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Reassessment of all patients and results are always entered in their medical records

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Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware of the evidence of reassessment of all patients and results which are always entered in patients’ medical records. The results of these reassessments noted in the patient’s medical record is for the information and use of all those caring for the patient.

Health care practitioners  – predominately doctors and nurses are the ones who routinely conduct reassessment of patients in the following situations:

  1. to determine the patient’s response to treatment and whether the intervention remains appropriate
  2. to plan for continued treatment or discharge
  3. at intervals based on a patient’s condition and when there has been a significant change in his or her condition, plan of care, and individual needs or according to organisation policies and procedures

HIM / MR practitioners also need to be aware that a reassessment is integral to ongoing patient care i.e. it is a continuous process, and it is the key to understanding whether care decisions are appropriate and effective, and are normally carried out at intervals based on the patient’s condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.

However, the periodicity of reassessment depends on the condition as well as a patient’s needs extending to the plan for continued treatment or discharge, or as defined in organisation policies and procedures as in the following situations:

  1. acute care patients are reassessed by the doctor(s) at least daily, including weekends, and when there has been a significant change in the patient’s condition
  2. non-acute patients maybe assessed less than daily and determined by a hospital policy which defines the circumstances in which, and the types of patients or patient populations for which, a doctor identifies the minimum reassessment interval for these patients
  3. nursing staff may be observed to periodically record vital signs as needed based on the patient’s condition in response to a significant change in the patient’s condition
  4. if the patient’s diagnosis has changed and the care needs require revised planning
  5. to determine if medications and other treatments have been successful and the patient can be transferred or discharged
  6. the care of patients undergoing moderate and deep sedation especially the frequency and type of patient-monitoring requirements
  7. the minimum frequency and type of monitoring during anaesthesia which is written into the patient’s anaesthesia record
  8. monitoring of physiological status during anaesthesia administration which is written into the patient’s anaesthesia record
  9. the patient’s physiological status is monitored during surgery and immediately after surgery
  10. the patient’s readiness for discharge based on the patient’s current reassessed health status and need for continuing care or services as determined by the use of relevant criteria or indications from a referral and/or discharge plan begun early in the care process and, when appropriate, which had included the family to ensure patient safety
  11. the collaborative monitoring process on medications by doctors, nurses, and other health care practitioners when they jointly evaluate the medication’s effect on the patient’s symptoms or illness and monitor and report for adverse effects like allergic responses, unanticipated drug/drug interactions, or a change in the patient’s equilibrium raising the risk of falls among others, thus in both cases to allow the dosage or type of medication to be adjusted when needed
  12. when patients are been monitored to their response to a collaborative plan among doctors, nurses, the dietetics service, and, when appropriate, the patient’s family, to provide nutrition therapy after a screening process during an initial assessment to identify those at nutritional risk
  13. dying patients and their families are assessed and reassessed according to their individualised needs by evaluating and managing their symptoms and preventing complications to the extent reasonably possible in the care of these dying patient to optimize his or her comfort and dignity

As I researched for this post, I found that this is the NOT the last in the list of medical record documentation requirements I have found as required by the Joint Commission International (JCI) standards for documentation required in a medical record.

I will still need to discuss on these other medical record documentation requirements:

  1. when a hospital policy identifies adverse effects that are to be recorded in the patient’s record and those that must be reported to the hospital
  2. when the patient’s response to nutrition therapy is recorded in his or her record
  3. when assessments and reassessments need to be individualised to meet patients’ and families’ needs when patients are at the end of life, and assessment findings are documented in the patient’s medical record

Nonetheless, any hospital’s medical record documentation, irrespective if the hospital had undergone the journey to JCI accreditation or is planning to do so, all of which will contain reassessment findings recorded in them, including that related to needs when patients are at the end of life.

So if you are practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then your hospital will need to fully comply with the JCI Standard AOP.2 which states that “All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.” Documentation of reassessment of patients in their medical records also satisfies the JCI Standard MCI.19.1, Measurement Element 5 requirement which states that “Patient clinical records contain adequate information to document the course and results of treatment.”.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

“Seems nine codes for a turkey assault is a bit silly.”

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A turkey is  a large bird, one species commonly known as the wild turkey is native to the North American continent, while the domestic turkey is a descendant of this species.

