NURS 6401 week 11 Discussion Essay
The Stewardship of Health Information
The objective of this topic is to analyze how the health authorities have led processes of change in the governance of health systems in the Region of the Americas, as they move toward universal access to health and universal health coverage. Stewardship describes the capacity of health authorities to lead and support joint action, which allows the creation, strengthening, or changes to governance structures in the health system. Governance is understood to be the institutional arrangements that regulate the actors and critical resources that influence conditions of coverage and access to health services ().
In order to make universal access to health and universal health coverage possible, health systems must overcome their institutional limitations, generally characterized by segmented coverage and fragmented services. The health authorities must exercise stewardship in order to strengthen governance of the financial model and of the health services, human resources, medicines, and technologies that constitute the sector (.
An analysis of the strategies of universal access to health and universal health coverage implemented in the countries in the Region of the Americas allows us to recognize different processes of change that address these issues. The differences lie both in the way health authorities practice stewardship and in the kinds of governance innovations proposed as engines to transform health systems.
This topic is divided into three sections. First, the various aspects of leadership capacity and governance in the health sector are discussed. Second, there is an analysis of health system transformations in the countries of the Americas, the role of stewardship by the health authorities, innovations in governance, and the main objectives and progress made. Finally, by way of conclusion, this document indicates the challenges that must be addressed in order to move toward universal health.
Tens of billions have been spent on new EMR and Pop Health software in the last two years. Billions more will be spent in the years ahead. Tens of millions in fines have been levied for PHI breaches. Millions more will be levied in the years ahead. Billions more have been spent on maintaining legacy systems. What’s at the center of it all? Data. How do providers, collect it, protect it, archive it and make it useful for providing care?
Data stewardship. What is it exactly? And why does it matter in healthcare? Before answering those questions, I wanted to better understand what other industry people think. So I Googled it. While I have more than 2 decades in the healthcare data space, the one thing I’ve learned is that change is the only constant. As a result, I am always learning…learning from my customers, learning from my team, learning from other subject matter experts.
So back to the aforementioned Google search on this concept of data stewardship and how others in the industry view it. In short, most industry people view data stewardship as the tactical execution within the strategic umbrella of data governance. One perspective noted that governance is not about the data, rather the people and process for managing an asset. In this case, the asset is the data. Each person is entitled to their own perspective.
Experience, however, has taught me a different perspective. Data stewardship is both strategic and tactical. More importantly, it’s a purposeful perspective of data as something of value entrusted to your care for responsible management and use. In healthcare, providers don’t actually own the data. Most of the data belongs to patients and the communities they serve. Those data owners entrust providers with information that will hopefully contribute to helping them receive the best care possible. Need proof about who owns the data? Look no further than the regulatory requirements for maintaining and protecting PHI.
With that alternative perspective about data stewardship, let’s now explore where it all begins. It begins with understanding the attributes of the environment. That includes stakeholders and roles, regulatory requirements, tools, and available resources. Unfortunately, stewardship often takes a back seat to a race to retire aging legacy systems. While there is a reasonable sense of urgency to do so, based on things outside one’s control (like a flickering green screen, or a looming maintenance renewal), leaders must think strategically. Tactically mitigate risk in the short term while investing time and resources in thoroughly understanding the whole of the current environment. Use a SWOT to model a complete picture. If you are thin on resources and/or expertise, consider using a third party. Sometimes we are too close to a situation to be objective. A qualified third party can go a long way to ensuring objective perspective.
