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HEALTH INFORMATION DEVELOPMENT, CHALLENGES AND PROSPECTS FOR HOSPITAL MANAGEMENT
Presenters:Mal. Gambo Dauda,Mal. Mustapha Sani, &Bilkisu Halliru Muhammad
MEDICAL RECORDS DEPARTMENTNATIONAL ORTHOPAEDIC HOSPITAL, DALA-KANO29th July, 2015
OUTLINE Introduction Concept Clinical Documentation’s standard protocols Health information Management a Multi-
disciplinary activity. Total Quality Management (TQM) Checklist Health Information utilizations Challenges in modern day Records System. An overview of procedures performed and
other clinical activities Recommendations Conclusion
INTRODUCTION:
Prior to advent of information technology, health information was managed in a very crude method for health business transaction.
The Health Information Management is dated back to medieval period along with the history of medicine during the Hippocratic tradition. The needs for Health Information in a more modernized form was thought of which led to evolution of health information technology.
Looking at the theme of the presentation: Health information Development, Challenges and prospect for Hospital Management, much is thought of what it takes to sustain a standard world class hospital records in conformity with the World Health Organization (WHO) set standard.
The word ‘Health Information Development’ is the clinical in-put (clinical data generation) continuously during the process of Health Care Service Delivery(HCSD). The challenges are the shortcomings that are encountered during and after care service and the hospital Management is dependable on the standard Health Information Management and reporting to ascertain the level of clinical activities, utilization of the technology and the cost benefits to the health industry.
The task is enormous, since it involves a collective responsibility of the various specialties, going by code of professional ethics. There is no denying of the fact that the anchor of the ongoing health reforms is Health Information based and for this to be achieved, maximum attention should be paid to health information Development and Management in our domain, at all level of Health Care Services Delivery.
2. CONCEPT
Health Information is a derivative of clinical findings being documented and generated during the process of Health care services delivery arising from patient’s problem and complain being presented A. K. Afuye (1989).
It involves human and material resources which amounted to collection, collation and analysis for storage, retrieval and dissemination of the same clinical information for the purpose of effective Management and continuity of care.
The Health Information should contain sufficient data to justify the investigation being carried out, diagnosis being confirmed, treatments being given, duration of Hospital stay and result of the outcome of care.
Conceptually, health information is processed data that is really meaningful and useful to the recipient (users).
3. CLINICAL DOCUMENTATION STANDARD PROTOCOL
It is the professional responsibilities of either the Doctor or Physician and other health care providers who are incharge of the patient’s condition or problems to document in detail the conditions of the patient based on ethical standard.
The Traits of Clinical Documentations are as follows:
Accuracy Timeliness Completeness Conciseness Relevancy Adequacy
The Standard Protocol A full clarking of the patient’s problems A full investigations has to be carried out to confirm
diagnosis Treatments or Management of the case This depends on the nature of ailment and clinical
findings based on priority which could be any of the followings:
Medications Admission for surgery or observations for a period of
time Counseling may be necessary Rehabilitation Referrals Follow up procedures Treatments outcome (prognosis)
The treatments protocol gave birth to Problem Oriented Medical Records(POMR).
DR. Lawrence Weed (1969) outlined four basic principles as a pre-requisite for acceptable World Health Organization (WHO) set standard for Clinical Management as follows:
A need for adequate data base during clinical documentations
Identifications of the problems from the data base
Developmental plans towards solving the problems
Commencement of full implementation of the plans
The Data Base Content This forms the body of patient Health Information as follows: Determination of the problems Patient illness Physical examination Provisional diagnosis Confirmed diagnosis Patient profile Review System Approach Pathological measures Radiological measures Therapeutic Measures Prosthetics and Orthotics measures General Nursing Care Services Many others
Then define the database to contain standard health information.
HEALTH INFORMATION MANAGEMENT, A MULTI-DISCIPLINARY ACTIVITY:
The Health Records Officer is the custodian of Health Information. He/she collects, collates and analyze clinical data and report same to the Hospital Management.
Who generates the clinical data is the Doctor and other health care providers, who is directly or indirectly attending and treating the patients.
The treatment of patient has many dimensions depending on the specialty and the nature of the condition. In a larger specialist Hospital, it is highly multi-dimensional approach. Many different kinds of ailments (diseases) are reported and managed clinically and on hierarchical basis.
The Clinical Management of conditions is highly “network” since the entire HealthCare Services Providers (HCSP) maintain a team spirit – internally and externally (health information linkage).
