Medical and Health-Related Errors - The Impact of Recordkeeping upon Patient Well-Being

Running head: MEDICAL AND HEALTH-RELATED ERRORS

Medical and Health-Related Errors:

The Impact of Recordkeeping upon Patient Well-Being

Andrew Sexton

University of Puget Sound

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MEDICAL AND HEALTH-RELATED ERRORS

Introduction

As healthcare technology has rapidly evolved on a global level, the providers’

patient population has grown concurrently. The high volumes of patients who all have

records documenting their healthcare generate a large amount of data. This data is not

immune to human error because it needs to be organized. “US healthcare delivery is in

the midst of a profound transformation which results at least in part, from Federal public

policy efforts to encourage the adoption and use of health information technology”

(Middleton et al., 2013). This research proposal focuses on the following question: Will

the conversion and subsequent standardization of medical recordkeeping practices to

individually managed, electronic platforms reduce medical and health-related errors?

Literature Review

Before Electronic Data Collection

A study conducted by Tufo and Speidel (1971) prior to innovations in electronic

health recordkeeping identified many underlying causes of medical error associated with

improper health recordkeeping. Their findings emphasized that regular review of the

accuracy of medical records allows the viewer to refine the data and reduce the

occurrence of errors. This practice appears to be routine in any situation involving large

amounts of vital and impactful data. Their research evokes the idea that even before the

widespread implementation of electronic recordkeeping technology, there was a large

yearning for standardization in medical data collection and the use of health records to

improve the quality of patient care.

Research conducted by Jao, Helgason, and Zych (2009) examined how hard copy

forms of patient billing produced large amounts of error when compared to computerized

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modalities. They designed and implemented a computerized system to compare with

existing methods of hard data entry associated with patient billing. The physicians in the

study who implemented the computerized recordkeeping system found that the amount of

errors experienced was dramatically reduced. The computerized health billing and

recordkeeping system reduced patient cost and ultimately allowed the physicians to

provide a high quality of patient care. Their findings suggest a direct correlation between

the increased efficiency associated with electronic modalities of health recordkeeping and

improved quality of patient care.

Computerized Medical Recordkeeping

Bowman (2013) examined the impact of electronic health record systems on

information integrity. She posed the true benefits of the standardization of electronic

health recordkeeping against the potential drawbacks. The study proposed that “poor

electronic health record system design and improper use can cause electronic health

related errors that jeopardize the integrity of the information in the electronic health

record, leading to errors that endanger patient safety or decrease the quality of care”

(Bowman, 2013). The findings support the notion that errors related to electronic health

recordkeeping are a direct result of improper data entry. Improper data entry also

accounts for errors among more obsolete forms of hard copy data entry in health

recordkeeping. The study suggested that reducing basic design flaws, improving the ease

of usability, and improving the data capturing process would all lead to improved patient

care associated with the reduced occurrence of errors in electronic health recordkeeping.

A study conducted by Dayan et al. (2013) used the Israeli Defense Forces to

observe the costs related to the quality of patient care received when the primary care

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physician utilized electronic health records. The researchers examined the efficiency and

effectiveness associated with electronic health recordkeeping, and the associated cost

savings. The total population of patients sampled was sourced from specialty clinic

providers for the Israeli Defense Forces. The study established an assessment scale to

quantify the qualitative ratings of patient care. They found that electronic health

recordkeeping increased efficiency, improved the quality of patient care, and decreased

the costs associated with less accurate methods of recordkeeping.

Electronic Health Records Gain Traction

The Canadian Adverse Events Study conducted by Baker et al. (2004) examined

how occurrences of adverse events in hospital settings indicated a need to improve

patient safety. The study outlined adverse events as any situation that resulted in

unintended injury or complication resulting in death or prolonged hospital stay. These

adverse events stemmed from errors in health care management. They randomly selected

sample populations of patients from a number of Canadian hospitals, and screened patient

charts with noted adverse events to identify how they could have been prevented. Their

findings suggest that out of millions of annual hospital stays in Canada, a large portion of

adverse events stemming from improper health care management were potentially

preventable.

