Health Records – at Risk? (Part 4)

An electronic ripple effect
For Rupal Patel-Shah, a registered nurse who manages the hospital’s interventional radiology department, incoming patients are no longer an unknown quantity until the chart is presented upon arrival. Instead of having to flip through the chart to find data on lab work, review orders in the chart and view essential information such as allergies, everything is available in advance on the computer. Patient history and recent notes from nurses and doctor’s office visits can be called up as needed, along with past encounters and diagnostic images in the radiology department. Radiologists, RNs and technicians can see notes from the other two hospitals in the system, Glenbrook Hospital and Highland Park Hospital—a valuable feature because the Evanston facility gets a lot of transferred patients from those community hospitals, says Patel-Shah. The department still deals with limited paper-based data from outpatients and transfers from outside the Evanston system, but this information is scanned in.

The scanned and internally created chart information populating the electronic record each day makes the medical records department a quiet place instead of a beehive of paper-passing activity, says Teresa Bunsen, director of medical records. The main Evanston facility now employs 47.5 FTEs in the medical records area—about the same as for Community Hospital’s much smaller operation—and only 77 FTEs are needed for the three hospitals combined. Fourteen of those Evanston employers are “coders” who work from home using a dedicated connection to the hospital’s computer system, says Bunsen. Coders assign numerical procedure or disease codes to charted services for billing purposes.

The electronic medical records system aids clinicians by gathering information as it’s generated and routing it to the appropriate blanks in the documentation notes. Faxes from physician offices, laboratories and other sources of data outside the Evanston system go to a fax server and are converted to electronic images, so there is no paper on the hospital’s end. Doctors no longer have to pore through paper charts to sign dictations, authenticate verbal orders written down by others, or co-sign orders of residents. At one time, a room in an area of the medical records department was filled with paper charts, and no one could leave with a chart; that policy constituted the only security the records had. That room was also the only place physicians could juggle and sign sheets in the binders; now the eight carrels in the signing area each have a flat-screen computer, a phone and a writing area, but little in the way of paper. It’s no longer the only place to get the work done, either. Doctors can view and sign electronically from their offices or anywhere else they can get to a computer, says Bunsen.

Besides security improvements, electronic records have been a boon to financial and operational improvements. One tally of efficiency is known as “discharged but not final billed,” a dollar-volume tally of patient discharges for which all the billing codes are not final. The codes can’t be final until doctors view certain chart details and sign off. In the spring of 2003, the dollar volume stood at $38 million. As of late September 2005, that figure had plummeted to $5.6 million, says Bunsen.

Three sides of the security triangle
The aspect of patient-data security currently getting the most attention is confidentiality, but Rhodes of AHIMA says there are two other aspects to consider: integrity, or the assurance that information is comprehensive and accurate, and availability, or the ability to deliver essential information when and where it’s needed. Paper-based methods of capturing and storing records can lead to problems with both integrity and availability.

With one copy of all medical encounters in one folder, the risk of losing an important piece of information is always a concern. Sometimes it’s intentional, says Rhodes. A patient who argues he did not sign a consent form for a medical action might ask to see his record and wait for nurses or records professionals to get busy and destroy evidence of his consent. Hospital staff and medical providers also have been caught trying to eliminate documentation in a patient’s chart, he says.

The materials used to collect and compile paper records can be a source of problems for information integrity. For example, adhesives often are used to paste reports or results to a page. A doctor may dictate a report into a digital recorder, and someone later transcribes it on a word processor using paper with peel-off adhesive backing. “Even the best adhesives eventually lose their adhesive properties,” says Rhodes. Something dislodges it from a chart and it’s filed back in the wrong place or lost entirely.

As recently as 10 years ago, electrocardiograms were printed on thermal paper, using heat rather than ink. But a heat-produced image eventually starts to fade. Meanwhile, carbon-less paper copies placed near thermal paper speed up the process of thermal degradation, causing a loss in legibility. Stored on top of each other in a closed record, a thermal document eventually ends up as a blank page. Those technologies are not in wide use now, but inkjet printers cause a new range of problems when pressed on other pages—jumbling text to the point that it’s illegible.

