I'm Henry The VIII I Am

Henry VIII continues to be a fascinating case study and the focus of movies, books, songs (if you wonder about the title it comes from Herman's Hermits' Song of the Same name)


and recently ShowTime's series "The Tudors" which has certainly captured much of the intrigue if not all the historical accuracy. So what does this have to do with clinical documentation you may ask.

Henry VII is famous for his six wives but is also subject to substantial debate as to the cause of death. He died on 28 January 1547 after suffering through a bad fever. As was common at the time he was bled during his illness by the "physicians" of the day, and like so many cases this likely contributed to his death. But here we are 462 yeasr later and we continue to debate the cause of his death. There have been many suggested causes of his death:

• Syphilis
• Untreated type II diabetes
• Obesity
• Tuberculosis
• An infection coupled with breathing problems

and probably the most commonly held view is that Henry VIII died of syphilis. A position promoted some 100 years ago but currently thought to be inaccurate. But the list of possible causes of death today would be a lot shorter had the method of data capture been an EMR. Imagine Henry's physician documenting the case - he would be presented with a list possible causes of death as known in 1547:

Tudor EMRCause of Death:

• Consumption
• Smallpox
• Consumption with SmallPox
• Other

But Henry's medical record was one of the best medical records of his time and included the following information (from Trivia Library):

At 22 he contracted smallpox..At 33 he had his first attack of malaria...At 35, after a serious jousting accident, ...develop chronic migraine headaches and the extraordinarily painful leg ulcers which eventually crippled him...at44, Henry suffered his worst jousting accident and lay unconscious for two hours....fits of blind anger ..acute insomnia, painful sore throats, and recurrent, agonizing headaches. ....became prematurely gray and abnormally obese; in one four-year period his waist measurement increased by an astounding 17 in., ....At 45 he developed a strange growth on the side of his nose...At 49 he probably became sterile or impotent...at age 55, he could hardly walk ...increasingly absentminded, ...his last eight days in bed, too weak even to lift a glass to his lips

But recent review of the notes suggest she may well have died from complications of Type II Diabetes. And it was the narrative that helped current researchers to come to that conclusion.

So unless we believe we know everything we need to know about healthcare, symptoms, signs and diseases then collecting the narrative is imperative to capture the maximum amount of information both now and in the future. If we loose the narrative we will be loosing information. Identifying data elements is important but these two worlds can live in harmony in Clinical Document Architecture Format (CDA) in the Healthstory Project that preserves the narrative but adds additional data elements.

If you want to hear more come listen to the presentation:

Clinical Narrative and Structured Data in the EHR: Venus and Mars Live in Harmony with CDA4CDT on Wednesday Oct 7th @ 11:15 in the Grapevine Ballroom D, Gaylord Texan, at the AHIMA Convention in Grapevine Texas. Hope to see you there

Does the Information get Captured - Not even a Fraction of it

In an HIT moment with Andy Kapit, the CEO of Coderyte Mr HISTalk explores the trouble with coding. There are some good insights into the challenges facing the clinicians in the system and several great quotes.

They down-code because they are afraid to get audited, afraid that the system will not be reasonable. They are afraid to stand out and afraid that the fact that their patients are ‘sicker’ means that their higher codes will make them stand out. They are afraid — period.

There is enough in the way of pressures without adding more burden to clinicians in worrying about audit's and the veritable army of folks and companies who are employed just to investigate and find discrepancies. Ironically they are probably using more sophisticated tools to identify poor coding than the doctors themselves are using to create the codes.
As Andy says it creates "adversarial culture not only reduces the morale of the physicians, it forces the data to be more flawed than it needs to be"....sigh...it's true it does, fear is not the answer. It's just like tax returns as described in a recent article in USA Today that suggested there will likely be an increase in tax cheating because of the high profile cases of folks who appear to have gotten away with it but:

Americans are among the most law-abiding taxpayers in the world, in part because the IRS uses computer matching programs that make it difficult to cheat, says Walter Pagano, a former IRS agent who is a partner at accounting firm Eisner.

But this is not clinicians cheating but a fundamentally flawed system cheating them through fear. As Andy said - talked about flawed....

Think about it — the most complex series of events most people endure in their lifetimes are reduced to three-, four- or five-digit codes

The heritage of these codes dates back to Henry VIII and the tabulation methodology used by Graunt to describe the 50 or so causes death that were the precursor to ICD coding system (this is from memory but the original article was in the Journal of Public Health: Public health, data standards, and vocabulary: crucial infrastructure for reliable public health surveillance. and I cannot find the copy of the article so if you have this please send it to me)

But it was this that really struck a cord

Physicians have these well-trained powers of observation and, with the full color of their narrative, describe what is wrong with us and what they are going to do about it. In that language are rich and complex concepts — some of which are negated, historical, related to a family member, or are equivocal because more information is needed. Does all of that valuable information get captured in the medical coding process? Not even a fraction of it. The information captured in the record accurately reflects the actual health of the patients. The information healthcare uses to evaluate the quality of care and outcomes is inaccurate — out of fear and is both measuring and rewarding the wrong things.

Excellent points indeed. To further complicate the issue the content is then dumped into text based files that contain a one dimensional view of detail.....so much better to start storing this information in a richer more suitable container to capture the full story.... The Healthstory: "Comprehensive electronic clinical records that tell a patient’s complete health story." Such information to include the rich complex concepts and whatever codes are necessary to make the information computer interpretable. It can also include the billing codes and other richer vocabularies including Snomed-CT, Radlex and even ICD-10 should that ever arrive.

The project needs more members, both those providing the capabilities and the information as well as those consuming or using the information. You can sign up here.

I'd love to hear feedback on the Healthstory project - good and bad. If you are not a member - why not?