Health Cards (12)
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Colleagues:
I will attempt at this time to answer issues addressed in Health Card
responses 7,8,9, and 10 from Merrick Zwarenstein, Janice Price, and
Paula Tavrow. I certainly appreciate the dialogue and interest to date
and hope that others will join us in our preliminary evaluations
regarding the utilization of the "Hand Carried Comprehensive Health
Card" (CHC) as a viable instrument in the documentation of heath care
services. Perhaps a scaled down version of the CHC needs to be
considered, but first, let us enjoy the debate.
Merrick, no there is no evidence that the collection of the information
as outlined previously impacts positively the health status of
individuals or their communities. Since the CHC has yet to be utilized
within the context of a developing country we cannot claim a positive
impact. Conversely, we cannot state that it will have a negative health
impact either. As you have so correctly stated, it has yet to be
reviewed or tested. Currently our evaluations are presumptive at best
and we need to apply the laws of science in making the final conclusion
as to the appropriateness of such an instrument.
Regarding the issue of "diverting staff attention away from
communicating with the patient" I would see the use of such an
instrument as platform for effective communication with the patient,
not to mention the potential savings in time attempting to locate the
patient's clinical record and/or gathering accurate historical
information. Here are my arguments:
1) If (and I am well aware that could be a huge if) information is
documented in the CHC as suggested in the outline, then information will
be available to the HCW that otherwise would have been unavailable to
the HCW without further interrogation of the patient. And then, the
patient's responses may be in question due to the amount of time lapsed
between the event and the current examination, as well as the tendency
for patients to provide answers they perceive the HCW is seeking. We
must keep in mind that community health workers(CHW), and other
caregivers, should be allowed to document certain episodes of illness as
warranted by protocol. This would move us to my second comment:
2) The HCW will have in hand historical data necessary to make informed
decisions regarding care and treatment. This data would include any
diagnoses and treatments from other providers such as the mother or
other caregiver, volunteer community health worker, other HCW regardless
of service or location. Thus it would simplify the acquisition of a
medical history.
3) In many rural settings the filing methodology incorporated by the
local clinic personnel is lacking in many respects. Just locating a
patient record is frequently futile and time consuming. Many of us have
often seen records in disarray or scattered on the floor. The concept of
an "alphabetical index" is a concept only and not a reality in many
clinical settings. On the contrary patients are known to maintain their
own records at an extremely high success rate.
4) It is my opinion that most of the data in the card would be
summarized by a clerk or health informatics specialist. The HCW
(physician, nurse, physician assistant etc.) would not necessarily be
the one doing the documentation.
Merrick, I am open to suggestions regarding a feasible evaluation that
would be efficient and acceptable to the medical community. One of main
reasons for posting this on the Afro-Nets was to raise some interest in
the concept. Now that we have "stirred up" some interest and concerns,
can you provide some additional practical advise that would assist us in
scientifically answering your question, "Do we know that the card does
more good than harm"?
Janice, greetings to you in Seattle and welcome. I knew that the idea
of such a comprehensive instrument as the CHC would get the attention of
those concerned with privacy. Thanks for responding. No, you are not
out of line to be concerned about privacy and discrimination. Did you
happen to read the "AIDS and Child Health" paper by Dr. G. Foster from
the Amsterdam Homecare Conference, 20 May 1997? It was just posted on
Afro-Nets recently. In the light of that article and the use of a CHC to
document and disseminate health related data, would such an instrument
be of value in addressing the epidemic, or should we be concerned more
about privacy? Would it be more important to protect our perceptions of
privacy, or that HCWs would have enough information at their disposal to
assist in combating this the epidemic? As most of us who have worked in
the developing world know, the community knows what's going on in the
village. The status of an individuals health is oftentimes recognized
by many. Also, discrimination does not need documentation to thrive. It
exists, and is promoted long before the pen makes its mark on a sheet of
paper. I would appreciate it if you would qualify your concerns for
privacy and discrimination. Thanks.