Paper records can be damaged where they are stored. “I’ve had water mains bust and flood the records,” says Rhodes. The extremes of this type of damage were plainly seen in the aftermath of Hurricane Katrina’s storms and resulting floods, in which nearly a million people’s medical records were destroyed or became unavailable for use by doctors when patients were relocated and thus separated from their medical documentation.

Records also can slip behind office furniture or be otherwise misplaced. Rhodes recalls a time when a record slipped behind a cabinet and wasn’t found until the records area was remodeled years later. “The electronic record is not going to fall behind the counter.”

Making the comparisons relevant
Privacy and information control are central issues as the healthcare industry begins to envision a future where patient details are kept in computers. Publicity about the benefits of accessible and complete medical information will help build support. But publicity about the perceived downside of having sensitive data in electronic form can slow this momentum or even threaten the forward movement to electronic health records.

Both the current paper and the envisioned electronic methods of keeping and using medical records have their downsides. “We are having a debate about privacy of health information in the United States, and we need to explain to the American people why electronic systems are preferable to paper,” said Dr. David Brailer, National Coordinator for Health Information Technology, in a speech on Feb. 17, 2005. That explanation must include showing how paper records work.

“Paper medical records are difficult to secure and keep private—records can be left unattended on people’s desks, inadvertently placed in the trash, or transported among clinician offices via taxicabs or other couriers,” Brailer said. “Even when they are in secure facilities, it is not possible to restrict viewers to only the information they need to see to do their work. We rarely can identify when privacy of paper records has been compromised. By comparison, electronic records have strict security measures in place to prevent misuse or unauthorized access by using audit trails, access permissions and viewing restrictions.”

The challenge, he continued, is “to be disciplined about developing the business rules, policies and protections that get consumer health information where they want it—immediately—and keep it from going where they don’t—ever.”

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Health Records – at Risk? (Part 3)

Medical records: the processing plant
At the end of Amy’s hospitalization, the elements accumulated in her active chart are merged with the existing medical chart down in the medical records department. Workers from the records department pick up the entries that comprised the active charts of discharged patients from trays in the nursing units and take them to a room where they are logged into a computer tracking system as received. For patients without a running record, new folders are created with a bar-code ID number. Then records technicians flip through all pages of the chart to see if there are any deficiencies—unsigned orders, reports needing dictation or physician signature, etc. Those problems are flagged and deficient charts are sent to one of several areas where physicians go to check what they need to complete. In 2004, the records department of Community Hospital delivered 14,287 medical records to other in-hospital locations for physician completion.In an electronic environment, no records would have to be delivered and laid out for doctors. The chart assembly and analysis area of a medical records department would not exist out in the open. In a paper environment, that area is a hub of paper-passing. On the day Amy underwent her tests, a staff of 17 medical records department employees over a period of 14.5 hours filed 420 patient reports into charts, moved 898 patient reports from one location to another within the department and moved 483 full medical records from one location to another both in and outside of the department. The mid-size hospital’s records unit employs 48 full-time-equivalent workers on three shifts per day, with about 20 on the day shift.

Much of Community Hospital’s volume of clinical reports and results is computerized already. Besides the lab and radiology reports that are created online and printed to nursing floors, the departments of physical medicine, respiratory therapy, dietary management, social services and others enter information directly into a clinical documentation system. However, since the paper record is still considered the legal document, all reports are printed to the medical records department for filing 24 hours after patient discharge. The paper record is also the only means of keeping information in one place for the long term. Community Hospital is gradually transitioning to electronic medical records, but right now it doesn’t have the storage capacity to maintain lifelong patient records. All information is purged 60 to 90 days after being entered to make room for new patient information. Nurses can go online for results during a patient’s hospitalization, but a paper copy is routed to the paper chart.

