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Understanding reasons for making a request to change the medical record

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It is rare to find any research topic ever published on why requests are made by patients who want to make changes to their medical record. I found one recently, and here to share with you what researchers discovered as the main reasons for making a request to change the medical record, and what types of information they wanted changed, and whether they result in modifications to the medical record.

In their qualitative research, the researchers studied content analysis of all patient-initiated amendment requests, an ‘amendment request’ defined as the process by which patients ask for changes to be made to their records, received over a 7-year period.

Readers can now view the infographic below (click on the infographic to view a larger image in a new tab of your current window) which shows a summary of all relevant findings from this research.

Medical-Records-Amendment-Requests-Study

Also from this study, I deduced that when patients were given the opportunity to further participate in their care by allowing them to review their medical record, their medical record accuracy could lead to improvement after the identification and correction of errors or omissions.

I agree with the authors that doctors can make mistakes in the medical record, and that it is necessary to correct these mistakes at some point This is especially true when a patient discovers any mistake or omission upon reviewing his or her own medical record. However, it is uncommon when a patient will not want any information there anyway but such requests must be expected.

An ‘amendment request’ is a rare request as most patients, in the developing and under-developed world and even perhaps in the developed countries are unaware of the basic right to review their own medical record and the absence of any policy to grant patients the right to make an ‘amendment request’.

References:

  1. David A Hanauer, Rebecca Preib, Kai Zheng, Sung W Choi 2014, Patient-initiated electronic health record amendment requests, J Am Med Inform Assoc amiajnl-2013-002574 Published Online First: 26 May 2014 doi:10.1136/amiajnl-2013-002574, viewed 1 June 2014, <http://medicalresearch.com/author-interviews/electronic-medical-records-study-examines-patient-initiated-amendment-requests/5721/>
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MRPM.VOW.02.14: Healthcare’s four-letter word? It’s ‘silo

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To continue the series of videos for 2014, this week’s Video of the Week (VOW) pick is about the change that must evolve when it is common practice that hospitals, clinics and doctor’s offices, digital health devices and services all continue to keep close tabs on their information and silo their data.

Those of you who have been following the trends at healthcare conferences and exhibitions for some time will recognise it is common at one after another conference and exhibition when we see vendors show off systems that work great, but we soon realise that they don’t get along with each other. I think it has become less of a desire to acquire new systems and more of a requirement in the rapidly changing healthcare industry, keeping up with new technologies and innovations.

You would also already been aware that departments within the hospital or health network, digital health devices and services all keep close tabs on their information and have control over a certain subset of data that they’re not into sharing, they just all seem to silo their data.

And for those of you who are familiar with mHealth, surely are all too familiar that mHealth devices continue to over-emphasize the collection of vital signs and real-time transmission to healthcare providers.

Enters Patrick Soon-Shiong, a South African-born surgeon who is pushing for a vision of integrated healthcare through a network of digital, genomic and clinical solutions. He envisions a future healthcare system as an integrated system that connects all the dots which follows a human being through the continuum of life serving a patient throughout his or her life, not just in sickness.

In the accompanying video (click on http://bcove.me/2cwzbmrg to watch the video, which will open in a new tab of your current browser window), watch and listen to Soon-Shiong discoursing among other things the following views:

  • healthcare has to break the rule of capturing vital signs at all times and focus more on gathering data and identifying trends;
  • likens a health journey much like a long plane trip, during which a true operating system which encompasses clinical decision support, machine learning and “adaptive amplified intelligence” pulls in data from all sources that “integrates pieces of the puzzle” and gives you inputs from the consumer so that the caretaker can plot a course, and adjust that course as things happen and manage outputs;
  • that the Electronic Medical Record (EMR) is “basically a flight log” that needs to be tapped for information at times which could be a part of that solution, but not the whole solution;
  • he believes that healthcare isn’t being held back by technology as a barrier, rather the real problem is a workflow management problem since technology is not been used properly, and is falling behind other industries like banking and entertainment;
  • nobody is taking the trouble of taking each of their siloed pieces and integrating them into a single healthcare system; and
  • he concludes that change management as the next challenge while taking advantage of the fear to resist wholesale change in healthcare.

References:

  1. Healthcare’s four-letter word? It’s ‘silo’, mHealth News, viewed 28 April 2014, <http://www.mhealthnews.com/news/healthcares-four-letter-word-its-silo?single-page=true>

  2. Healthcare’s four-letter word? It’s ‘silo’, mHealth News, viewed 28 April 2014, <http://bcove.me/2cwzbmrg>

JCI Hospital Accreditation Decision Rules

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The Joint Commission International (JCI) had announced the updated Accreditation Decision Rules for Hospitals as was published on their webiste.on 13 March 2014.

By and large a Health Information Management (HIM) / Medical Records (MR) practitioner in a hospital setting will not be briefed about everything hospital accreditation, especially matters like how the decision is made to accredit a hospital. That notwithstanding, If you are working at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for accreditation status, I think it is important to be aware on how all information from the initial or triennial full JCI and any required follow-up focused survey are used to make the decision regarding a hospital accreditation.

The hospital must meet five (5) conditions to be accredited. The conditions requires that the hospital must be able to demonstrate that there is acceptable compliance with each standard, there is acceptable compliance with the standards in each chapter, there is overall acceptable compliance,  the total number of measurable elements (MEs) found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations) for a hospital surveyed under the hospital accreditation standards within the previous 24 months, and the ME in the International Patient Safety Goals ( IPSG) is scored “Not Met”.