I have never encountered coding for being assaulted by a turkey using ICD 10 in Malaysia. This morning I was amused to find out from a blog that a US legislator, Rep. Ted Poe (R-Texas) was fully aware of the array of ICD 10 codes available for the following conditions, especially the codes available for being assaulted by a turkey:

  • Nine codes for being assaulted by a turkey, one code for being assaulted by a turkey for the first time, one code for being assaulted by the turkey a second time etc.
  • Five codes for being hit in the face by a basketball; and
  • Three codes for being injured by walking into a lamppost.

Poe highlighted these codes in his recent speech when he had criticised the forthcoming ICD 10 medical coding mandate in the US by October 2014. He believes that the level of such detail required for ICD 10 coding “a bit silly”, and would pose challenges for US health care providers.

A check using ICD 10 does not provide codes for the above external cause of injury(s), with such specificity.

But such specificity is provided for in ICD-10-CM.

For example, encounters with a turkey (not necessarily the same turkey) is classified to nine codes, one for “contact with turkey”, one code for “struck by turkey” which has three other codes under this code that describe this diagnosis in greater detail, and one code for “pecked by turkey” which has three other codes under this code that describe this diagnosis in greater detail.

But this is not the same as I think as Poe comprehended based upon his remarks, meaning nine codes assigned for nine encounters of one patient, each of these nine codes assigned for assault by turkey multiple times by one same turkey or different turkeys!

I think it would be absolutely absurd if a patient were to present at a hospital with nine encounters, one after another encounter as a result of assault by a turkey or turkeys, right?

If a patient was struck by a turkey in Malaysia, how would I code to ICD 10. Malaysia does not use ICD-10-CM.

One has to examine Volume 3 of ICD 10 first, to make “clever” (not implying anything here, perhaps “trained” is a better choice of word) decisions in order to assign a near accurate code using ICD 10, unlike my pal in the US using ICD-10-CM. I say “clever” because, you need to find what term(s) define the external cause of injury, which means narrowing down the choice of adjectives defining the lead term(s) for the external cause of injury to search for in Volume 3. I think a good command of the English language is absolutely necessary.

If the doctor had written “struck by turkey” then it would be easy to turn to Section II, Volume 3 and search for the lead term “struck”. Otherwise it is like finding a needle in a hay-stack, searching for the right lead term to look under.

While medical records documentation is not near the desirable quality to expect in most instances, experience in ICD coding will ease this burden when one had encountered such coding problems. However, Health Information Management (HIM) / Medical Records (MR) practitioners still need to examine the entire medical record to find clues to assign an appropriate ICD-10 code in such instances, or simply get back to the attending doctor for help and advice.

So an amateur coder would look under “contact”,  and/or “hit” (which asks to “see Struck by”), and/or “exposure”.  If you look under (i) “contact”, you will find “contact with animal NEC” and the code W64.-., (ii) “hit”, you will find that you are redirected to go to “see Struck by”, and if you look under (iii) “exposure”, there is no find.

So you just go to “struck” for (ii) above or from “hit” to “struck” and your find “animal (not ridden) NEC and the code W55.-

Since birds are also animals like mammals, reptiles, fish and insects, then the turkey is an animal.

So the code is either W55- OR W64.-.

Checking Volume 1, W55.- states the code as “Bitten or struck by other mammals” while W64.- states the code as “exposure to other and unspecified animate mechanical forces”.

A turkey is a bird and not a mammal, so W55.- is not appropriate already, and I am left with W64.- only.

A turkey which strikes a patient must have been agitated, be it either a wild or a domesticated one ( I can only visualise a domesticated turkey in Malaysia, like those bread for poultry at Jitra, Kedah, Malaysia or a patient raring turkeys at his or her home).

So if the turkey strikes at the patient, then it runs towards the patient with mechanical forces using its legs. Thus, its movement is animated, and mechanical, and I would choose to assign the ICD 10 code W64.-, in this case of a patient exposed to a turkey attack or assault which runs towards the patient with animated motion using the mechanical forces of its legs.

From this example it is clear that ICD 10 is not as specific as ICD-10-CM.  That is why ICD 11 is on the way which I think will be more granular that ICD 10.

