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ICD-10 ‘drives him crazy’

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This is what Kaiser Permanente’s CEO  George Halvorson thinks and feels about ICD-10.

“I hate ICD-10. It drives me crazy, it adds so little value, and I can’t find any therapeutic upside”

“The upcoming deployment of ICD-10 is anathema to my organization”

“The use of ICD-10 is a response to running out of current diagnosis-related group (DRG) codes rather the a logical expansion based on clinical data”

“They’re putting the current codes into certain buckets to expand them, and they’ve run out of room”

“It is more suited to work with a paper-based medical record system”

“I am looking toward the ICD-11 iteration, in the hopes it might be better integrated with electronic health records”

“Kaiser’s rollout of an EHR system is saving about $3 billion in annual costs by making it more efficient to treat chronic conditions and combat sepsis, which kills tens of thousands of hospital patients a year”

However, communications officer Ravi Poorsina at Kaiser said Kaiser will still deploy ICD-10 since according to him,  “I think we’re required to”.

Abridged from Kaiser CEO on why ICD-10 ‘drives him crazy’ by Ron Shinkman, June 26 2012, FierceHealthFinance

Note: The above remarks by Halvorson were made during a question and answer session after delivering a keynote speech at the Healthcare Financial Management Association’s Annual National Institute on Monday, June 25 2012, at the Mandalay Bay Resort and Convention Center in Las Vegas, USA.

The perils BYOD bring to healthcare – but before that, what is a mobile device exactly?

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In the earlier post Patient data breaches in the BYOD and BYOC era, it is evident that risks to patient data are growing as mobile devices pose significant risks for privacy incidents for healthcare organisations, providers and entities responsible for safeguarding protected health information (PHI), such as medical records

Further to that post, I wish to expand and take this subject of risks to patient data into more than one post, continuing with this second post on the BYOD and BYOC era – but this time in this post, on what is a mobile device exactly.

But before that, I have no doubt and you would probably or even agree with me with me that mobile devices like smartphone and tablet increase personal.productivity and mobility as you can discover from this image.

Source: cropped with Adobe Photoshop, from an infographic found at ClickSoftware Enterprise Workforce Mobility
(view a larger image in a new tab of the current window when you click this image)

This trend will only continue given the continuous influx of increasingly powerful, inexpensive smartphones, tablets and other mobile devices. The Bring Your Own Device (BYOD) phenomenon is posing a direct and significant challenge for IT everywhere and in particular healthcare providers.

So what is a mobile device exactly?

Mobile devices include familiar things you carry with you(portable) like thumb drives, smartphones, external hard drives, tablets and laptops. Does this list end here?  Researching on mobile devices for this post, the list does not end there as the term “mobile devices” is still a non-definitive term, due to the rapid expansion and evolution of portable devices connected to the Internet.

Smura, Kivi, and Toyli (2009) believe a mobile device must meet three criteria:

  1. ability to make voice calls
  2. physical size of device
  3. the operating system.

Smura et al.’s definition however already appears to be outdated as mobile voice telephony has been decreasing in volume and duration since 2007 (Thompson, 2010), as we instead increasingly use our mobile devices for text messaging (SMS), emailing, and accessing Internet-enabled apps or sites. Some of us also use the immensely popular iPod Touch, which allows users to interact with Internet content but does not offer the ability to make phone calls.

The other criterion by Smura et al. is size, the smaller the size the greater the portability and ease of access in multiple environments. What entails being “mobile” is then their relative size, since mobile devices are smaller in size, more portable, and can be accessed with ease and flexibility. This is the core difference between mobile devices and other portable, Internet-enabled devices such as laptops and netbooks.

So can digital cameras, e-readers, and game consoles be also called mobile devices?

Devices like digital cameras, e-readers, and game consoles support one core functionality (i.e., photography, reading, or gaming), while mobile devices, on the other hand are portable computing devices running multiple software.

Hence, the inclusion of operating system(OS) by Smura et al. as a defining trait is not a central characteristic. The OS helps distinguish between devices like digital cameras, e-readers, and game consoles that are “limited, for specific purpose” versus mobile devices that are mufti-functional. The key difference between them is single versus multiple functionality.

One other place I looked at, was into Wikipedia. We usually run to Wikipedia for answers to anything we wish to know. I ran up to Wikipedia too and looking up Wikipedia’s definition, a mobile is “small, hand-held computing device, typically having a display screen with touch input and/or a miniature keyboard and less than 2 pounds (0.91 kg)”. Wikipedia lists calculators, digital cameras, and MP3 players as mobile devices. This definition seems to entail pretty much any portable electronic device, as even Glen Farrelly blogged in his blog Webslinger.