Since the 5 conditions encompass the relevant standards that HIM / MR practitioners manage in the daily routine management of health information management / medical records management in a hospital setting, he or she must be made aware of by circulars or at least briefed on these 5 conditions to be accredited.

If the HIM / MR practitioners in their practice fail to comply with any relevant standard, any relevant standards in each chapter, and contribute to non-compliance of MEs found to be “Not Met” or “Partially Met” is not above the mean (3 or more standard deviations) for a hospital surveyed under the hospital accreditation standards within the previous 24 months, than he or she would be deemed to be contributing negatively to the overall performance during the hospital survey process and towards accreditation been denied!

The HIM / MR practitioner is advised to be aware of At Risk for Denial of Accreditation conditions, especially the 5 conditions regarding relevant standards and MEs.

Below is a flowchart (click on the flowchart below and it will open in a new tab of your current window; click on the resulting image in this new tab for a larger view of the flowchart image – zoom to see bigger fonts or simply print to read) showing all the decision rules that will be taken by the JCI Accreditation Committee to validate if your hospital meets the criteria for accreditation. From the chart, there are two potential outcomes. The outcomes may be that the hospital meets the criteria for accreditation or does not meet the criteria and is denied accreditation. The charts also shows At Risk for Denial of Accreditation conditions.

accreditation-decision-rules

References:

  1. Joint Commission International, 2013, Joint Commission International Accreditation Standards For Hospitals, 5th edn, JCI, USA
  2. Joint Commission International, 2014, JCI Announces Updated Accreditation Decision Rules for Hospitals,  viewed 31 March 2014, <http://www.jointcommissioninternational.org/jci-announces-updated-accreditation-decision-rules-for-hospitals/>

JCI Standard GLD.3.2 – leadership role in the dynamics of communication within a hospital, Part 1

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This afternoon, I am to write about the Joint Commission International (JCI) Management of Communication and Information (MCI) Standard MCI.5 which states that “The leaders ensure that there is effective communication and coordination among those individuals and departments responsible for providing clinical services.”

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Image credit: http://www.danieldecker.net/

Surely, the Health Information Management (HIM) / Medical Records (MR) practitioner’s practice is not responsible for providing clinical services, thus Standard MCI.5 will definitely not require any HIM / MR practitioner to comply with it.

However because Standard MCI.5 is included among other standards found in the MCI Chapter of the JCI manual (4th edition) that mostly apply to the practice of HIM / MR (all of which I have completed posting on this blog), I still wish to write about this standard so that HIM / MR practitioners will be aware and also that they will appreciate the ongoing communication and coordination among those individuals and departments responsible for providing clinical services in a typical hospital setting. A HIM / MR practitioner will perhaps then understand and appreciate the demand for medical records use in the dissemination of patient care information among fellow colleagues operating from different departments responsible for providing clinical services.

From the post The JCI Manuals, 5th Edition are effective 1 April 2014  (this link will open in a new tab of your current browser window), readers will now know that hospitals need to begin to focus their hospital accreditation program based on the 5th edition of the JCI international standards for hospitals.

Examining this 5th edition of the JCI international standards for hospitals, I found that there are many changes to this 5th edition of the hospital manual. Expect to find requirement changes that “raise the bar” on compliance expectations in addition to finding more clarity over and above nearly all of the text that appeared in the 4th edition.

One major change I found on further examination of the 5th edition is that you can no longer find the MCI Chapter in the 5th edition. The “Management of Communication and Information” (MCI) in the previous edition (4th edition) is now known as the “Management of Information” (MOI) chapter (5th edition).

Nonetheless, I looked for the Standard MCI.5 in the MOI chapter of the 5th edition, but it was no longer there among the rewritten MOI chapter. Delving deeper, I found that Standard MCI.5 is now moved and consolidated with similar requirements of Standards, and in this case to the “Governance, Leadership, and Direction” (GLD) chapter in the 5th edition.

The Standard MCI.5 now combines with MCI.4 (also from the 4th edition) in the GLD chapter of the 5th edition “to better align hospital leadership requirements; revises standard, intent, and MEs to clarify expectations” (JCI 2013, p.161) to form the Standard GLD.3.2 in the 5th edition which states that “Hospital leadership ensures effective communication throughout the hospital. “

I shall be writing about the Standard GLD.3.2 of the 5th edition in the next part. What I plan to write in this next part will also relate to the Standard MCI.4 which states that “Communication is effective throughout the organization.” which I have already posted in the post JCI Standard MCI.4 – accuracy and timeliness of information in the hospital through effective communication (this link will open in a new tab of your current browser window).

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joint Commission International, 2013, Joint Commission International Accreditation Standards For Hospitals, 5th edn, JCI, USA

The JCI Manuals, 5th Edition are effective 1 April 2014

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JCIH14EBJCIHSPG14Joint Commission International (JCI) Accreditation Standards for Hospitals, 5th Edition and The Joint Commission International Accreditation Hospital Survey Process Guide, 5th Edition are both now effective starting 1 April 2014.

JCI claims that the Accreditation Standards for Hospitals, 5th Edition is trimmed to contain lesser standards, has better structure and logical flow between standards requirements, and now incorporates two new chapters to cater for Academic Medical Center Hospitals

The JCI Accreditation Hospital Survey Process Guide, 5th Edition manual like the previous edition is designed to help hospitals learn about and be better prepared for the JCI survey process. However, it now contains help for Academic Medical Center Hospitals prepare for their surveys.

References:

  1. Joint Commission International, 2014, viewed 30 March 2014, <http://www.jointcommissioninternational.org/>