References:

  1. Badriyah Turkey Farm, viewed 15 April 2013, < http://badriyahturkeyfarm.blogspot.com/ >
  2. ICD10Data.com, viewed  15 April 2013, < http://www.icd10data.com/Search.aspx?search=turkey&codebook=AllCodes >
  3. Kasperowicz, P, Floor Action Blog, The Hill, viewed 15 April 2013, < http://thehill.com/blogs/floor-action/house/292961-lawmaker-rejects-medical-code-mandate-mocks-nine-codes-for-being-assaulted-by-a-turkey >

JCI Standard MCI.1 – Communication with the Community

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It is natural to think of the Public Relations (PR) department of a hospital when a hospital needs to deal with a community it serves to facilitate access to care and access to information about its patient care services. Thus, it is not surprising to pass the buck to a representative of the PR department of a hospital sitting in a Management Of Communication And Information (MCI) Committee to deal with, and in order to comply with the Joint Commission International (JCI) Standard MCI.1 which states “The organization communicates with its community to facilitate access to care and access to information about its patient care services.”

I think if you are a leader championing the JCI MCI standards, this leader must not merely delegate this MCI standard to the PR department representative to deal with, but must also nurture as teacher, mentor, colleague, and friend to guide and be responsible to coach in the implementation and compliance of this standard, thus to care for and encourage the growth or development of MCI standards for the hospital. In this scenario, it is important for this leader to be knowledgeable in PR by at least researching the subject matter and linking his or her literature reviews with this standard.

From my interactions with representatives of PR department of hospitals, they normally deal with the management of both internal and external communications. They told me they are responsible for promotions of the hospital and implementation of the hospital’s marketing programmes that are related to overall mission and vision of the hospital, also manage and improve the flow of information within the hospital and between the hospital and the community it serves. Public relations professionals also serve as liaisons to the community and work closely with other health partners in the locality in preventive health. The responsibilities of a PR person in a hospital setting includes writing and distributing news release, feature articles to the press, compiling press list, witting of newsletters, handling and maintaining a media information service, arranging press, radio and television interviews for management, preparing marketing plans for various programmes and create strategies in promotional and marketing efforts. In summary, the PR department is responsible for community relations, hospital publications, media relations special events and support for fundraising.

Since the measurable elements for this standard requires a hospital to (i) implement  a communication strategy, (ii) provide information on its services, hours of operation, and the process to obtain care through mass media interventions, such as those delivered by leaflets, booklets, posters, billboards, newspapers, radio and television, and (iii) provide information on the quality of its services, “the quality of services as is always determined by certain attributes that they have or should have. The most important attributes health services should have, are accessibility and availability,usage facility, public’s acceptance and all these always in relation to their cost.” (Athina and Andriani, 2012, p. 205) which is provided to the public and to referral sources with defined communities  and populations of interest,  I personally think that the PR department in a hospital is best suited to manage and measure this standard based on what I have already said in the preceding paragraph.

With all what I wrote above and what I intend to say in the next paragraph, let me remind you that all of us serving in the socioeconomic system of healthcare, including doctors and patients carry on our lives as person-systems within a hierarchy of multiple and overlapping systems of family, community and wider society. The internal needs of patients as person-systems, i.e. the patient is unwell, the patient’s family, workmates, employers and hospitals will tend to accept the sick role of this patient. After a defined length of time, the patient seeks the professional endorsement of a doctor for a clinical transaction, which is a subsystem of the hierarchy of systems comprising health care.  At the end of the day, the person-systems of doctor and patient constituting of the patient, members of family, community systems and professional (e.g. the doctor) or economic systems, all support a speedy and complete return to health for the patient.

Members of the MCI Committee must be aware that the approach it chooses in understanding and measuring as well as complying with this standard, is driven by the care delivery for the population served by the hospital in advising patients on how to leverage the system to ensure coordination of care across the continuum, integrated across the continuum among defined communities and populations of interest with healthcare specialists in the hospital.

So what is this “defined communities and populations of interest”,  if you are a member of  a  MCI Committee, you need to focus on?

Marie and Sandra (2011, pp. 46-47) define population of interest as “a population at risk or those with a common risk factor leading to the threat of a particular health issue. It also may be defined as a population of interest known as a healthy population who may in fact improve their health by making certain choices that will further promote health and/or protect against disease or injury. For example, an adolescent population that engages in alternative sports and chooses to wear protective gear avoids serious injury.”

I have been asked how and what does the PR department do in order to understand patterns and trends within this population of interest. First, I think it is the best interest of the PR department to be comfortable enough with information technology to collect and organise data, initiate and develop appropriate databases for their practice to better assess and serve the population of interest. I also think the PR department must design cross-sectional studies at finding out the prevalence of a phenomenon, problem, attitude or issue by taking a snap-shot or cross-section of the population. Pre-test/post-test studies could also be undertaken to measure the efficacy of a program on the same population to determine if a change has occurred.