Middleton et al. (2013) conducted a study via the American Medical Informatics

Association to examine whether electronic health recordkeeping would enhance patient

safety and quality of care. They developed a set of recommendations pertaining to

specified areas of healthcare practice, where provider end-users were urged to incorporate

electronic health recordkeeping into their practice. A usability assessment was developed

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in order to quantify and accurately gauge the effectiveness and ease of adoption of

electronic health recordkeeping practices within a clinical setting. The results of this

assessment as outlined in the study’s findings elucidate the need for a standardized

electronic system in health recordkeeping that provides functional and efficient use

among end-user providers.

Research conducted by Schoen et al. (2007) examined the reported health care

experiences of adults across seven countries. A pinnacle commonality among participants

from all seven countries was a higher incidence of patient reported error associated with

being under the care of multiple practitioners, or for those being treated for comorbid

conditions. The participants completed surveys regarding their qualitative views toward

healthcare accessibility and efficiency. These results were then posed against quantitative

data sets relating to socioeconomic conditions of the seven different countries. Their

findings present the crucial idea that the standardization of health recordkeeping through

electronic modalities will lead to increased patient quality of care, improved efficacy in

medical practice, and the ability to reduce errors associated with synthesizing data from

multiple sources.

Research by Schwappach (2014) examined patient-reported medical errors among

eleven different countries and identified common risk factors associated with patient-

reported medical errors. An international survey was conducted that factored in differing

foreign health care systems and modeled error-reporting probability. Among the eleven

different sample populations surveyed, regression analyses identified the risk factors

associated with patient-reported medical errors. Poor care coordination stemming from

improper medical recordkeeping practices was the greatest common risk factor for

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patient-reported error. Their findings emphasized the importance of a standardized

system of electronic health recordkeeping on an international scale. They highlighted the

commonalities among multiple countries pertaining to preventable patient-reported

medical errors associated with improper health recordkeeping.

Continued Need for Standardized Electronic Medical Recordkeeping Practices

Research by Pirkle, Dumont, and Zunzunegui (2012) suggests that a lack of

resources affects the quality of health care assured by medical recordkeeping. They assert

that clinical situations where resources are limited detract from the meticulousness of

medical recordkeeping. Their findings suggest that medical recordkeeping should have a

standardized level of quality control, regardless of the associated operational funds. By

broadening the availability of recent innovations in the field of electronic health

recordkeeping to clinical settings with varying levels of resources, medical recordkeeping

can improve the quality of patient care. This improvement relates to efficiencies that

enhance patient data accuracy and reduce associated practitioner error.

Thompson (2010) examined medical recordkeeping in an occupational health

setting. They emphasized the importance of policy related standards being applied to

clinical practice and how compliance to outlined procedures results in increased quality

of patient care. Their findings display that improved quality of patient care correlates

with proper adherence to policies guiding the use of medical recordkeeping systems.

They explained how government regulation provides a standardized level of

accountability for all end-users of electronic health recordkeeping systems. This study

further advances the view that “a national network of electronic health records is being

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viewed as a way to improve the quality of care, improve patient safety, and lower costs”

(Thompson, 2010).

Hypothesis Development

The overarching hypothesis being tested through this research explores how

improper recordkeeping practices have a positive correlation with medical and health

related errors. Multiple hypotheses will be used to examine how various independent

variables explain more variance in the dependent variable. Multiple variables will be

established in order to test the validity of these hypotheses. The following exogenous,

independent variables are being examined to determine the strength of their correlation

with improper recordkeeping and medical and health related errors: gender, age, race, and

level of education completed. Improper recordkeeping is established as the exogenous,

mediator variable. Medical and health related errors are established as the endogenous,

dependent variable. The hypotheses test whether or not the independent and mediator

variables cause the dependent variable to occur. The observed interaction between the

various independent variables and single mediator variable will determine whether they

are capable of explaining more variance in the dependent variable, as apposed to if they

were acting in a mutually exclusive manner.

The first hypothesis states that survey respondents who identify as being male will

be strongly, positively, and directly correlated with medical and health related errors. The

underlying assumption behind this hypothesis is that there are fewer individuals who

identify as being male that work in the medical recordkeeping field. With a smaller

overall population, the rate of occurrences of medical and health related errors would

increase relative to smaller total population.

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The second hypothesis states that survey respondents between the age of 18 and

35 will be strongly, negatively, and directly correlated with medical and health related

errors. The underlying assumption behind this hypothesis is that younger individuals have

more agile minds that allow them to conduct data entry procedures with less occurrences

of systematic and human error.