From there, a provider organization needs to create a data stewardship governance framework identifying owners, policies, process and priorities. Ahhhh, priorities. That’s a tough one. The best practice for identifying priorities is to keep things simple. Follow the stellar advice of Jim Collins, Author of Good to Great… “If you have more than three priorities, you have no priorities.” Whether a goal or major pain point, focus on the priorities that directly support the board-approved organizational strategic priorities. It’s the best practice for maximizing the probability of buy-in from stakeholders. One additional note: over-communicate with the entire organization. While it’s not prudent to communicate every detail, dangers, and the like, people still need to know that change is afoot and WHY.NURS 6401 week 11 Discussion Essay
Thirdly, invest time to build a roadmap for creating and preserving the ideal environment of data stewardship. It’s best for the governance team to guide the effort and involve input from multiple stakeholders across the organization. This is far more than an IT initiative. This is an organizational imperative. Still a smaller team must own it, socialize it for feedback, and ensure the objectives are properly managed to completion. In most communities, data has a minimum shelf life of 7-10 years due to regulatory retention requirements. In some communities, data must be kept in excess of 20 years. A cornerstone of retaining and securing data over time means retiring vulnerable and/or costly legacy systems. Creating the right path for this extensive work is critical to optimizing resources, maintaining compliance, and reducing costs…all results that support achieving an ideal environment of data stewardship.NURS 6401 week 11 Discussion Essay
Health information management professionals (HIM™) provide services in all aspects of records management – including data collection and data quality management, integrity, standards, disclosure, coding, disposition, and privacy of health information. They perform detailed analysis of the information in the health record to facilitate health care delivery, patient safety and decision support. They play a role in ensuring the confidentiality of health information within the patient record and are advocates of the patient’s right to private, secure and confidential information. HIM professionals are essential in quality programs, and provide guidance on documentation, communication, eHealth implementation, EHR infrastructure, and policy issues.
Health data is coded and used for analysis by organizations such as the Canadian Institute for Health Information (CIHI), the Canadian Patient Safety Institute and the provincial ministries of health to look at adverse events. Hospital decision support departments use the adverse events, Hospital Standardized Mortality Rates (HSMR), complication rates, in-house infections etc. – to improve how they treat patients.
“Over the years I have been most fortunate to serve in different capacities that contribute to patient safety. As a decision support analyst, I provide indicators and analyses from our incident and infection control databases to our clinical teams to assess safety and risk. Leading the hospital accreditation process in the past included working with all teams to ensure that standards around patient safety were addressed. This included workflow analyses, staff education, communications and policy revision,” explains Jeanette Martin, Decision Support Analyst at Winchester District Memorial Hospital. “I truly feel that HIMs in all capacities greatly contribute to patient safety. From the core coding staff that collect data that provides much of the foundation for decision-making to the actual strategic level decision-makers. We all have our roles to play and I am proud to play mine every day.”
HIM coders – who bring strong biomedical science education, coding classification and abstracting knowledge – collect data from hospital visits (acute, ambulatory care, rehab, etc.) and codify the data using the International Classification of Diseases, Canadian adaptation or modification (ICD-10-CA) and the Canadian Classification of Interventions. The ICD codes were developed by the World Health Organization and are used internationally and adapted for use by country if needed.
As active participants in patient safety in a transforming Electronic Health Record (EHR) environment, HIMs champion patient safety and quality care by advocating for and managing complete, timely, accurate, and meaningful data. The Canadian Health Information Management Association (CHIMA) requires all certified HIM professionals to participate in Continuing Professional Education, ensuring HIM professionals maintain their knowledge, awareness of evolving data, new EHR developments, infrastructure innovations, and standards related to eHealth transformations, supporting their role as data and information stewards.NURS 6401 week 11 Discussion Essay
HIM professionals play an important role in patient safety as hospitals and ministries use the data they collect and analyze to:
• Ensure that patient information is secure and protected
• Improve healthcare quality by reducing medical errors, health disparities, and by advancing the delivery of patient-centered medical care
• Reduce healthcare costs resulting from inefficiency, medical errors, inappropriate care, duplicative care, and incomplete information
• Provide appropriate information to help guide medical decisions at the time and place of care
• Improve the coordination of care and information among hospitals, laboratories, physician offices, and other entities for the secure and authorized exchange of healthcare information
• Improve public health activities and facilitating the early identification and rapid response to public health threats
• Facilitate health and clinical research and healthcare quality
• Promote early detection, prevention, and management of chronic diseases.
In 2009, the Health Informatics (HI) and Health Information Management (HIM) Human Resources Report was released, which highlighted a serious risk of labour and skill shortages over the next five years. An additional 6,320 to 12,330 HI and HIM professionals are needed by 2014. HI and HIM™ professionals who require broader skills will increase from 8,880 in 2009 to between 13,690 and 32,170 by 2014.