I have also been asked how and what does the PR department do when identifying defined communities. My advice is that the PR department must be involved in gathering census data that provide the PR department with evidence about the overall health status of the population living in a particular community. The PR department could use the Internet which provides a wealth of data such as geography and history of a community as well as census track boundaries and data.

Armed with knowledge on defined communities  and populations of interest, the PR department  must surely be able to show evidence that there is (i) a communication strategy to reach the defined communities  and populations of interest , (ii) information on its services, hours of operation, and the process to obtain care, and (iii) information on the quality of its services, which is provided to the public and to referral sources with defined communities  and populations of interest, in order to fully comply with Standard MCI.1.

All this is possible when the hospital and the PR department jointly develop and revise strategic and operational plans to address community needs for a healthier community within larger geographic or political areas as reflected in the hospital’s mission and required by the JCI Standard GLD.3.1 which states that “Organization leaders plan with community leaders and leaders of other organizations to meet the community’s health care needs.”, thus recognising that they have responsibility for and can achieve an impact on the community.

References:

  1. Athina, L & Andriani, D, 2012, Quality assurance in healthcare service delivery, nursing, and personalized medicine: technologies and processes, Medical Information Science Reference, Hershey, PA, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Kingsley, N & Sam, S 2009, Problems With Patients: Managing Complicated Transactions, Cambridge University Press, Cambridge, UK
  4. Louise, LI & Carolyn, LB 2008, Public Health Nursing: Leadership, Policy & Practice, Delmar Cengage Learning, New York, USA  
  5. Marie, TL & Sandra, BL (eds.) 2011, Public health nursing : practicing population-based care, Jones and Bartlett Publishers, Sudbury, MA, USA
  6. Stephan, J & Frank,  MG 2011,  Information and Communication Technologies in Healthcare, CRC Press, Boca Raton, FL, USA

ICD 11 – The Content Model, Part 2

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ICD 11 book coverIn this second part of the ICD 11 Content Model posts, I will aim to provide an insight into the basic structure of the model.

As you can read from the post ICD 11 – The Content Model, Part 1 (this link will open in a new tab of your current window), the revision process of the The 11th revision of the International Classification of Diseases and Related Health Problems (ICD ) is a broad participatory Webbased development process by the World Health Organisation (WHO).

This collaborative development of new content and proposed changes for ICD 11 is the responsibility of a Revision Steering Group (RSG) within the WHO ICD Revision Organisation Structure, which serves as the planning and steering authority in the update and the run-up to the revision process of ICD 11.

Today the Beta Draft of ICD 11 is available as the culmination of an information infrastructure and workflow processes started initially by Topic Advisory Groups (TAGs) for various specialty areas. The Webbased development of ICD 11 which is still open for comments and suggestions by interested parties in a social process on the Web, is integrated with knowledge of (i) diseases and health conditions, the eotiology and the anatomical and physiological aspects of the disease, (ii) input of all chapters and codes from existing clinical modifications of the ICD, and (iii) mappings to other terminologies and ontologies from other WHO-FIC (Family of International Classifications) members into computer systems, thus creating draft classifications for field testing as it is available in the Beta Draft of ICD 11.

I can prefigure the complex problems of developing ICD 11, which surely was undertaken and managed by using systematic approaches to deal with its development in a prescribed way and by using analytical techniques to identify and dissect the orderly arrangement of the mass of data already in a confused state into logical patterns thus promoting understanding and pointing the way to an appropriate decision within a clearly defined framework and a concrete context, the ICD 11 Content Model.

Thus, the Health Informatics and Modeling Topic Advisory Group (HIM-TAG) – also a part of the WHO ICD Revision Organisation Structure,  was entrusted to develop the ICD-11 Its task was to ensure that the Content Model remains the critical component of ICD 11 that specifies the structure and details of the information that should be maintained for each ICD category in the revision process.

The WHO (2013) describes the Content Model as a structured framework that captures the knowledge that underpins the definition of an ICD entity in the following ways:

  • includes the full scope of health care diseases and related health conditions (such as traditional medicine entries) so as to be as congruent with the overall structure 
  • ICD 11 entities are represented in a standard way from the currently set of different 13 defined dimensions or  main “parameters”, each parameter expressed using standard terminologies known as “value sets” by observing basic taxonomic and ontological principles including:
    1. key definitions: disease, disorder, syndrome, sign, symptom, trauma, external cause,
    2. separation of disability and joint use with the International Classification of Functioning, Disability, and Health (ICF),

    3. attributes  – etiology, pathophysiology, intervention response, genetic base, and

    4. linkages to other classifications and ontologies, including that of for Primary Care, Clinical Care and Research
  • the Content Model enables content experts to view and curate i.e to pull together and sift through and select for presentation its contents using software tools that allows automatic error checking and enforces constraint enforcement thus maintaining the correctness or validity of the stored data (integrity ). 

