Research Topics: Patient Confidentiality

Surgical Care of an Ophthalmic Surgery Patient

Cataract: Fading of the Light      Cataract is generally defined as an opacity or loss of optical uniformity of the crystalline lens. The development of cataract is therefore a continuum, extending from minimal changes of original transparency in the crystalline lens to the extreme stage of total opacity. During the early stages of cataract development there may be no perceptible effect on the patient’s visual function while in the late stage of opacity the patient’s visual function may be reduced to the mere distinction between light and dark. Cataracts become significant to the patient when they interfere with visual function. There are a variety of techniques and instruments available for the measurement of these various factors. High contrast resolution or acuity is measured according to the standards established by Snellen. Visual acuity often is referred to as “Snellen” acuity.  The chart and the letters are named for a 19th-century Dutch ophthalmologist Hermann Snellen (1834–1908) who created them as a test of visual acuity.  Visual acuity refers to the clarity or clearness of one’s vision, a measure of how well a person sees.  In the past, measurement of Snellen acuity was the only way that visual function was quantitated. Each of the other factors has a variety of different techniques available for its measurement in the evaluation of visual function. In each case there is no single established test. However, many techniques produce valid reproducible and useful measurements. In addition, the factor of ambient light level can be evaluated in its effect on the measurement of each of these aspects of visual function, and for this purpose several devices have been made available which simulate the glare production of intense light directed into the eye, light which is scattered by the developing cataract and may interfere with the patient’s visual function in each category. Cataract Surgery (Pre-Operative Measure)             Cataract surgery is one of the most common and effective types of surgery performed today. More than a million and a quarter cataract surgeries are performed in the United States every year, and more than 90% of patients report an improvement in their vision after surgery (Given, 2005). The process of evaluation and care for the patient with visual functional disability begins with awareness by the patient of his or her limitation. It then leads to consultation for the confirmation of diagnosis, the evaluation of prognosis and planning of appropriate therapy. Patients may become aware through self diagnosis, through conversation with family members or friends who have experienced similar visual functional disabilities or perhaps through a public service vision screening program. Screening programs are of significant public benefit and are very common in seeking the risk factors associated with diabetes, hypertension, amblyopia, glaucoma, carcinoma of the breast, etc. The objective of screening programs is the identification of risk factors in patients who are asymptomatic with the purpose of establishing earlier diagnosis. Visual functional disability may reach an advanced stage in patients who feel entirely asymptomatic. This is the apparent explanation for studies which have shown that a lower incidence of automobile accidents occurs in states where visual screening for driver licensure is carried out relative to those where no such screening is performed (Gray, et. al, 1999). In most circumstances, cataract surgery is elective. For the patient with gradually developing cataracts, management consists of reassurance, support and education about the cause of visual disability and its prognosis. During the development of nuclear sclerosis, myopia is induced and changes of spectacle lens prescription will often improve visual function. The use of strong bifocals, appropriate lighting, occasional magnification and other visual aids may satisfy the changing vision requirements as a cataract progresses. Therapeutic dilation of the pupil assists the occasional patient to see around central posterior subcapsular cataract, however, it may also increase glare and visual discomfort. The patient will make the elective decision regarding cataract surgical intervention. The decision will be based on full information regarding the correct diagnosis, the prognosis for improvement and a detailed discussion of the potential risks and benefits of the procedure. However there are contraindications wherein surgery should not be performed under the following circumstances. Since surgery is an elective decision on the part of the patient, or with the consent of the immediate family of the patient in cases that the patient is not mentally sound to decide for herself (Diane McDonald), surgical operation should not be pursued when the patient or the family do not desire to do so. If the use of glasses or visual aids can still provide functional vision satisfactory to the patient’s needs and desires, after a diagnosis with an ophthalmologists, then surgery would be a distant option. The surgeon and the ophthalmologists however could also decide not to pursue surgical procedure if repeated medical diagnosis shows that surgery will not improve visual function. They could also decide not to give surgical intervention to cataract patients if it shows in the medical record of the patient that she is unfit for surgery. It is very important to have a pre-operative diagnosis before committing to surgical intervention.             The majority of patients undergoing cataract surgery are elderly persons, a patient population with a high prevalence of concurrent multiple medical problems such as coronary artery disease, cerebrovascular disease, hypertension, diabetes mellitus, dementia, arrhythmias, chronic obstructive pulmonary disease, alcoholism, thromboembolic disease requiring anticoagulant therapy, and nutrition problems (American College of Eye Surgeons, 2001). Although the data are limited, anticoagulation does not appear to pose a substantial risk for seriously complicating ophthalmic surgery, whereas discontinuing these drugs may impart some increased risk for new thrombotic events in the patient with pre-existing cardiovascular, cerebrovascular, or thromboembolic disease. In addition, patients undergoing cataract surgery commonly have dysfunctional problems of aging, including psychosocial, economic and nutritional difficulties (ACES, 2001). Functional problems and their cause (often multiple and complex such as Alzheimer in the case of Diane McDonald), defined as difficulties that interfere with daily routines, are often unappreciated when conventional histories and physical examinations are done. Preoperative medical examination and appropriate testing should be done in all patients undergoing cataract surgery, whether the surgery is done in the hospital or elsewhere, and regardless of the type of anesthesia to be used. Preoperative medical management should be guided by the patient’s age, the presence of concurrent medical illnesses, the patient’s use of medicine and the patient’s relative proximity to the location where surgery is performed.             