The Health Records Officer’s going ConcernQuestions are raised: Are the problems of the patient properly and
clinically documented? Does it follow the standard ethics and channels? Are the modern technology available for
utilization? Are there positive perceptions of our clients
concerning the services being rendered to them?
What about patient length of stay after surgery to avert additional cost?
Do we maintain Health Records of patients in our various Departments/Units and report same to the Health Records Department regularly?
If the response to these questions is “yes” then we hope for an optimistic satisfactory outcome of HCSD in our Hospital environment.
TOTAL QUALITY MANAGEMENT OF PATIENT HEALTH RECORDS
Concept: This is a criteria to ensure an effective clinical
practice going by professional ethics, which simply regulates the management of patient care.
In a nutshell, the care provided should be relevant, adequate, standard and have a positive bearing as regards patient satisfaction.
It is a measure to set standard in all aspect of patient health care services through a continuous process of monitoring and evaluation of all kinds of procedures and professional skills being adopted during care services.
Methodology of Total Quality Management of Patient Health Records: Dala Case Study:
The discharged case folders leave the wards for Central Pool and after the activities of the collective stake holders, the case folders are collected by Health Records Officer in the Quality Control Unit of the Department.
Then in the Total Quality Control Unit the following activities take place:
The permanent arrangement is carried out to ascertain efficiency and flaws if any.
The Extraction of provisional and confirmed diagnosis and procedures and other clinical data within the content of the case folder.
Clinical Coding and Indexing of clinical data being extracted using ICD tools.
The case folders leave for Computer Unit for data capturing.
The case folders leave for Records Filing Library for permanent filing.
Then the case folders are now ready to be used for Research, Education and Training by the Consultants, Residents and other Researchers.
Sustenance of Total Quality Management:
Patient detail history is paramount Detailed Clinical documentations are essential Constant review of cases Follow up of case problem Team spirit approach Channel of hierarchy Full participatory of specialties A written discharge summary on patient
discharge from the Hospital ward is paramount based on medical ethics.
Health Information Utilization: Health Records information is the
threshold of the health economy generally in anywhere in the whole world.
The significance attached to health information in our Hospital environment today cannot be over emphasized. The foundation and development of any Hospital is centered on a standard health information Management and reporting system.
The relevance of Health Information is evidence by the following instances:
The Daily Trust (editorial column) on health matter, captioned – medical practitioners negligence which gave birth to SERVICOM during General Olusegun Obasanjo regime it’s through Health Information.
Daily Trust of Tuesday 23rd June, 2015 captioned: World Bank and others make case for personal health Records emanated from relevance of Health Information.
The publication by first Consultant medical centre Lagos about late Patrick Sawyer from Liberia, Ebola Virus.(Health Information).
The Iraq War Secret Files were unknowingly released and the US and his Allied forces were worried (military information).
The Iraq War Secret Files were unknowingly released and the US and his Allied forces were worried (military information).
When the Secret file of Election Malpractices in Nigeria was released, election voting machine was deployed, what happened in 2015 election? You can answer that yourself. (Political Information)
Caption on “Health Information”. (extract from Newsletter)
“A healthy body often equals a healthy brain” “so”…
Think positive and be focused Be sociable Eat healthily Keep your mind active and learn new things Exercise for good health” An Extract from Health Records Archives:
Daily Trust Thursday July 2nd 2015. “Nigeria fear Ebola resurgence in Liberia” A 17 year old Liberian boy died from the virus, just seven weeks after being declared free of the virus by the WHO. (Health Information).
The Main Purposes of Health Information
Catalyst for communication across board in the Health Sector.
Provision of easy reference for continuity of patient care.
A documentary evidence of care provided and significance details
It assists in the quality review mechanism of patient care services
It’s a pre-requisite for medico-legal tussle and equally use for research, education and training.
Every hospital administrative planning is built on the basis of standard health information reporting system.
It’s used for monitoring and evaluation, comparison of performance of all the Health care providers and for Hospital accreditation.
Many others.
CHALLENGES OF HEALTH DATA MANAGEMENT:
Presently, the available health information is mostly paper-based and only small fraction is computerized. There are several attempt to articulate the structure and content of the Patient Health Records(PHR).
There is a drastic evolution on how to cope with the paper based health records in our present administration through several attempts and negotiations with banks, ICT companies and other private organizations for full computerization of Health Records.
The birth of Central Pool of discharged Health Records and the meetings of the Stakeholders Committees had reduced significantly the transition of case folders.