Historical medical records are fragmented in other ways. An outside firm began scanning old charts into an optical imaging system earlier this year, so the records department is pulling only paper charts from 2004 and 2005. Doctors can access records from 2001 and 2002 through the imaging system at the hospital. Everything before 2001 is on microfilm, pulled only on request.

The medical records used in patient care at Community Hospital are largely complete for inpatient services, because as the only hospital for miles around, it’s likely to be the only facility that has served most of the admitted patients. For hospitals in a larger healthcare system, records need to get to other facilities. When Rhodes was at a hospital system in Bexar County, Texas, it took a fleet of vans to circulate charts among the main hospital in downtown San Antonio, an adjacent ambulatory center, a new medical center in the suburbs and a network of satellite clinics. (A clinic operation has a separate set of security issues—See Appendix.) Many times the records required to make good decisions on behalf of a patient were in a truck and running late, says Rhodes. Sometimes a record got wedged somewhere during transit and wasn’t delivered at all. At Marymount, the hospital exchanges information with two offsite clinics by fax, e-mail or courier, says Smith. One courier drives all day among the three sites, handling not only clinical records but also deliveries for the materials management department and business office.

In an electronic-records environment, the prospects of a patient record being lost, stolen or spied on would dwindle to almost zero, Rhodes says. “People can’t hide it, hoard it, it can’t fall between the seats in the van.” 

Handling patient data electronically
At three-hospital Evanston (Ill.) Northwestern Healthcare, nursing stations are uncluttered and nearly devoid of paper with any medical details on patients. The only paper kept by routine is a hanging file of electrocardiogram strips—and the hospital system has a project underway with its IT vendor to have these stored electronically as well. Since an electronic record went into operation more than a year ago, there is little out on the nursing floors for people to glance at it or take elsewhere. At a 36-bed surgical unit in the flagship Evanston Hospital, for example, the only access to patient records is through seven mobile computers wheeled around by the five to seven registered nurses on a typical shift, plus nine wired computers placed around the nursing station.

It wasn’t that way before, says unit nurse Kimberly Marrese. When she started at Evanston in 1999 it was the same story as Community Hospital and elsewhere: A unit clerk was in charge of getting all the paper to the right place and continually calling diagnostic departments to make sure appointments were set up for patients on the unit. “There were papers everywhere, names floating around—this is so much better.” Now the system manages orders automatically; they’re sent without having to “filter through every single person” along the way, says Marrese. The unit clerk, or secretary as they’re called at Evanston, sees some clinical information when she signs onto the computer system, such as demographics and emergency contacts, but she doesn’t see a patient’s plan of care and can’t read physician or nurse notes—there’s no need for her to know these details.

Nurses and doctors have unrestricted access to clinical information, but their electronic mark is on everything they call up on a computer screen using a password-protected sign-in. Employees doing clerical, billing or reception work can see only what they need to see to do their job, and some workers have no access rights at all—including those who transport patients from one place to another. “The people coming to pick up the patients can’t get the chart,” says Marrese. “They have no reason to.”

As tests are ordered, results reported, progress notes created and patient details jotted, the patient chart comes together without anyone taking part in it. The computer system takes care of it as a byproduct of conducting electronic business. The computer also manages access by more than one user at a time, which removes the temptation of physicians and others to hide or hoard the single available copy of a patient’s record. Charts are “always” open to more than one user, says Marrese. Besides nurses and physicians, various therapists and technologists can share the record online, as can pharmacists and administrators such as performance-improvement specialists and, of course, security-monitoring staffers. 

Out on the nursing unit, Marrese relies on one of the wireless flat-screen personal computers stationed on rolling carts, nicknamed “Jetsons.” “We take it everywhere we go,” she says. Having it with her inherently protects privacy because the computer is not standing in a hallway while open to a patient’s chart. If a nurse or other authorized user goes away from a computer, it logs the person off after a few minutes. When the nurse comes back, she can sign in and the screen will be in the exact place she was working, eliminating the time it would have taken to start at the beginning and find her place. 

