effect, I think this document is a fantastic teaching resource for staff members, outsiders, and even consumers about the processes of the hospital.

It’s important to note that a hospital should only put in the policy what staff are going to do and what they are going to be able to do on a consistent basis.

Hence useful policies and procedures are among the things that are more advantageous to a compliance program, and they should not be ignored.

Goodbye to manuscript in medical notes

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The readability and speed of information retrieval have improved dramatically with electronic patient encounters.

For quick data retrieval and trend analysis, almost every industry is now automated and digitalised. Take a look at the stock market or organisations like Federal Express or Walmart.

Why not the medical field?

Moving to ICD-11

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The International Classification of Diseases(ICD) is the international standard for the systematic recording, reporting, analysis, interpretation, and comparison of mortality and morbidity data.

The World Health Organisation (WHO) presented and released the 11th edition of ICD(ICD-11) at the World Health Assembly on May 25, 2019, for adoption by member states,

This release has since come into effect on January 1, 2022, to replace the 10th revision(ICD-10), currently in use.

While ICD-10 is still widely used, unfortunately, despite the updating process, ICD-10 is known to be clinically outdated, and structural changes are needed in some chapters.

There is also an increasing need to operate in an electronic environment, as well as the need to capture more information for morbidity-use cases.

According to the WHO, the 11th revision is a scientifically rigorous product that accurately reflects contemporary health and medical practice and represents a significant upgrade from earlier revisions.

The WHO ICD-11 revision goals include to;
1:
Ensure that ICD-11 will function in an electronic environment by:
a. presenting a digital product
b. providing linkage with terminologies (e.g., SNOMED)
c. defining ICD Categories by “logical operational rules” on their associations and details
d. supporting electronic health records & information systems;

2:
Provide a multi-purpose and coherent classification for mortality, morbidity, primary care, clinical care, research, and public health;

3:
Consistency & interoperability across different uses; and

4:
Deliver an international, multilingual reference standard for scientific comparability, i.e. in English, French, Spanish, Russian, Chinese, and Arabic.