The third hypothesis states that survey respondents between the age of 36 and 55

will be strongly, positively, and directly correlated with medical and health related errors.

The underlying assumption behind this hypothesis is that older individuals tend to

commit more human and systematic error in data entry.

The fourth hypothesis states that race will be weakly, positively, and inversely

correlated with medical and health related errors. The underlying assumption behind this

hypothesis is that an individual’s race should not have any impact upon whether or not

they commit human or systematic error associated with medical recordkeeping data entry.

The fifth hypothesis states that individuals who have completed a level of

education equivalent to or lower than a high school diploma will be strongly, positively,

and directly correlated with medical and health related errors. The underlying assumption

behind this hypothesis is that individuals who have not gone to college have spent less

time in an academic setting that requires high attention to detail needed to properly enter

data associated with medical recordkeeping.

The sixth hypothesis states that individuals who have completed an undergraduate

bachelor’s degree or higher level of education will be strongly, negatively, and directly

correlated with medical and health related errors. The underlying assumption behind this

hypothesis is that individuals who have completed higher education have been trained to

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accurately convey their thoughts. This academic training requires the individual to

produce precise and correct data.

Methodology

Sample (Participants)

A crucial component to gathering data for the purpose of this research involves

quantifiably defining recordkeeping. Once recordkeeping practices are quantified, sample

populations will be surveyed to determine whether proper recordkeeping is occurring,

and if so to what degree. The sampling frame will be comprised of a representative

sample of United States adults. The specific independent variables being examined

through the multiple hypotheses require a minimum age of 18 years old. This also relates

to the minimum age requirement for hirable employees in the United States medical

recordkeeping field. The sample population needs to be broad and diverse enough to

encompass a large variety of genders, ages, races, and levels of education completed.

According to www.census.gov (2016), as of April 2016, the total United States

population comprises over 320 million people. For the sake of practical data collection

one percent of this figure, or roughly 3 million individuals will participate in this

experimental research. Aiming for this amount of participants will allow for the data to

be more accurately representative of the demographics outlined by the experiment’s

multiple independent variables. A sample population of this size strengthens the validity

of the data. The sampling procedures used in this experiment will help reduce costs, use

time more efficiently, reduce the associated labor requirements, improve the accuracy of

the data, increase reliability in data collection, and provide test units to be modeled in

future research endeavors.

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http://www.census.gov/


In order to solicit potential experiment participants, the survey will be mailed to

every household in America. Nonprobability sampling will be used for the sake of

convenience, and to ensure that the probability of any particular member of the

population being chosen is unknown. This strengthens the credibility of the respondent’s

data. A quota sampling procedure will be employed to ensure that the various subgroups

of the total United States population related to the experiment’s independent variable are

pertinently represented.

Design

The experiment is designed to measure improper recordkeeping practices as a

multi-item construct. There will be three cells in the experiment representing the

following variables: independent exogenous, mediator exogenous, and dependent

endogenous. Six separate regression point displacement analyses will be run examining

how the first and second cells independently influence the level of variance in the third

cell. This type of regression analysis requires a pretest-posttest control group

experimental design in order to produce a single treated group score pertaining to the

independent variable. The regression analyses will examine how the second cell would

mediate the relationship between the first and third cell, thus determining whether the

second cell has a greater mediating effect upon the dependent variable than the

independent variable.

Variables

The first independent variable, gender, will be manipulated by employing three

separate moderating variables: male, female, and non-binary. This attempts to account for

any possible gender that participants may identify with. The second independent variable,

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age, will be manipulated by two moderating variables: the 18 to 35-age bracket, and 36 to

55-age bracket. This accounts for any relevant data relating to age collected from

participants. The third independent variable, race, will be manipulated by six different

moderating variables: white, black or African American, American Indian or Alaska

native, Asian, native Hawaiian or Pacific Islander, and Hispanic. This accounts for any

major racial demographics being examined in the fourth hypothesis. The fourth

independent variable, level of education completed, will be manipulated by two possible

moderating variables: high school equivalent or lower, and undergraduate bachelors

degree or higher. This accounts for the participant’s potential education background.

