Whither paper-based medical records systems?

I have this infographic (below) to share which shows how technology has advanced over the last 50 years (from 1960 to today), yet most of us accept that medical records are still kept in paper files, and that’s the way it is. Technology has evolved over those many years and has brought sweeping changes, brought about many changes, whither paper-based medical records systems? Since back in the mid-70s when I started my career in Health Information Management (HIM) / Medical Records (MR) Management there is no way I would ever have dreamt of where we are technologically today. I wonder what our medical records systems will be like in 2020 technologically when Malaysia envisions being a developed nation.

2020 is just under 8 years more to arrive, meanwhile, have we thought about how much time is being wasted on paper activities that could so easily be streamlined?

This is how it looks (below) at a typical medical records department here in Malaysia.

Image credit: A typical scene in a paper-based medical records department in Malaysia, MyTawau, Facebook

Is your life as an HIM / MR practitioner going to become easier – and much more organised if we moved to computer-based medical records, lured by the promise that once you move to a paperless way of organising things?

Talk about getting rid of paper, I hope hospitals everywhere can go from a large file room with tons of paper in files to a large server with high-tech programs, surely we’ve saved thousands of trees and dollars by doing so.

Although access online is available 24/7 for everything from shopping to helping with homework, it is not available for medical records. Patients, doctors, and other caregivers who rely on the medical system may find themselves in a dire situation when data about the most critical information about health and quality of life can’t be accessed in a timely manner that would and should guide future treatment. Yet it ought to be. The cost comes in wasted time, diminished quality of care, duplicate testing, needless expense, unnecessary worry, and, worst of all, lives lost.

Is then the paper-based medical records system not good enough anymore?

The technology applied in ATMs and online banking provides universal access to financial records, and one can access them online, too. The paper-based system of medical information currently in use has no connectivity, no ease of access for either patients or providers and limited security and tracking of access. It is a barrier to improved treatment. This kind of technology could and should be applied to healthcare as it means more than convenience, this technology will definitely save lives. What is needed, is making the connection, and I think the technological answer to the need is within reach.

I hope the day is not far off when we can walk into an HIM/MR department of a hospital and not see any more medical records still kept in paper files!

The Five Rights of Data Administration!

If you read the post Documentation of medication administration in medical records, I am sure you did not miss reading about how clinicians and nurses use the “Five Rights of Medication Administration” to ensure proper patient care.

If you work in an EMR environment, then the following infographic, entitled “The Five Rights of Data Administration,” created by Symantec to help Health IT staff and users like you, Health Information Management(HIM) / Medical Records (MR) practitioners answer important questions about the use, access, and availability of critical patient data. This infographic outlines specific best practices to ensure that patient information is kept secure regardless of where it is. The infograhic also helps you and Health IT staff in organizations like the hospital you work in better understand the administration of patient data

I believe HIM/MR practitioners working in an EMR setting need to adopt similar but modified best practices for ensuring proper security and privacy for patient data based on the specific best practices outlined in this infograhic.

Note: Click on the infograhic above to view a larger image in a new tab of your current window.

From this infograhic, you need to cultivate the following specific best practices with coordination, guidance and help from IT staff of your hospital.

  1. Right Time – data in EMRs should be available to authorised personnel in your department whenever they need it and must be backed up and secure
  2. Right Route – users like clinicians who need access to EMR data regardless of where they and the device they’re using, must have ready access to updated data your are responsible for at your end
  3. Right Person – ensure only the right people have access to certain information though access verification in your department
  4. Right Data – prevent unauthorised tempering or accidental corruption of data with only users entitled or authorised to have access to data in your department and minimising or banning Bring Your Own Device (BYOD) mobile devices
  5. Right Use – ensure only the “minimum necessary” information is provided to external sources who request data that can be extracted from your end of the EMR system, thus assuring confidentiality

Just like medication administration is taken very seriously with the utmost accuracy and attention to detail as they can mean the difference between life and death, the proper administration of patient data should also be taken very seriously as it too can prevent misdiagnoses or mistreatment without accuracy and attention to detail.

