Managing Health Information in International Waters

HIM Frontlines covers HIM professionals working in emerging roles and tackling difficult HIM problems.

When people ask Davi Trotti, MA, RHIA, what it was like to live onboard the hospital ship Africa Mercy, she tells them “During the week I live in Europe and on the weekends I live in Africa.”

That’s because for three years, Trotti was the only person with a health information management (HIM) background working aboard Africa Mercy, which is currently the only active “floating hospital” sponsored by Mercy Ships International. With a staff and crew of 450 people at any given time, about 40 percent were American, with the rest of the crew hailing from 35-40 different nations. Although English was the unofficial “state” language onboard, European culture dominated the ship. On the weekends, when crew members left the ship, they had a chance to travel and explore the African nations in which their ship was docked. During Trotti’s three years of field service, these nations included the Democratic Republic of Congo and Madagascar.

Mercy Ships have served developing nations all over the globe since 1978, which is remarkable considering that every person who works the ships does it for free. Everyone, from housekeeping staff up to orthopedic surgeons, are volunteers—and pay their own room and board, plus travel expenses to and from the ship. Their mission is exclusively to perform surgeries in parts of the world where surgeries for burn contractions, fistulas, cleft lip, cleft palate, facial tumors, and the like are not available or are unaffordable. The ships, including Africa Mercy, decide which countries to serve and then dock in a harbor for 10 months at a time.

Trotti had spent several years as an HIM professional working mostly for health IT vendors prior to signing on for a five-year stint as the health informatics manager for Mercy Ships. She ended up only being able to spend three years with Mercy Ships due to her parents’ declining health, but even that length of time is longer than most volunteers. Nurses and physicians typically spend anywhere from two weeks to two months on the ship at a time, and the rest of the support crew is a combination of long-term and short-term staff. A fully staffed ship has 450 crew members, and 200 to 250 are long-term staff like Trotti. An average of 1,200 to 1,600 people, including patients, passes through a ship in the 10 months that it’s docked.

Maritime Health Information Management

When she was hired as the health informatics manager, Trotti was the first person with an HIM background to fill that role. This is not surprising when you consider that the utility and functionality for medical records of Africa Mercy patients is much different than the average hospital in the United States or Europe. Since the care and services provided on Africa Mercy is paid for by outside donors and fundraising, there’s no need for billing codes like ICD and CPT, says Trotti.

“Because we’re not doing DRGs we’re not looking to see length of stay versus acuity level…They’re not quite that far along in how they deal with data,” Trotti said.

As Trotti explains, every patient was entered into a pre-existing Access database, but operative notes and history and physical notes were all kept on paper, which were later scanned, entered into the database, and shredded. Most of the patients seen on the ship were treated surgically and discharged—unless they underwent orthopedic procedures that required physical therapy and rehab.

“My job really centered around helping them keep statistics, which came from the database,” said Trotti. “I made sure the data was accurate, then pulled out numbers that we used to share with our donors.”

The healthcare professionals on the ship took pains to protect patient privacy even though the countries where the ship was docked and the nationalities of the providers aren’t subject to HIPAA law scrutiny. For example, patients were asked to sign privacy forms when they were treated, but staff also had to account for language barriers and be prepared for the fact that in some countries patients weren’t able to read or write.

Another privacy challenge staff had to weigh was the need to photograph the patients they saw. Photos were taken, in part, to document the “before” and “after” cases where the ship’s surgeons performed dramatic appearance altering procedures, and to help identify patients who returned at a later date. But the photographs are also used for fundraising purposes and to help tell the story of Mercy Ships to potential donors (click here for examples).

Before Trotti joined Mercy Ships, another records manager tried to get the medical staff to use ICD codes. However, nobody on staff had any coding training and the initiative was quickly abandoned in favor of a more basic approach to documentation.

Even without a standardized medical coding system, part of Trotti’s work involved streamlining more basic terminology discrepancies due to the myriad languages spoken on the ship.

For example, an American term for a surgical instrument might be different than the Australian term for it. Or, the individual documenting a surgical procedure might not know whether to use an American spelling or the British spelling for a word.

“They’ve considered buying an electronic health record (EHR), but when the hospital is running full time, there’s no place to house people who’d come in and set up a system. The Internet might not be at capacity to do that,” Trotti explained. She said the ship’s Internet access comes via a satellite connection, and they are sometimes able to access whatever service provider the local population uses.

“We bring state of the art technology, but we’re bringing it to Africa, so there’s this give and take,” Trotti said.

Mary Butler is the associate editor at The Journal of AHIMA.

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