The dependent variables will be measured using figures associated with the

occurrence of adverse events in medical settings in the United States. This quantitative

data is available via United States government health censuses. The moderator variables

will be measured based upon whether they strengthen or weaken the correlations derived

from the multiple regression analyses. The mediator variable will be measured by

establishing a system to quantify qualitative evaluations of proper recordkeeping

practices. A separate and independent study will be conducted that surveys individuals

within the recordkeeping field who can provide credible qualitative statements that will

translate into valid quantitative data. In order to account for the effects of extraneous

variables and measure their effect upon the experimental outcomes, randomization will

be employed. This involves the random assignment of subjects and treatments to groups

in order to equally distribute the effects of the confounding variables to all conditions.

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Procedure

The experiment will be conducted with the goal of minimizing threats to internal

validity while concurrently maximizing external validity. Internal validity exists to the

extent that an experimental variable is truly responsible for any variance in the dependent

variable (Babin & Zikmund, 2016). A potential threat to internal validity is the history

effect, when some change other than the intended experimental treatment occurs during

the course of the experiment that affects the dependent variable. Another potential threat

to internal validity is the cohort effect, where changes in the dependent variable arise due

to differing historical situations between multiple experimental groups. The maturation

effect is a seemingly unavoidable threat to internal validity because the rate of its’

occurrence decreases with growth and experience. In order to avoid testing effects as a

threat to internal validity, the surveys must be presented to potential participants in a

manner that encourages objective responses. Instrumentation effects as threats to internal

validity can be easily avoided by meticulously composing the survey questions. Sample

attrition will not present itself as a potential threat to internal validity because the data is

recorded upon receipt of the completed survey.

External validity is the accuracy with which experimental results can be

generalized beyond the experimental subjects (Babin & Zikmund, 2016). In order to

maximize external validity, regular manipulation checks will be conducted to ensure that

the manipulation produces differences in the independent variable. Attention filters will

be incorporated into the survey to ensure the respondents are genuinely answering the

questions.

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Discussion

The main purpose of this study is to illuminate how recordkeeping practices have

a critical impact upon patient well being due to medical and health-related errors. A high

quality of patient care should be a universal standard. In order to promote a high quality

of patient care within a clinical setting, the literature suggests that the advent of patient

monitored electronic health records will further reduce medical related errors. The

reduction in errors associated with health recordkeeping practices will reduce the overall

occurrence of adverse events in clinical settings, leading to increased quality of patient

care, and a reduction in practitioner liability. To corporate figureheads and academicians

alike, this study will provide concrete empirical data to support the beneficial and

arguably necessary transition toward individually managed, personal health

recordkeeping.

The proposed experimental research has a few limitations that present themselves

in its’ early conceptual stages. As the proposed research is the first of its’ kind to be

conducted, a large amount generalization needs to occur to transition from broad

questions to specific inquiries. Likewise it is unclear what confounding factors may

present themselves in the form of undesignated and extraneous moderating variables.

There is a potential for false face validity to occur within the bounds of this experiment.

The initial data may appear valid superficially due to unexplored confounding variables.

A specific generalization with the independent gender variable may occur because only

three moderator variables exist.

Future research beyond the initial proposal should encompass a much greater

sample size of the total population of United States adults. The greater the sample size,

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the more valid the data becomes. In future related research an additional mediator

variable should be employed: technological error associated with electronic health

recordkeeping. As the electronic medical recordkeeping industry beings to advance, new

and improved technologies will be associated with operational errors. Research by Audet,

Squires, and Doty (2014) explains that current various electronic health recordkeeping

modalities have emerged during the innovator’s phase of the diffusion curve. This

suggests that health information technology as a larger industry is still in its’ infancy, and

as such has ample time to gravitate toward the standardization of individual personal

health recordkeeping.

Conclusion

The central hypothesis being tested through this research is how improper

recordkeeping practices have a positive correlation with medical and health related errors.

In accordance with the six generated hypotheses, six separate regression point

displacement analyses will be run to test the correlation between improper recordkeeping

and medical and health related errors. The goal of this research is to determine whether

the conversion and subsequent standardization of medical recordkeeping practices to

individually managed, electronic platforms will reduce medical and health-related errors.

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http://www.census.gov/popclock

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Medical and Health-Related Errors - The Impact of Recordkeeping upon Patient Well-Being