DEMONSTRATIONS:THE AGREED TERM (CASE FOLDER
MOVEMENT)
WARD ADMITTED PATIENT
DISCHARGED CASE FOLDER
CENTRAL POOL’S CONVERGENCE OF ALL STAKEHOLDERS ACTIVITIES
HEALTH RECORDS DEPARTMENT
TOTAL QUALITY CONTROL
MEDICAL DIRECTOR’S OFFICE(Outstanding debtors)
DATA CAPTURING (COMPUTER UNIT)
FILING ROOM
“THE PRACTICE NOW”WARDS ADMITTED PATIENTS
DISCHARGED CASE FOLDERS
CENTRAL POOL
HEAD OF CLI. SER. & TRAINING
MEDICAL DIRECTOR’S OFFICE
ACCOUNTS DEPARTMENT ADMINISTRATION
DEPT
SOPD CLINICS, DOCTORS/THEATRE
ANAESTHESIAAUDIT DEPARTMENT
(Billing System & Refund)
(Outstanding debtors)
Secretary, Central Pool
(Medical Reports/Discharge Summary)
(Day cases) Billing System Certification)
STAFF & RELATIVES CONSULTANTS
HEALTH RECORDS DEPARTMENT
(Office Consultation, Case folders) (Case folder withhold)
TOTAL QUALITY CONTROL/DATA CAPTURING
FILING ROOMRemaining Part of the Case
Folders
ADDRESS THESE CONSTRAINTS FOR IMPLEMENTATION
Poor data culture Poor response to statistical returns Case folders still disappear from Central pool Discharged summary is yet to be effected Medical reports issue is still affecting case
folders for clinics Billing system for refund in
Accounts/Audit/Admin. Bermuda triangular “Day Cases” movement
(from SOPD Clinic to Anaesthesia) never return to the Department
Office consultation/staff relatives case folder hardly come back
Funding hampers full computerization although the Management has the political will.
A proposed new site for Health Records Department (Accommodation)
Poor Clinical research culture in the Hospital environment (RET).
There is a political will for provision of modern computers for data capturing but funding is a clog in the wheel of progress as at now.
AN OVERVIEW OF PROCEDURES PERFORMED AND OTHER CLINICAL ACTIVITIES FOR THE PERIOD UNDER REVIEW:Statistics Reports on Patient Care Services for 1st and 2nd Quarters (January to June, 2015).Definition: It is a scientific approach to patient
information Management in a numerical form (data) which portrays maximum understanding about the patient care services being rendered.
Development of Clinical Data: Extraction of raw data Registration/documentations Consultative Clinics attendance Daily Wards Statements Ancillary Services activities. Procedures performed in the theatre. Many others.
Statistical Information Coverage Areas:
Medical Director’s Office (MD) Director of Administration (DA) Head of Clinical Services & Training (HCST) Director of Nursing Services (DNS) Head of RET Federal Office of Statistics and Planning
(FOSP) Federal Ministry of Health (FMOH)
Significance of Statistics: Administrative Planning Medical Education Research and Training Comparism and measures of standard care Measurement of bed utilizations Indicator for acquisition and utilization of
technology Precursor for bed complement and turnover
of patient Many others
Our shortcomings: Delay in data returns by some clinical
Departments Lack of interest in the part of some
providers The users hardly request for data Lack of zeal for research study except
during Resident’s filling of log or Consultant given assignment and during student’s dissertation or project writing.
Data Comparisons1st and 2nd QuartersClassification of Procedures Performed by Team Consultants and other Doctors.
1st Quarter 2nd
Team(s)
Major Interm.
Minor Grand Total
Major Interm.
Minor Grand Total
Green
62 12 15 89 47 39 50 136
Blue 40 13 7 60 9 36 58 103
Pink 66 22 13 101 20 47 100 167
White
77 27 26 130 15 34 44 93
B/Plastic
22 - 19 41 47 -- 44 91
G/Total 267 74 80 421 138 156 296 590
Hospital Bed State1st Quarter 2nd Quarter
a.Admissions - 367
b.Discharges -
285c.Deaths - 6
422
429
2
Procedures Performed by Gender 1st
January to March
2nd
April to JuneGRAND TOTAL
Male and Female
Male and Female
Major 96 patients 182 278
Intermediate
80 “ 117 197
Minor 53 “ 96 149
Grand Total 229 395 624
Records of Bed Usage 1st Quarter 2nd Quarter
LOS 21 days 28 days
Turnover Interval (days)
49 days 23 days
Turnover 1 patient 2 patients
% Bed occupancy
30% 55%
Average Daily No. of Bed Occupied
69 Beds 123 beds
SOPD Consultative Clinics: 1st
January to March
2nd
April to JuneGrand Total
Green Team 634 patients 776 Patients 1410
Blue “ 511 “ 571 “ 1082
Pink “ 497 “ 618 “ 1115
White “ 517 “ 1065 “ 1582
Burns/Plastic
243 “ 318 “ 561
G/TOTAL 2402 3348 5750
National Health Insurance Scheme (NHIS): 1st
January to March2nd
April to June
Patient Attendance
1093 1531
Accident & Emergency (HR) 1st
January to March
2nd
April to June
A.