INFOGRAPHIC: Format Of ICD-10 Diagnosis Code

Image

The ICD-10 Code Structure accommodates for the expanded number of characters in diagnosis codes which allows a greater specificity to identify disease etiology, anatomic site, and severity as can be seen from the diagram below.

The following infographic is an example of the ICD 10 code for S52.521A, which is self-explanatory and shows the more detailed information gained through the added characters.

The example of the forearm fracture above demonstrates the use of the full code titles, unlike that used for the ICD-9 diagnosis code set.

Nightingale rose graph

Going back to the post 8 Ways You Can Visualise Proportions,  I provided a WAY 8 using the Nightingale rose graph – or the polar area diagram to visualise proportions, and this is a follow-up on WAY 8 from that post.

The Nightingale rose graph was a diagram by Florence Nightingale (1820 – 1910). Nightingale, an Anglican English nurse became famous for tending to the wounded soldiers during the Crimean War, she loved doing night rounds and was dubbed “The Lady with the Lamp”, she laid the foundation of professional nursing and established her nursing school at St Thomas’ Hospital, London in 1860, new nurses take the Nightingale Pledge, and nurses celebrate the annual International Nurses Day on her birthday. Florence Nightingale was also a writer and an accomplished statistician  who in 1858, became the first female fellow of the Statistical Society of London (now Royal Statistical Society).

Florence Nightingale met William Farr, the Compiler of Abstracts in the General Registry Office and an innovative statistician at a dinner party in 1856. Both cared deeply about improving the world through sanitation; both understood the importance of meticulous records in providing the evidence needed to bring about change.

Now let’s move on and look at the original diagram drawn by Nightingale as below, “Diagram of the causes of mortality in the army in the East”  dated 1858 was published in Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army and sent to Queen Victoria in 1858.

You can view a 1280p X 804p of this graphic from the post 8 Ways You Can Visualise Proportions

The legend of this graphic above displays the causes of the deaths of soldiers during the Crimean war. The legend explains that each wedge is divided into three categories.:

  • “Preventible or Mitigable Zymotic Diseases” (infectious diseases, including cholera and dysenter), in blue
  • those that were the results of wounds, in red
  • those due to all other causes, in black.

The legend also explains that:

  • the black line across the red triangle in Nov. 1854 marks the boundary of the deaths from all other causes during the month.
  • in October 1854, & April 1855, the black area coincides with the red,
  • in January & February 1856, the blue coincides with the black.

Note that the graphic on the right starts from April 1854 and ends March 1855, while the the graphic on the left April 1855 starts from April 1855 and ends March 1856.

In November 1854, the number if wounds was very high as compared to other months, so it must be a period of heavy fighting, as far more soldiers died from infection than from wounds.

Now, I like to compare Nightingale’s diagram as compared to pie charts we draw today.

As a simple example, here is a frequency distribution table showing the distribution of “marital status” from a counseling center survey.

Status        Frequency(f)    Percentage (%)
Single

10

50

Married

7

35

Divorced

3

15

N=

20

100

To construct a pie chart,  the percentage of all cases that fall into each category(single, married, divorced) of the variable(marital status) is computed. A circle (the pie) is divided into segments (slices) proportional to the percentage distribution. Since a circle’s circumference is 360°, 180° (or 50%) is apportioned for the first category, 126° (35%) for the second, and 54° (15%) for the last category.

The pie chart displays like this:

 

From the graphic of Nightingale’s diagram which resembles a pie chart, it can be seen that each wedge is drawn from the common centre. As I have described above, in pie charts, we draw the area of each wedge proportional to the figure it stands for.