We looked at how voice telephony, portability and accessibility due to size, computing power, operating systems, Internet connectivity, and functionality increasingly blur distinctions between mobile devices.

It is obvious there are overlaps across technologies and Internet access, appears now to be the defining point in distinguishing mobiles which are portable computing devices running multiple software (e.g., contacts, calendars, document processing, file management, etc.) and offering a range of mufti-modal inputs and outputs, including text/SMS, email, instant messaging/chat, voice telephony, photography, video, applications, and mobile Web browsing.

Glen Farrelly offers the definition of a mobile device which includes smartphones (e.g. BlackBerry, iPhones, Androids, Nokia.), tablets, (e.g. iPad, PlayBook, etc..) and networked portable media player and personal digital assistants (e.g. iPod) as a device that has:

  • the ability to connect to the Internet
  • supports user input and interaction,
  • offers multiple functionality
  • and has the physical size of a tablet computer or smaller

References:
Webslinger, glenfarrelly.blogspot.com
Wikipedia, en.wikipedia.org/wiki/Mobile_device

Informed Consents – 5 required documentation in the medical record providing information to patient and family

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“Every human being of adult years and sound mind has a right to determine what shall be done with his own body….”, is an often quoted (in bioethics and legal literature) statement by Justice Cardozo from the well-known case Schloendorff v. Society of New York Hospital, 105 N.E. 92, 1914.

Informed consent as Wikipedia informs us “is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards”. It is interesting to note that this term was first used by Paul G. Gebhard, an attorney well educated from Yale and Harvard Law School and the senior partner in the government, health care and association group of the Chicago law firm of Jenner & Block, in a 1957 medical malpractice case in which a patient contended that a physician at a Stanford University hospital had not fully disclosed the risk in a recommended treatment.

As an informed consent grants the right to a patient to be involved in their care decision, the inform consent informs a patient of those factors related to the planned care required for an informed decision.

Informed consent can be obtained when at several points in the care process. Informed consent can thus be obtained when a patient is admitted for inpatient care before certain procedures or treatments for which the risk is high.

It is important to know the following:

  • the consent process is clearly defined in the hospital’s policies and procedures incorporating relevant laws and regulations
  • the role patients and families in the informed consent process – (i) they are informed as to what tests, procedures, and treatments require consent and how they can give consent (for example, given verbally, by signing a consent form, or through some other means), (ii) they understand who may, in addition to the patient, give consent
  • trained designated staff members inform patients, obtain and document patient consent. Here I like to quote the Malaysian Medical Council  (MMC) which “upholds that the responsibility for obtaining consent lies with the  practitioner performing the procedure. He is the best person who can ensure that the necessary information is communicated and discussed”,  as stated in its “A Guidebook for House Officers”, paragraph 4.12, pages 37-38, dated 23 April 2008. A statement from a booklet by the MMC,  “Good Medical Practice”,  paragraph 3.7, page 13 also defines and states the role of doctors in providing an informed consent.

Now that you as a HIM/MR practitioner finished reading from the above a brief overview of the basic human right of a patient to informed consent, you need to know the kind of documentation that goes into a medical record.related to informed consent which is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures.

A medical record will contain an informed consent for :

  1. surgical or invasive procedures
  2. anesthesia other than local including moderate (“conscious”) and deep sedation
  3. blood and blood products used
  4. high-risk procedures and treatments

When informed consent is taken, the following will also be recorded in a medical record:

  1. identity of the individual providing information to patient and family
  2. patient’s signature or a record of verbal consent

Thus,  the 5 required documentation in the medical record providing information to patient and family includes numbers 1 to 4 as given above and number 5, ” identity of the individual providing information to patient and family and the patient’s signature or a record of verbal consent”

Whether or not your hospital is been accredited by the Joint Commission International(JCI), you need to play your role to ensure that an informed consent is documented in the medical record when a patient had surgery, anesthesia, used of blood and blood products, and undergone other high-risk treatments and procedures.

If you hospital is been accredited by JCI, then you must be informed that JCI Standard *PFR.6.4 applies to an informed consent documentation in a medical record. JCI Standard PFR.6.4 states that “Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures”.