The stationary computers on the nursing station are mainly for clinicians who don’t work full time on the unit: doctors, medical and nursing students, discharge planners, social workers. Doctors can have multiple charts open at once, but nurses can see charts only one at a time. Marrese says it’s easier for nurses to enter information on the wrong chart in a computer than on paper charts in front of them, and this restriction discourages such errors. An exception is the women’s hospital attached to the Evanston facility, where nurses may have to see charts of mother and child together. Clinicians can compose notes at the same time in a chart, but not orders.

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The Gender Pay Gap in Healthcare

We have come a long way over the years in regards to gender equality, but we still have not come far enough when it comes to women’s pay grades in the healthcare field. Sadly, women still make significantly less than men in this field, yet they consist of a large portion of employees in this area. This discrepancy is quite jarring in today’s environment and the reasons behind it are a both unjust and unwarranted. This is an issue that needs to be kept in the spotlight in order to enact the necessary changes.

Most people probably don’t even realize that this problem exists, but it does. Women in all healthcare roles, from nurses to medical managers and doctors, make less than their male counterparts in the same position. In some instances, such as in the case of male nurses, the difference is significantly high, with men earning up to 19% more, according to Physicians Weekly. This is especially upsetting since women account for over 90% of the nursing field and are typically from a minority background. Although some claim male nurses can do more due to their size, such as lifting patients, that is a negligible difference and in no way should account for such different pay scales.

The wage gaps exist across all medical professions, particularly in hospitals. A report in The Hospitalist uncovered that female doctors earn up to $10,00 less per year than their male colleagues. The fact that a woman in such an authoritative position is still being paid less is both disconcerting and reassuring. While it means that this lesser pay rate occurs to women of all classes, it also means no matter how successful a woman is, she will never earn top dollar.

The fact that women consistently earn less is an unavoidable fact that needs to be addressed. A recent study by Kennesaw State University (KSU) revealed that overall women receive up to 35% less than men in similar roles and that trend shows no sign of changing. KSU also examined the reasons behind the wage gap, citing reasons such as women being excluded from the inner networks and their not receiving the proper support to advance their career. Although these are valid reasons, it only scratches the surface.

While not having support can stall a career it doesn’t explain why a successful doctor still receives lower pay if she is a female.

The fact is that in this day and age women are stills seen as the inferior sex and the pay gap in the healthcare field reflects this way of thinking. Healthcare professionals work notoriously long hours and literally hold our lives in their hands. the thought that someone in this position would receive less pay because she is female is preposterous. Men and women who perform the same job with the same degree of success deserve equal pay. There is no explanation to make the wage gap make sense, because it doesn’t.

There are a few bright spots in the medical field – notably in the field of nursing, especially the salaries paid to nurse practitioners and really for the pay for most nurses. Another fantastic option is becoming an ultrasound technician – for the four year degree required to gain certification as an ultrasound technician, the salary paid out is very high. These two careers are generally dominated by females and represent an opportunity to beat the gender wage gap.

 

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Health Records – at Risk? (Part 2)

Recording a record’s journey
A porter wheeled the 58-year-old woman out of an elevator and down the deserted corridor of the community hospital during an early morning in mid-June of 2005. In a back pocket of the wheelchair was the binder of personal medical information—the patient’s chart—that went wherever she did. It would be the first and most solitary of the five trips the chart would take this day with a porter pushing the wheelchair and the patient staring ahead, thinking about the tests she would undergo to shed light on her stroke-like symptoms.