Janice, I have just received Health Cards (10) over the weekend and I
will attempt to respond to your concerns. You state that you would
refuse to carry one of these health cards. Why? As a resident in the
state of Washington do you drive? Can you refuse to carry a drivers
license if you so choose? Can you refuse to present that license to the
officer should he happen to stop you?
We as individuals are members of a society. In a very real sense we are
corporately accountable to each other for our actions. As a licensed
driver in the state of Wisconsin I am glad that the state requires
others, as well as myself, to have a license. How would you like to
drive on the highway knowing that a large portion of the automobiles on
the road do not have licensed drivers behind the wheel? Isn't it nice
knowing that almost all the drivers on the road have taken a test to
verify their ability to keep them from hitting you head on? Or, that for
the most part they are obeying the "corporate" rules of the road as
dictated by the state? Now, let us consider the issue of TB within the
corporate and societal context. B is an extremely communicable
disease. It is out of control in many parts of the world. We as
individuals and as a society are accountable for the spread of this life
threatening disease to our family, friends, and other "contacts". If
the CHC is found to be a useful instrument in following TB patients and
contacts, especially in areas of high migration, then why do I have a
"right" to say, "I refuse to carry this card because it violates my
right to privacy" as we greet our new neighbour with a "kiss of death"?
Now having made the above statement I would like you to read Dr. Fosters
previously paper on "AIDS and Child Health". How is the medical
community going to even begin to address Africa's prodigious health
problems without information?
It is apparent that your argument does not take into consideration the
potential overall benefits of such a card on the health status of the
populace. Janice, there are advantages and disadvantages to everything
in life. Most treatments for disease have some negative side affects.
It is always a trade off, and that takes us back to Merrick's question,
"Will the cards do more good than harm?" As of yet we do not know the
answer to that question, and we will never know unless we at least
attempt to appropriately test the cards. I am fully aware of the
corruption and abuses of power that permeates some of these countries.
It has been my experience that these abuses can be addressed if one has
the proper information upon which to base appropriate disciplinary
actions. You will never even begin to address these issues until you
design a system that provides the basic information needed for
addressing the problems. After all, cash registers were invented to
prevent employees from robbing the till. Nightly reconciliation
procedures in the "developed" world keep many people honest. People of
any country are no different. Proper controls, no matter how futile in
the beginning, we eventually have a positive impact on our HCWs.
Until the health care sector begins to implement an information
infrastructure that will provide a foundation upon which to build its
intervention strategies they will continue to fall short in providing
appropriate and effective health care. HIV/AIDS, TB, ARI, Malaria and
the like will continue to destroy Africa's children because we can not
provide our HCW, project leaders, and national ministries with the
necessary information that will help them combat these devastating
health risks that have prevailed for so long.
Janice, privacy is an issue that needs addressing. There should be
specific protocols set in place to ensure that privacy is maintained,
but let us not have a "knee jerk" response to a potentially useful
instrument. I would like you to expound as to specific reasons for
refusing to carry such a card. Thanks.
Paula (Health Cards 9) - I think that perhaps some of your concerns were
addressed above. In general I would like to state that if your concerns
are valid, then why are the industrialized nations moving towards a
"smart card"? The CHC is nothing more than a paper version of the
electronic smart card.
Why would a patient going to a clinic for services not want to present
his/her health card to the provider? In a non migratory situation the
HCW would have most of the information from the card in patient's clinic
record. It is assumed that the HCW would already know what is in the
patient's CHC.
The issue of providers treating "for a price" already flourishes. You
don't need a CHC to encourage it. As stated above, proper controls and
evaluations need to be implemented in order to combat these issues.
"If you shoot for nothing, you'll hit it every time." - Unknown
At this stage we do not scientifically know the impact of such an
instrument, but we need to find out.
Looking forward to your responses.
Bill
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William Billingsley
Impact Demographic Health Surveillance Information Systems
Application Software Technologies, Inc.
1841 South Ridge Road
Green Bay, WI 54304, USA
Tel.800-992-0533
Tel. +1-414-499-0533
Tel. +1-414-655-3962 (Cell)
Fax +1-414-490-3218
Tel. +1-715-823-6375 (Home)
mailto:wbillingsley@aztechcon.com
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