“As the e health record gets rolled out across Canada, the role of the certified health information management professional will become increasingly important in ensuring our health information is protected, and properly managed,” says Gail Crook, CEO and registrar of CHIMA and CCHIM. “Without certified professionals doing the work, more errors occur, data is compromised and patient safety is at risk. As our health records go paperless, the privacy, confidentiality and safety of those records need to be managed by a certified HIM professional in order to ensure the best patient care.”NURS 6401 week 11 Discussion Essay
Over the course of a week, I visited my elderly friend hospitalized with a broken hip, cognitive impairment, and chest pain. A steady stream of providers flowed through the room: doctors, nurses, therapists, dieticians, counselors, phlebotomists, and ministers, at least 30 or 40 different people, probably more. They changed from day to day and shift to shift. And with each change came a slightly different version of my friend’s story. Somehow, her story got confused very early in the process. Some said she fainted, others understood that she tripped and fell. Some asserted her chest pain was sharp and got worse with deep breaths—suggesting a pulmonary problem, while others believed it was “pressure like,” a characteristic of cardiac pain. A covering cardiologist understood that she had a fever (she didn’t) and, with a normal electrocardiogram, that pneumonia was the most likely diagnosis. The covering hospitalist thought she had angina but deferred to the cardiologist. The family didn’t know who to believe, or who was in charge.
The Vanishing Of Primary Care Physicians
Traditionally, this has been the role of the primary care physician. However, among all the providers that paraded through this patient’s room, none was her primary care physician. Banished from the wards to achieve greater efficiencies and lower inpatient costs, the primary care physician is conspicuously absent from inpatient care. Hospitalists have been shown to effectively reduce inpatient lengths-of-stay. And the demands of an ever-increasing outpatient work load keep primary care physicians chained to their offices. While the efficiencies produced by this division of labor are well-documented, another silo has been created that further fragments patient care.
In the process, the patient’s story is being muddled, and there is a negative impact on the patient and caregiver experience. In a study conducted in 2009, 75 percent of inpatients were unable to recall the name of the doctor in charge of their care. This creates confusion and anxiety for patients and their families, and also calls into question how well patients are understood by their new providers. The patient narrative does not begin with the acute events that precipitated admission, it is a chronical that often includes the interwoven effects of multiple comorbidities and nuanced decisions to go down prior pathways of care. It includes social and psychological barriers to health, spiritual beliefs, and attitudes about death. Patients are unlikely to share such intimacies with providers they have just met and whose names are unknown to them. NURS 6401 week 11 Discussion Essay
We hoped that the electronic health record (EHR) would help integrate information and, thereby, patients’ care. Elements of the real narrative were likely buried in this patient’s EHR that sat at the nurses’ station. However, it seemed that the details were quickly forgotten or confused by the time these providers made it to the room. The confusion was probably compounded and perpetuated as providers relayed their understanding to each other in a high-stakes version of the telephone game. It fell to family and friends to protect the integrity of the story so that it could be told and retold with some semblance of accuracy.
Other Obstacles For Navigating Stewardship
The disappearance of the primary care physician from the hospital is not the only problem. There are other assaults on the story. Ultra-specialization has fragmented patients, and their story, so that the specialist may focus only on the story of the relevant organ. Hand offs among providers are a constant threat to the story, and with more providers that threat multiplies. The EHR, which should be a guardian of the story, is subject to abuse as time-pressured clinicians mechanically copy and paste elements of the story without processing the details, and errors get inadvertently perpetuated. Interoperability gaps further interrupt the story. The proliferation of increasingly precise diagnostic tests has created the illusion that the story, as well as the physical exam, is unimportant, and in some ways, a quaint artifact of the past.
In this case, the errors in the patient’s history were not just a matter of confusion, there appear to have been fundamental flaws in recording the patient’s history, a failure to listen to the story. When I was a medical student, many years ago, we were told that 80 percent of the diagnosis is in the patient’s history. Listen carefully to the story, and you will be able to make the diagnosis more accurately and with less testing. And, if you convey it well, others will be better able to care for the patient. We were drilled in getting the details of each patient’s story right and accurately conveying it without notes and “without deviation, hesitation, or obfuscation,” as one of my preceptors would say. We practiced for hours with emphasis on delivering a compelling presentation. We probably overdid it. But the point was well made—the patient is only really understood, and properly cared for, in the context of their story. It’s important to listen and to get it right. NURS 6401 week 11 Discussion Essay