During the course of this episode of care, the sensitive details of the patient’s medical past and current travails would be only as secure as the ethics of the hospital workers pushing her wheelchair or flipping through the chart to read observations. The confidential details on the patient above, who we’ll call Amy, would be safe in the hands of respectful workers at an undisclosed facility in America’s heartland, which we’ll call Community Hospital. But if that were not the case, a quick grab and a few flips through the conveniently organized binder would have easily yielded the woman’s demographic data, including Social Security number; her history of high blood pressure, diabetes and a prior stroke; the six medications she was taking; her allergies to several drugs; and the full report from the emergency room the night before. And unless there was an eyewitness to spot the breach of confidentiality, no one would ever know.

This report follows the journey of a paper-based medical record for one day. In so doing, the report compiles a chart of its own: direct observations, high-level insights, anecdotes, statistics and analysis on the handling of personal health information in today’s predominantly loose-leaf system of originating and keeping records. In the gathering debate over whether electronic medical records present security risks, it’s essential to acknowledge the less-than-perfect state of security that exists on paper today.

From the time a record is mobilized for use, it goes by cart, box, courier or car to different floors of a facility or to other facilities across a community. It gets wheeled down halls, put in door slots, leafed through by many people. Even when a record is sequestered in a records room, each test result or status report routed to the record involves another set of eyes and hands.
Contrast that with an electronic record system, which automatically adds items to a patient’s file without involving couriers and restricts access to those needing to know—often granting selective access to parts of the record instead of full access to the whole chart. Any attempt to “flip through” the record is caught and catalogued by an automatically vigilant electronic system known as an audit trail.

Between 7:20 a.m. and 2:50 p.m., the chart traveling with Amy will change hands 17 times. A visitor to the Intermediate Care Unit where Amy is staying will take a personal phone call while standing over the chart on the counter of the nursing station. The chart will be perused not only by the attending doctor and assigned nurse but also by technicians in the neurology, cardiology and radiology departments as well as by a physical therapist and an occupational therapist. All professionals, but all looking at anything they want to look at.

Nurses’ station a magnet for paper
Amy’s paper chart of past encounters in the hospital is 4 inches thick, wrapped in a manila folder. It stands on end, filling a 4-inch-wide cubbyhole behind the nurses’ station—one of 25 such boxes for charts labeled by room and bed number. Most other charts are thinner, though the chart for one room is wedged in; it’s probably 5 inches thick when not pressed together. Another is stacked off to one side, much too big for the designated room slot.

This is where the “old charts” will stay for the duration of each patient’s hospitalization after being sent up from the medical records department. The doctor attending Amy reviewed her chart between 6:30 and 7 a.m., but otherwise no one will see her record of previous medical conditions, excepting what clinicians asked and wrote down during the ER episode that initiated this admission or what resulted from yet another oral history the doctor took as part of conducting an exam and assessment. The binders passed around on the nurses’ stations and sent with patients during tests or therapies—the “active charts”—are started from scratch each time a patient is admitted. Other hospitals don’t fetch the previous record from the medical records department at all. At Marymount Medical Center in London, Ky., doctors occasionally ask for a patient’s full record to be sent up from storage to the nurses’ station in charge of a patient, but otherwise those charts stay put, says Stacie Smith, the facility’s director of health information management and also its privacy officer. Just like at Community Hospital, the chart on admitted patients at Marymount is started on the nursing unit.

The nurse responsible for attending to a given patient at Community Hospital is also charged with collecting, collating and compiling the “active chart” on that patient. Aiding nurses is the unit clerk, a kind of traffic cop for the nurses’ station and the central point of contact for information and communication. The chart-making routine is a feat of paper-handling accomplished through an array of trays, wall slots, printers and couriers.

