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Once implemented, a screening system must be continually evaluated in terms of its efficiency and effectiveness. The objectives of a screening program should be seen in terms of both the outcomes of those patients who are screened (that is, whether trauma patients who abuse or are dependent on alcohol and other drugs eventually benefit from having their AOD problems identified) and the effectiveness of the mechanisms that have been employed to protect AOD-related information about patients. Protecting Information in Patients' RecordsAs described in Chapter 6, Federal confidentiality regulations protect AOD-related information that is gathered by an identified unit that provides alcohol-or-other-drug-abuse diagnosis, treatment, or referral for treatment or by a clinician whose primary function is the provision of such services. In such situations, AOD-related information must be kept separate from other information in the patient's record that is not subject to this protection. The potential administrative problems that may arise from the requirement to segregate certain AOD-related information may be reduced in a number of ways. In the following section, four models are proposed for complying with the Federal regulations and protecting patients' autonomy and privacy. The potential advantages and disadvantages of each model are described.
Model 1: Segregation of Protected Information Within the RecordTo prevent inappropriate disclosure of protected information, it can be placed in a separate section in the chart that is designated as confidential, perhaps held together with a clip or rubber band. With this "rubber band" approach, this portion of the chart could then be shared among caregivers in the hospital on a need-to-know basis, without being open to the view of every staff person who picked up the chart. Sharing protected information with outside agencies would require that the patient sign a specific consent form. AdvantagesThe physical separation of protected information in a patient's chart serves to remind care providers of the need for protecting this information. DisadvantagesSome providers may see as burdensome the requirement to give special handling to some of the information in some patients' charts. They would rather be able to handle all patients' charts in a uniform manner. Separation of protected information, moreover, may inadvertently promote the view of AOD problems as "separate" from other health issues and may impede efforts to raise providers' awareness of AOD abuse as integral to a patient's overall health care. This reaction can be minimized if it is made clear to staff that the purpose is to comply with Federal regulations. Moreover, many care providers may feel this approach is impractical, given time constraints and the need to see at a glance all pertinent information about a patient. Further complications arise with computerizing medical records and restricting access to them. Model 2: Keeping Protected Information in a Separate LocationProtected information can be kept in a separate location from the rest of a patient's chart, such as in a locked cabinet or other similarly secure area. This approach provides, in effect, a stronger "rubber band" than that described in the first model. With this model, a "gatekeeper" can be assigned who specializes in and understands Federal regulations pertaining to AOD abuse information. This person will be responsible for making the decision of when this information can be shared. Only this designated recordkeeper would have access to the protected portion of patients' medical records. This person could also be responsible for handling requests from outside agencies for protected information and ensuring that proper releases were signed before such disclosures were made. Physical separation of clinical information is not unusual. Patient charts from past years are generally kept in a separate location. Physicians routinely request charts to be sent to them from this location so that they can review historical clinical information about the patient. In addition, nurses are quite accustomed to keeping some medications locked up and accessible only to designated personnel. AdvantagesThis physical separation of protected information from the chart, with access restricted to a designated recordkeeper, affords the greatest degree of protection of confidentiality. This approach gives the patient greater control over dissemination of information to agencies outside the hospital. Patients can also be reasonably assured that protected information will not be exposed to any staff member who handles the chart, but must be specifically obtained from the recordkeeper. Restricting access in this manner may also have the effect of making staff more aware of the issues of confidentiality. DisadvantagesOne of the primary drawbacks of separating protected information in this manner is the potential inconvenience to caregivers who may need access to it. In addition, since the information is not with a patient's chart, a caregiver will not be able to gain the total picture of a patient from the chart alone. Having a designated recordkeeper with the responsibility of releasing protected information to hospital caregivers may necessitate training a staff person regarding circumstances under which the protected information can be shared among staff within the institution. In some institutions with limited funding, adding this responsibility may be impractical. Model 3: Using Discretion in Recording InformationAOD-related information obtained and used to guide a patient's medical management does not have to be protected according to the Federal regulations. Physicians and staff can protect the patient by recording only as much AOD-related information as needed to make a recommendation. With this model, the information recorded in a patient's chart would be kept focused on those specific medical and surgical issues that are clinically related to the reasons for the patient's presenting condition (the traumatic injury and its sequelae), to its antecedents, and to planning for followup care. In this model, the "rubber band" consists of the scrupulousness and conceptual discrimination on the part of the caregiver who enters information in the chart. Labeling charts with information about confidentiality regulations may be considered. This method of handling information can be thought of as a "minimalist" approach. Only information essential for an appropriate treatment plan is noted. This approach represents a major departure from the standard medical concept of "chart everything," in the expectation that all possible information will be useful for optimally treating the patient.