Patient Attendance 1298 1645
Clinical Research Attendance 1st
January to March
2nd
April to June
B. Clinical Research Attendance
10 12
Wednesday Clinical Conference Attendance 1st
January to March2nd
April to June
C. Wednesday Hospital Presentation
647 1279
Clinical Research AttendanceClinical Departments/Units
1st
January to March2nd
April to June
PHARMACY(Patient Attendance)
3358
4394
PATHOLOGY(Specimen Examined)
3666 5932
RADIOLOGY(Patient Attendance)
1351 1887
PHYSIOTHERAPY(Treatments given)
2209 2814
OCCUPATIONAL THERAPY (Treatments)
172 377
PROSTHETICS/ORTH.(Patient Attendance)
33 57
MEDICAL SOCIAL SERVICES(Patient Attendance)
493 *
PLASTER ROOM(Dressings)
562 840
Laundry (items) Received/Issued out
2075 4392
TAILORING (swab) 1802 3620
CATERING (Patient served) 6413 15736
SPECIAL DIET (Patient served)
1010 1580
MEDICAL LIBRARY (Readers)
59 354
ITEMS (issued) 625 865
NURSING (Wards)PRE & POST OP
229 patients 395 patients
ADMITTED PATIENTSNURSING CARE
367 patients 422 patients
PATIENT ATTENDANCE DURING RESIDENT DOCTORS’ STRIKE FROM 8TH JUNE TO 8TH JULY, 2015, SOPD/A&E/NHIS CON. CLINICS
PATIENT ATTENDANCES/NO TEAM(S) CONSULTANTS A &
E
SOP
D
NHIS G.T
01 White Drs. Isa/Donwa 110 271 - 381
02 Pink Drs. Nkanta/Alabi 85 170 - 255
03 Green Drs.
Abubakar/Mamman
123 158 - 281
04 Burns/Plastics
Drs.
Dafiewhare/Giwa
- 91 - 91
05 Blue Drs. Salihu
(MD)/Mustapha
72 150 - 222
06 National
Health
Insurance
Scheme
(NHIS)
Dr. Suleiman - - 487 487
GRAND TOTAL = 390 840 487 1717
RECOMMENDATIONS
The doctors should endeavour to be writing discharge summary despite their tight schedules going by the professional ethics.
The central pool system should be positively re-defined to avoid the hiccup in the SOPD Consultative Clinics.
The clinical Departments/Units should report their data to Health Records Department as at when due for further processing to the Management to avoid unnecessary delay.
The Hospital Community should be aware that the Health Records Department is the only custodian of Patient Health Records going by the ethics and not the other way round. The stakeholders should expedite action.
All users of Health Records should try to liaise with the Department for efficient movement and Management of the Records.
Try to assist the Department to maintain the confidentiality of the patient records by due authorization for release.
Let us retrospect on the SERVICOM Charter and the Medico Legal aspect of these patient health Records by trying to avoid proliferation and unlawful handling of the case folders.
The abuse of Health Record Forms during HealthCare Service Delivery should be avoided for the sake of cost of printing.
CONCLUSION: The “slogan” when doctor forgets, the
records remember is a reality, of the fact that Health Records of the Hospital represents the indices of the degree of medical excellence. It also represents the image of the Hospital to the outside public and is an image maker itself concurrently.
The Department has potential contributions towards the overall progress and development of the Hospital as the major player.
The Health Records Management is predominantly interface going by ethics of various specialties and the outcome is the data base formation and general linkage based on the Health Care Service Delivery.
We deliver to you what is previously documented by you using the law of Charles Babbage, as such we solicit for standard Health Records documentation in all sphere within the Hospital circle during the process of HCSD. Remember we are all team players.
Thank you.
Next week (05th August, 2015):PHYSIOTHERAPY DEPARTMENTFortnight (12th August, 2015):PROSTHETIC & ORTHOTICS DEPTFor the download of this Lecture, please log-on to www.orthopaedicdala.org and follow the link in the Homepage,
…Have a Nice Day