Each category ICD 11 entity in the Content Model will be described by 13 different, defined dimensions or main “parameters” as can be seen below.

ICD-11-content-model

More in the next post on the ICD 11 Content Model.

References:

  1. World Health Organisation, 2012, Content Model, viewed 18 March 2013, < http://www.who.int/classifications/icd/revision/contentmodel/en/index.html >

Healthcare Big Data – Part 1

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Big Data 3Vs cardboard-box-iconTo continue from from the introductory post Big Data – Introduction (this link will open in a new tab of your current browser window) and Big Data – Big Data Basics (this link will open in a new tab of your current browser window), this first part will introduce the subject of big data in healthcare and end there.

As you would surely be aware even as a Health Information Management (HIM) / Medical Records (MR) practitioner from your practice of managing medical records that an individual patient’s clinical signs and symptoms, medical and family history, and data from laboratory and imaging evaluation found in his or her medical record is used by the attending doctor to diagnose and then treat the patient’s illnesses. This traditional clinical diagnosis and management approach to treatment has been and still is often a reactive approach, i.e., the doctor starts treatment/medication after the signs and symptoms appear.

However given the genetic variability between individuals and advances in medical genetics and human genetics eversince the Human genome project completed in 2003, medical genetics and human genetics have since provided both scientists and clinicians to understand health and manage disease, that is to say that it has been providing a more detailed understanding of the roles of genes in normal human development and physiology and the risk for many common diseases, not in the same way diseases have been understood in the traditional reactive approach.

Standard test data – of an individual patient’s clinical signs and symptoms, medical and family history, patient discharges, real-time clinical transactions and data from laboratory and imaging evaluation found in his or her medical record, and data in personalised medicine or PM when medical decisions, practices, and/or products are tailored or customised to the individual patient with the use of genetic information (genomic data) – from the study of biological data of the complete set of DNA within a single cell of an organism of the individual, or a combination of the two, creates vast collections of data – Healthcare Big Data..

Healthcare Big Data has tremendous potential to add value from analysing and mining these vast collections of data now available to hospitals in general.

But Healthcare Big Data must be managed, leveraged and integrated to help personalise care (as in PM), engage patients, reduce variability and costs, and ultimately improve quality.

In order to manage, leverage and integrate Healthcare Big Data, Big Data solutions are needed to transform health care with big data. Big Data solutions apply analytics to examine, better analyse and understand the large amounts of data of unstructured clinical data in the form of images, scanned documents, and encounter or progress notes in its native state, integrate it with operational structured data based on historical and current trends, to uncover whatever hidden patterns, unknown correlations and other useful information, and then they help predict what might occur in the future with a trusted level of greater reliability. Healthcare Big Data analytics is all useful information because such information can provide competitive advantages over rival hospital organisations and result in business benefits, for example more effective marketing and thus generate increased revenue.

In the next post on Healthcare Big Data, I shall be blogging about the challenges in aggregating the Healthcare Big Data from multiple sources.

References:

  1. Denise, A 2013, Leveraging big data analytics to improve healthcare delivery, ZDNet,  viewed 30 March 2013, < http://www.zdnet.com/leveraging-big-data-analytics-to-improve-healthcare-delivery-7000013072/ >
  2. Geoffrey, SG and Huntington, FW (eds.) 2010, Essentials of Genomic and Personalized Medicine, Academic Press, Elsevier Inc, San Diego, CA, USA
  3. Lorraine, F, Michele, O’C,  & Victoria, W 2012, Data, Bigger Outcomes, American Health Information Management Association, viewed 18 November 2012, < http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049741.hcsp?dDocName=bok1_049741 >
  4. Margaret, R, 2012,  DEFINITION big data analytics, TechTarget, viewed 1 April 2013, < http://searchbusinessanalytics.techtarget.com/definition/big-data-analytics >
  5. Neil, V 2013, Big Data Use In Healthcare Needs Governance, Education, InformationWeek, viewed 30 March 2013, < http://www.informationweek.com/healthcare/clinical-systems/big-data-use-in-healthcare-needs-governa/240151395 >