Couriers deliver to the unit clerk’s inbox a steady stream of envelopes with paper reports, everything from simple patient histories to analyses of stress tests. Progress notes and strips of electrocardiograph printouts go the nursing unit’s charge nurse, who puts them in the boxes for each nurse under her supervision. Neurology tests go the mailbox of the nurse manager, who hands them to the unit clerk. Lab and radiology results print automatically to printers on the appropriate nursing unit, and the unit clerk files those and all the other items coming her way in one of five wall-mounted boxes, each covering five beds. Nurses check the boxes, leaf through for their patients’ information, and add the new materials to active charts kept on a shelf.
Personnel from the hospital lab go through all the charts on the night shift to pull various reports printed during the day and replace them with a one-page cumulative report. The pulled pages are tossed into a wastebasket with a special green trash bag in it, which designates sensitive patient information to be shredded. The trashcans holding patient-identifying details can be seen in clinical care areas throughout the hospital, usually next to the black-bagged regular trashcans. Periodically the green bags are removed and taken to be disposed.

Amy’s chart for this admission was started with the pages of tests, observations and demographic details that accompanied her on the cart transporting her from the ER. As the first full day dawned in her hospital stay, she was scheduled for four more tests—then abruptly, a fifth—that would add pages to the chart and prompt a progression of people to view her personal information.

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Health Records – at Risk? (Part 1)

A side effect of the electronic cure being prescribed for the use of medical records is a mounting concern about the safety of the sensitive healthcare information contained in the records. How completely will a connected electronic system of record-keeping prevent unauthorized eyes from seeing medical details unnecessarily? Without a satisfactory answer to this question, consumers may not see connected health information for what it is: the key to coordinating and maintaining sound documentation of their health history in a far more comprehensive and secure method than any medical caregiver can provide today.

As important a concern as security is to consumers, they should understand that electronic systems offer much more than current paper-based methods when considered in the broader context of why patient records exist at all. Electronic systems offer a quantum leap in the beneficial uses of medical records, by allowing the full value of all information ever written down or stored as images at many sites of care to be indexed and utilized by multiple caregivers in multiple locations at any time. The security of electronic systems and their ease of access have been much-discussed, but the state of security for records kept in paper binders and manila folders has not attracted the same amount of attention. Warnings that an electronic system is not bullet-proof, and may be a threat to confidentiality of personal health information, do not take into account the security weaknesses of paper records.

What does the average citizen know about the current security of a paper medical record? The National Alliance for Health Information Technology figured the only way to find out was to see the process first-hand. In June 2005, a representative visited a typical hospital using paper records, and a paper-deluged community medical clinic. In September the representative visited a hospital using an electronic system.

This is the report of what we saw, what we learned, and what the public can use to make a reasoned comparison between current and emerging approaches to medical record security. It also looks at protecting the integrity of the information for safe and sound medical decision-making; making critical information available when needed; and addressing the efficiency, and with it the effectiveness, of nurses and doctors in providing care to their patients.

Recording a record’s journey
A porter wheeled the 58-year-old woman out of an elevator and down the deserted corridor of the community hospital during an early morning in mid-June of 2005. In a back pocket of the wheelchair was the binder of personal medical information—the patient’s chart—that went wherever she did. It would be the first and most solitary of the five trips the chart would take this day with a porter pushing the wheelchair and the patient staring ahead, thinking about the tests she would undergo to shed light on her stroke-like symptoms.

During the course of this episode of care, the sensitive details of the patient’s medical past and current travails would be only as secure as the ethics of the hospital workers pushing her wheelchair or flipping through the chart to read observations. The confidential details on the patient above, who we’ll call Amy, would be safe in the hands of respectful workers at an undisclosed facility in America’s heartland, which we’ll call Community Hospital. But if that were not the case, a quick grab and a few flips through the conveniently organized binder would have easily yielded the woman’s demographic data, including Social Security number; her history of high blood pressure, diabetes and a prior stroke; the six medications she was taking; her allergies to several drugs; and the full report from the emergency room the night before. And unless there was an eyewitness to spot the breach of confidentiality, no one would ever know.