AdvantagesRecording AOD-related information in a patient's chart in this way has the beneficial effect of reminding care providers to relate a patient's AOD problem to his or her current reason for hospitalization. AOD problems would thus be seen as an integral part of the patient's medical management, rather than as a separate issue that is unrelated to his or her physical injuries and their sequelae. "Chart everything" may still be the correct posture for medical diseases that are publicly accepted as not deriving from the patient's negligence. But that approach presents substantial ethical problems for a disease that is pejorative in the public mind. Recording a minimum of information may lessen patients' fears that acknowledging an AOD problem will have disastrous consequences. If patients understand that their discussions with care providers about their AOD problems will not be recorded, this method can provide another tool against the common AOD problem of denial. DisadvantagesHandling patients' charts in this manner would result in a nonindividualized record that might not reflect patients' individual needs surrounding all of the adjunct issues related to the hospitalization. Additionally, since there would be no requirement to physically separate this information from the rest of the patient's chart, caregivers in turn would not be routinely reminded of the need for protecting certain AOD-related information. Model 4: Protecting the Entire RecordComplying with the Federal confidentiality regulations can be achieved not only by meeting the requirements they specify, but by actually exceeding them. In other words, an institution can choose to go beyond the requirements of the regulations and protect all information in all patients' records. As long as the Federal regulations governing confidentiality are met, additional information or restrictions can be added to the release form, which must comply with Federal requirements but does not have to be limited in scope. If this approach were adopted, the entire record of every patient would be treated in accordance with the laws protecting confidentiality. All information in all patients' medical records would be shared among caregivers inside the hospital on a need-to-know basis. The patient's specific, written permission would be required to allow the release of any information to agencies outside the hospital. The hospital would thus become a sort of protective sanctuary of patients' medical information, with the patients themselves holding the key. In light of the magnitude of the problem of AOD abuse and its relationship to hospitalization, increased safeguarding of information in the hospital records of all patients is a reasonable consideration. AOD information should be an integral part of the history taking for all patients admitted to the hospital. This model might require or be facilitated by hiring staff whose specific job is to deal with confidentiality issues and to educate patients and staff about these issues. AdvantagesPatients may often be reluctant to sign a consent form for disclosure of AOD-related information because of the stigma surrounding AOD problems. Under this approach, however, additional restrictions on the disclosure of this information would be added to the consent form, to the effect that none of the patient's hospital records would be released to any individual or organization outside of the hospital without his or her express, written consent. This restriction may help allay many patients' apprehensions about the dissemination of this information. Requiring patients' consent for disclosure of any information outside the healthcare institution would put the responsibility for disclosure in the hands of patients, who would then truly be in control of this information. Protecting the entire medical record may also help to address other medical conditions, such as human immunodeficiency virus (HIV) infection, that are potentially stigmatizing or that raise potential difficulties with insurance coverage. This approach could move hospitals and the healthcare system further along in the overall mission of recognizing that AOD issues are an integral part of patients' medical history and should not be segregated from other information. It could also promote the understanding of AOD issues as an important part of the medical record and of patient management, rather than as a separate area of concern. The potential benefits of this model include increased protection of patients' privacy, improved information management, and an enhanced commitment to improving the institution as a whole. This model could be viewed as a first step in focusing on the primary mission of providing optimal patient care and of placing the patient at the center of this mission. It can also make an important contribution to identifying the reality of the AOD problems in our midst and the need to address them. DisadvantagesThis option is far reaching and is not a quick or simple approach. It will involve finding ways to integrate AOD-related issues into the system as a whole, which will require hospitalwide evaluation. The practical considerations raised by this model include its requiring more time to be put into effect and the need for a stepwise approach to implementation. In light of the increasing access to patients' records through electronic means and the potential confidentiality problems this access poses, as well as upcoming reforms in healthcare, this approach may be a tenable option. Patients in small community hospitals often have fears that their stigmatizing conditions (such as AOD abuse or HIV infection) may become known to the community. Allowing the entire medical record of a patient with such a condition to be communicated within the hospital on a need-to-know basis may raise the possibility of social stigmatization in a small community. It may be possible, using this approach, to allow transfers to other hospitals when necessary through the creation of a network among medical facilities. A positive effect that may result from this approach in community hospitals, however, may be increased efforts to protect individual confidentiality.