Thus her diagram is different from the common pie chart we know as follows:

  • the data is plotted by month in 30-degree wedges. In each month, red represents deaths by injury, blue death by disease, and black death by other causes
  • the radius of each slice (the distance from the common centre to the outer edge) is altered to achieve the area for each category; she measured each proportion along the linear radius distance
  • the red, black and blue wedges are all measured from the centre, so some areas mask parts of others unlike the wedges which appear distinct and separate like in the pie chart above
  • the areas of the wedges are not proportional; I tend to agree with Henry Woodbury that Nightingale used the word area in the generic sense of section or range as she made in her annotation, but the data actually maps to the radius of each wedge
  • the numbers of deaths from the various causes are not stated but shows their relative size

Nightingale’s diagram, often referred to as Nightingale’s Rose or Nightingale’s Coxcomb –  although she did not refer to them as such, is so visually interesting and so iconic (a rose, a coxcomb) like when I first saw her diagram in Randy Krum’s blog , I tend to agree to Henry, so beware the inherent risks in visual explanation, as more often that not we assume its conclusions without examining its data(Henry, W. 2008)..

I think too that it better sense using a stacked bar chart that introduces a scale, more readable labels, and a single chart for the entire 1854-1856 period. These changes provide context and continuity, and make clear the two campaigns of the war as can be viewed below:

Source : dd.dynamicdiagrams.com

or like this:

Source : dd.dynamicdiagrams.com

Lesson learned:

Because of her novel methods of communicating data by creating graphs as we have seen above to highlight the death toll from diseases above the death toll from wounds in the Crimean War, Nightingale returned to Great Britain and continued to fight for better conditions in hospitals, and this made her a pioneer in establishing the importance of sanitation in hospitals.

Abridged, and adapted from the following sources:

  1. Coolinfographics, Randy Krum’s blog
  2. Charts, Worth a thousand words, Dec 19, 2007, The Economist
  3. Nightingale’s Rose, By Henry Woodbury, Jan 9, 2008, dd.dynamicdiagrams.com
  4. Nightingale’s ‘Coxcombs’, May 11, 2008, understandinguncertainty.org
  5. Statistics: A Tool for Social Research, Eighth Edition Joseph F. Healey, 2009, Wadsworth Cengage Learning, Belmont, CA, USA
  6. Wikipedia

Patient data breaches in the BYOD and BYOC era

Health information is becoming increasingly vulnerable to data breaches as hospital employees turn up for work with mobile devices such as smartphones and tablets and use consumer-friendly and easy-to-use cloud storage services.

This proliferation of mobile devices in the workplace and hooking up onto cloud storage services is among the factors most likely to cause a data breach at hospitals in the US(a worldwide phenomenon, I must add), as indicated by 31 percent of healthcare organisation respondents from the 2012 HIMSS Analytics Report: Security of Patient Data*.

Bringing your own device and using cloud storage services has led to the new digital lifestyle era at the workplace, and two new acronyms, BYOD(Bring Your Own Device) and BYOC(Bring Your Own Cloud)!

You know your own devices well, so what then is this cloud storage service?

Image credit: https://www.marconet.com/blog/what-is-the-cloud-and-how-should-you-use-it-infographic

Now that the graphic would have given to those others who prefer inspiration, but maybe “just an introduction” to the tech-savvy, I think it was enough to arouse leaders in workplaces that manage patient data to think about the possibilities of anyone who could use such free and easy cloud services for criminal uses, thus beware it’s highly probable that mobiles devices and the cloud could be used to breach health information security at any HIM/MR Department.

In a future blog, I shall take you further to discuss some best practices for hospital data security.

*The 2012 HIMSS Analytics Report: Security of Patient Data, the third installment of the bi-annual survey of healthcare providers nationwide, shows a steady rise in data breaches over the last six years, despite increasingly stringent regulatory activity surrounding reporting and auditing procedures, and heightened levels of compliance –  a report as commissioned by the information security practice of Kroll Advisory Solutions