This report follows the journey of a paper-based medical record for one day. In so doing, the report compiles a chart of its own: direct observations, high-level insights, anecdotes, statistics and analysis on the handling of personal health information in today’s predominantly loose-leaf system of originating and keeping records. In the gathering debate over whether electronic medical records present security risks, it’s essential to acknowledge the less-than-perfect state of security that exists on paper today.

From the time a record is mobilized for use, it goes by cart, box, courier or car to different floors of a facility or to other facilities across a community. It gets wheeled down halls, put in door slots, leafed through by many people. Even when a record is sequestered in a records room, each test result or status report routed to the record involves another set of eyes and hands.
Contrast that with an electronic record system, which automatically adds items to a patient’s file without involving couriers and restricts access to those needing to know—often granting selective access to parts of the record instead of full access to the whole chart. Any attempt to “flip through” the record is caught and catalogued by an automatically vigilant electronic system known as an audit trail.

Between 7:20 a.m. and 2:50 p.m., the chart traveling with Amy will change hands 17 times. A visitor to the Intermediate Care Unit where Amy is staying will take a personal phone call while standing over the chart on the counter of the nursing station. The chart will be perused not only by the attending doctor and assigned nurse but also by technicians in the neurology, cardiology and radiology departments as well as by a physical therapist and an occupational therapist. All professionals, but all looking at anything they want to look at.

Nurses’ station a magnet for paper
Amy’s paper chart of past encounters in the hospital is 4 inches thick, wrapped in a manila folder. It stands on end, filling a 4-inch-wide cubbyhole behind the nurses’ station—one of 25 such boxes for charts labeled by room and bed number. Most other charts are thinner, though the chart for one room is wedged in; it’s probably 5 inches thick when not pressed together. Another is stacked off to one side, much too big for the designated room slot.

This is where the “old charts” will stay for the duration of each patient’s hospitalization after being sent up from the medical records department. The doctor attending Amy reviewed her chart between 6:30 and 7 a.m., but otherwise no one will see her record of previous medical conditions, excepting what clinicians asked and wrote down during the ER episode that initiated this admission or what resulted from yet another oral history the doctor took as part of conducting an exam and assessment. The binders passed around on the nurses’ stations and sent with patients during tests or therapies—the “active charts”—are started from scratch each time a patient is admitted. Other hospitals don’t fetch the previous record from the medical records department at all. At Marymount Medical Center in London, Ky., doctors occasionally ask for a patient’s full record to be sent up from storage to the nurses’ station in charge of a patient, but otherwise those charts stay put, says Stacie Smith, the facility’s director of health information management and also its privacy officer. Just like at Community Hospital, the chart on admitted patients at Marymount is started on the nursing unit.

The nurse responsible for attending to a given patient at Community Hospital is also charged with collecting, collating and compiling the “active chart” on that patient. Aiding nurses is the unit clerk, a kind of traffic cop for the nurses’ station and the central point of contact for information and communication. The chart-making routine is a feat of paper-handling accomplished through an array of trays, wall slots, printers and couriers.

Couriers deliver to the unit clerk’s inbox a steady stream of envelopes with paper reports, everything from simple patient histories to analyses of stress tests. Progress notes and strips of electrocardiograph printouts go the nursing unit’s charge nurse, who puts them in the boxes for each nurse under her supervision. Neurology tests go the mailbox of the nurse manager, who hands them to the unit clerk. Lab and radiology results print automatically to printers on the appropriate nursing unit, and the unit clerk files those and all the other items coming her way in one of five wall-mounted boxes, each covering five beds. Nurses check the boxes, leaf through for their patients’ information, and add the new materials to active charts kept on a shelf.
Personnel from the hospital lab go through all the charts on the night shift to pull various reports printed during the day and replace them with a one-page cumulative report. The pulled pages are tossed into a wastebasket with a special green trash bag in it, which designates sensitive patient information to be shredded. The trashcans holding patient-identifying details can be seen in clinical care areas throughout the hospital, usually next to the black-bagged regular trashcans. Periodically the green bags are removed and taken to be disposed.