Quality Improvement and AssuranceThe process of quality improvement focuses on identifying ways to determine whether services are being provided and whether desired outcomes are being met by the services. To make this determination, outcomes criteria, or the objectives of a program, are first defined. Outcomes indicators are then formulated to help assess whether goals are being met. Finally, outcomes measures are defined to determine whether the stated objectives have been achieved. The purposes of quality improvement are to judge whether objectives are being met, to identify areas needing improvement, and to modify services being offered and the ways in which they are performed to respond to identified needs. Quality improvement entails evaluating the performance of an organization as a whole, as well as the performances of individual caregivers. To be effective, this process must involve the leaders of the organization as well as individual clinicians. Monitoring outcomes and ensuring quality improvement is a process that should be carefully designed. Another Treatment Improvement Protocol in this series, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment, addresses issues that should be considered in evaluating programs and outcomes.
Outcomes Criteria and IndicatorsThrough the process of quality improvement, the various steps in the implementation of an AOD screening program can be evaluated and potential areas of difficulty identified. For example, one outcome criterion may be reducing the costs associated with complications that are avoidable with the timely identification of alcohol abuse. The complications arising from delirium tremens, for example, in a patient who is addicted to alcohol often require increased staff work loads, laboratory tests, diagnostic interventions, and consultations. Identifying alcohol dependence in such a patient before the onset of withdrawal symptoms will allow complications to be anticipated and averted. Other outcome criteria for a screening program may include the following:
Other criteria will become self-evident, as desired outcomes are identified. Some general questions to be borne in mind when measuring outcomes are
Indicators of outcomes are specific elements or steps in the screening process that can be evaluated and tracked over time. In implementing an AOD screening program in hospitalized trauma patients, each organization needs to define these indicators according to the populations served and the objectives that have been identified. The following are some examples of simple indicators based on extant data that do not have to be developed independently:
Outcomes MeasuresThe information obtained by tracking the various indicators allows specific measures of outcomes to be defined. Some examples of outcomes measures for delivery of care in an AOD screening program include the following:
Because patient nursing costs are not handled separately, as are fees for physicians' services, nursing costs are more difficult to estimate on an individual patient basis. However, nurse surveys (that is, asking nurses to document the amount of time they spend each day with a given patient) can be extremely useful as measures of outcomes. For example, the bill for a patient who required increased laboratory tests and diagnostic studies because of avoidable AOD complications would not reflect the cost of increased nursing services that were also required. Surveys designed to identify the effects of AOD screening on nursing staff workloads can be an excellent way to determine whether early identification of AOD problems results in improved delivery of care and decreased costs. Some of the questions that can be asked of nursing staff to gain this information include the following:
Measures of ConfidentialityAn important question in relation to measuring the outcomes of AOD screening of trauma patients is whether the intrusions into patients' autonomy, confidentiality, and privacy are being decreased. Another question is whether the ethical balance of benefits and burdens, goods and harms, justifies the aggressive stance being taken toward AOD screening of trauma patients. One way of measuring this outcome is to institute a protected audit of patient records that evaluates the appropriateness of the AOD-related notes that appear in the open portion of the record. The concept of a protected audit means that staff with a high appreciation of confidentiality in this area will perform the audit. After all, oversight and regulatory functions can also constitute privacy intrusions. (It should be noted that Federal confidentiality regulations do permit audits under certain conditions so that auditors and evaluators can gain needed information.) A selected or randomized continual inspection of charts could be done by a hospital ethicist, if one exists, or an ethics consultant, a designated member of an ethics committee or a confidentiality expert. The same person(s) should also conduct a quarterly audit of how effectively and with what goals the information in the closed part of selected charts is conveyed. The effectiveness of an institution's policies on patient confidentiality can also be measured by how well these policies are understood by the providersdelivering care specifically related to trauma. Surgical staff, trauma teams, and emergency department staff, including nursing staff, should attend regular inservice presentations on these concerns, with interactive demonstrations of the proper approach to protecting confidentiality. The approach used to safeguard AOD-related information will determine what outcomes are evaluated. Which of the four models described above is used will dictate the method of evaluating its effectiveness and its advantages and disadvantages. Providing Feedback to StaffFor their professional growth and encouragement, staff providing care to trauma patients with AOD problems need to know that their efforts are making a difference. To provide concrete feedback and positive reinforcement, linkages for feedback mechanisms should be established so that staff have some way of knowing the eventual results of the screening process.
Ways to link the personnel involved in AOD screening and assessment with the followup process should be explored. Positive reinforcement for these staff members should be delivered in a timely fashion to provide them with a meaningful context in which services are delivered. A personalized callback contact could be built into the AOD screening function. Patients could be asked to come in to tell success stories, both to staff and to patients receiving AOD counseling in the hospital. Another means to provide feedback to staff may include making calls to see how patients are following up with treatment. The patient's confidentiality, however, must be protected in making these calls. Callers must be careful not to make disclosures to persons other than the patient and must ensure that they are talking to the patient before asking followup questions. As part of the discharge process, a consent form can be offered to allow such followup contact. |
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