Still on the subject of JCI accreditation, it’s good to be aware not only of JCI Standard PFR.6.4, but also I think as an informed HIM/MR pratitioner to also know the following too:

  1. that a hospital has a clearly defined informed consent process described in policies and procedures
  2. who are trained to implement these policies and procedures
  3. what is clearly explained regarding any proposed treatment(s) or procedures to the patient and, when appropriate, the family

In addition, be informed that:

  1. designated staff members who are trained, not only to carry out the process of giving out the informed consent but also obtain and document patient consent in accordance to the  JCI Standard PFR.6 which states that “Patient informed consent is obtained through a process defined by the organization and carried out by trained staff in a language the patient can understand”.
  2. these trained designated staff members provide information as stated the elements (a) to (h) as in the JCI Standard PFR.6.1 which states that “Patients and families receive adequate information about the illness, proposed treatment(s), and health care practitioners so that they can make care decisions”

So much more to be informed on informed consent, and I think I covered pretty much already on JCI Standards PFR.6, PFR.6.1 and PFR.6.4

*PFR stands for Patient Family Rights

10 facts about a discharge summary

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When a patient is discharged from a hospital, a discharge summary or clinical résumé to document the care provided to the patient during his or her inpatient hospitalisation is prepared by any qualified individual such as the patient’s physician, a house medical officer, or a clerk.

This discharge summary placed in the patient’s record provides information for continuity of care and facilitates a medical staff committee review and it can also be used to respond to requests from authorised individuals or agencies (e.g., a copy of the discharge summary will suffice instead of the entire patient record).

10 contents of a discharge summary documents the patient’s hospitalisation which includes:

  1. the reason(s) for admission
  2. significant physical and other findings(e.g. brief clinical statement of chief complaint and history of present illness)
  3. significant diagnoses and co-morbidities(example, Principal diagnosis: Cellulitis and gangrene, left foot and lower leg. Comorbidities: Diabetes mellitus, insulin dependent, controlled. Staphylococcus aureus coagulase positive septicemia. Urinary retention)
  4. diagnostic and therapeutic procedures(example, Principal procedure: Amputation, left leg, above knee. Secondary procedures: Suprapubic cystostomy with permanent suprapubic drainage)
  5. significant medication and treatments(medical and surgical) and patient’s response to treatment, including any complications and consultations
  6. patient’s condition/status at discharge
  7. discharge medications and all medications to be taken at home
  8. follow-up instructions(patient education when applicable), to patient and/or family (relative to physical activity, medication, diet, and follow-up care)  including instructions for self-care, and that the patient/responsible party demonstrated an understanding of the self-care regimen
  9. unless contrary to policy, laws, or culture, patients are given a copy
  10. a copy is provided to the practitioner responsible for patient’s continuing or follow-up care

I am sure your hospital policy and procedures defines when a discharge summary must be completed, and that it must be placed in the record.

Such a policy and procedures are affirmed by the Joint Commission International(JCI) standard ACC.3.2 which states that “the clinical records of inpatients contain a copy of the discharge summary” and requires that a discharge summary must be prepared at discharge by a qualified individual, it contains follow-up instructions, that a copy  is placed in the patient record, the patient is given a copy of the discharge summary unless not allowed by hospital policy, laws, or culture, and a copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing or follow-up care.

JCI Standard ACC.3.2 is expanded by JCI Standard ACC.3.2.1 which further qualifies the contents of a complete discharge summary.

The above 10 facts listed above covers all that is required by the 6 MEs of ACC.3.2 and the 6 MEs of ACC.3.2.1, when the discharge summary placed in a medical record is reviewed during a Medical Records Review.

Note : In Malaysia, the patient’s physician or a senior medical officer but NEVER a clerk, is responsible to prepare the discharge summary.

5 transfer process entries that must be entered in a medical record

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A patient might require a hospital transfer for a number of reasons. The patient or the family might want a second opinion, the current hospital cannot address the needs of the patient, or the new hospital offers more advanced care among other reasons.

When a patient is transferred to another hospital or health care organisation, the transfer process is documented in the patient’s medical record.

A HIM/MR professional needs to be aware of five transfer process entries which must be included in a medical record when a patient is transferred to another hospital or health care organisation.

These 5 transfer process entries as documented in the medical record will state and/or contain :

  1. the name of the hospital or health care organisation and name of the individual agreeing to receive the patient
  2. any documentation or other notes as required by the policy of the transferring hospital for example, a signature of the receiving nurse or physician, name of the individual who monitored the patient during transport
  3. the reason(s) for transfer
  4. any special conditions related to transfer such as when space at the receiving hospital or health care organisation is available, or the patient’s status
  5. any change in patient condition or status during transfer for example, the patient dies or requires resuscitation

If your hospital is in the process of becoming a Joint Commission International(JCI) accredited hospital, you need to know that the JCI Standard ACC.4.4 requires that a transfer process from one hospital(health care organisation) includes the above mentioned 5 transfer process entries in the patient’s medical record.

However, do take note that the JCI Medical Records Review Tool does not list documentation required by policy requirements of the transferring hospital, as one of its measurable elements.