Amy’s chart for this admission was started with the pages of tests, observations and demographic details that accompanied her on the cart transporting her from the ER. As the first full day dawned in her hospital stay, she was scheduled for four more tests—then abruptly, a fifth—that would add pages to the chart and prompt a progression of people to view her personal information.

We will continue the journey of Amy chart in the next installment of this series…

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The Effect of Income on the Quality of Healthcare

It turns out affordable healthcare isn’t so affordable after all. Though that statement may sound funny, the fact that millions of Americans are without heath insurance and can’t afford even basic care is anything but funny. Healthcare is a serious issue in the United States, as those outside the top earning brackets can ill afford the medical services they need. The disparity between healthcare for the upper and lower classes continues to grow, at the expense of everyone. The Affordable Healthcare Act (ACA)was supposed to address and rectify these issues, but hasn’t. As lawmakers and insurance companies continue to battle millions of Americans hang in limbo, with no real resolution in sight. These people are no better off with the ACA than they were before it existed.

Before the enactment of the Affordable Healthcare Act America’s healthcare system was in a state of crisis. Insurance companies kept raising their premiums and changing what procedures were covered. This caused many employers to either decrease the number of employees being offered insurance or not offer insurance benefits at all to keep up with the rising costs. Ironically, these employers were paying more to insure less people. The majority of the workers who were not offered insurance, as a result, were middle income and low-income employees. Part of the reason for this is because higher bracket workers won’t accept less than the best, which means employers must offer benefits to attract these higher “quality” workers.

This left millions of Americans with no way to get health insurance, forcing them to go to the emergency room for things as simple as the flu because they couldn’t afford a doctors visit. Of all the different income levels in America the middle -lo income workers were the ones hit the hardest. While the lowest brackets could qualify for Medicaid and the higher brackets got actual insurance, the middle class could get neither. They didn’t make enough to get employee benefits or afford out-of-pocket costs and they made too much to get Medicaid, leaving them in a healthcare no-mans-land.

This income inequality in relation to healthcare caused an uproar with most citizens. People were dying because they couldn’t afford long-term care or medications that cost hundreds of dollars, while the upper 1% lived long and prosperous lives. It seemed the chasm between incomes was getting bigger and bigger with no solution. Many began to cry foul and began to question if this was a form of racism, since many in the lower brackets are Latino or African-American. The idea that hard working people could not get medical attention when they were sick was beyond ridiculous and many lawmakers began lobbying for change.

Eventually, after a long battle with congress President Obama enacted the Affordable Healthcare Act, which in theory was supposed to ensure that every American would have health insurance. At it’s core the ACA was supposed to reform insurance company policies, form exchanges offering subsidized policies and make Medicaid accessible to more people, so no one would be caught in no-mans-land. In reality, while there have been some improvements, overall there ha been no significant change, as many are still without coverage. Even with President Obama attaching a penalty to anyone who was uninsured and didn’t sign up for healthcare, thousands still haven’t joined because it is just too expensive.

On the positive side insurance companies must now answer for rising premiums and must follow stricter guidelines. Also, there are more people with health insurance now than in the last 10 years, which is a very good thing. Additionally, some employers are saving money because employees are getting insurance from the exchanges, allowing them to be more profitable. However, on the flip side there are still thousands who can’t afford insurance. Part of the reason is because Medicaid was not made more accessible, as it was intended too. That means many are still ineligible and do not make enough to afford coverage. Under the ACA a person would pay an average of $300 per month for a basic policy. That is a lot of money for people who live paycheck to paycheck, which means this issue is till unresolved.

The ACA has made some strides to improve healthcare in America, but until the costs go down it is still not a solution. instead it is just another form of insurance many lower income families can ill afford. $300 a month on insurance seems like thousands when you have to choose between paying rent and getting medicine. It is a choice no one should have to make. Hopefully the ACA will be refined so no one has to make that choice in the future.

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