The choice of general, local or topical anesthesia may affect visual outcome indirectly, through the effects of nausea, vomiting, coughing or sudden movement during the preoperative period. Many cataract patients are elderly with multiple medical problems, and thus at increased risk for morbidity during a period of general anesthesia. On balance, properly managed local anesthesia is simpler and safer than general anesthesia, especially in patients with significant cardiac or pulmonary problems. Local anesthesia was recommended to Diane since she has history with peripheral vascular disease.  Surgical Operation Most conservative surgeons agree that simultaneous extraction is appropriate only in unusual circumstances, for example, whenthe surgery requires general anesthesia and repeated generalanesthesia represents a risk to the patient. The principal concernwhich prevents many surgeons adopting simultaneous extractionis the risk of potentially blinding bilateral postoperative infection orendophthalmitis. With Diane McDonald, it was decided that no simultaneous operation would apply. Her surgeon decided to operate her right eye first since it is more seriously infected than her left eye. Surgery should not be routinely performed in both eyes at the same time because of the potential for bilateral visual impairment and loss of the ability to adjust surgical plans for the second eye that are based on the results of first eye surgery. However, there are occasional circumstances under which bilateral surgery may be indicated, but the potential benefits and risks to the patient should be critically considered and discussed with the patient (Cassels, et. al., 1999). Consideration of the appropriate interval between the first-eye surgery and second-eye surgery is influenced by several factors: the patient’s visual needs, the patient’s preferences, visual acuity or function in the second eye, the medical and refractive stability of the first eye, the need to develop binocular vision and the presence of symptomatic anisometropia as well as logistical concerns of the patient in traveling back and forth to the physician’s office (Talbot & Perkins, 1998). The patient and ophthalmologist should discuss the benefit, risk and timing of second-eye surgery when they have had the opportunity to evaluate the results of surgery on the first eye. This is going to be more complicated with Diane’s case, suffering from Alzheimer, the physicians cannot measure Diane’s progress through self evaluation because of her mental condition. The dramatic revolution in cataract surgery over the last 15 years has been spearheaded by the adoption of micro-surgical techniques. This includes transition to the extracapsular procedure and the development of safe, effective intraocular lenses, and the placement of the intraocular lens behind the iris. Effective treatment may require extensive additional complicated surgical procedures, e.g., glaucoma surgery, retinal detachment surgery, therapeutic vitrectomy, penetrating keratoplasty, and anterior segment revision. Prompt diagnosis and management of these conditions is a basic tenet of appropriate medical care. In the absence of co-morbid conditions and complications, a postoperative corrected visual acuity in the 20/40 to 20/15 Snellen acuity range is a reasonable expectation (80-90 percent likelihood) for a patient with functional impairment due to cataract (ACES,2001). The motivation for using small incision techniques in the cataract surgery is enhanced safety coupled with a more rapid rehabilitation following the procedure. The rationale is that the smaller wound promotes less likelihood of wound dehiscence, more rapid healing and reduced postoperative astigmatism. There is now evidence that (1) the use of small incision technique leads to a more rapid functional rehabilitation of the patient; (2) the use of phacoemulsification leads to less induced postoperative astigmatism; (3) specific or overall complication rates associated with small incisions by an experienced surgeon, compared to a large incision extracapsular procedure, are as good or better (Keener, 1990). Cataract Surgery (Postoperative Measure) During the past twenty years, improvements in the technology of cataract surgery have greatly changed the postoperative management of the cataract patient. The widespread transition from general to local anesthesia, the earlier visual rehabilitation with intraocular lens implantation, and the trend toward smaller and durable incision designs have resulted in a much earlier return to the activities of daily life. These changes have also reduced the need for direct face to face care by the operating surgeon. However, the postoperative care is the responsibility of the surgeon, personally or through delegation to colleagues. It is important that care be provided to the patient by competent surgeons, who are both aware of and able to manage any and all complications of the cataract procedure. The postoperative patient is ordinarily examined on the first day following surgery, then again during the month following surgery. Additional visits are thereafter scheduled according to the surgeon’s experience and the patient’s needs. However, through the entire convalescent period, immediate and appropriate care must be readily available to the patient at any time of day or night. The surgeon continues to bear this ultimate responsibility. The operating surgeon has the obligation to provide education and instruction to the patient regarding the following: resumption of activities, protection of the eye, the use of normal medications, the timing and scheduling of normal postoperative visits, the identifying signs and symptoms of possible complications, and detailed instructions for gaining access to emergency care. Since Diane’s suffering from memory loss due to Alzheimer’s, the surgeon and her immediate family or care giver should be instructed in providing instruction to the patient. Role of Surgical Nurse in Cataract Surgery Patients             In many surgical specialty areas, the current role of the surgical nurse practitioner (NP) continues to expand and evolve. This evolution may include the incorporation of the skills and functions of the Registered Nurse First Assistant (RNFA) into the role of the surgical NP. In 2003, new federal regulations were issued to universities, medical centers, and hospitals that trained resident physicians. These regulations included a mandate that resident physicians, including surgical residents, do not exceed an 80-hour work week. This has led to an increased demand for first assistants during surgical procedures (Zarnitz, 2005).             The American Nurses Association’s (ANA’s) Code of Ethics for Nurses with Interpretive Statements expresses the moral commitment to uphold the goals, values, and distinct ethical obligations of all nurses. Provision four in the Code of Ethics with Interpretive Statements reads: the nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. Accountability with responsibility is one of the foundations of perioperative nursing because perioperative nurses are accountable for patient outcomes during the surgical experience. Accountability is the quality of being answerable. This provision clarifies that perioperative nurses are answerable for their decisions and the outcomes of those decisions. Core activities for perioperative nursing care include assessment, diagnosis, outcome identification, planning, implementation, and evaluation. When these activities are incorporated into daily practice, perioperative nurses are empowered to provide safe and competent care.   Credit:ivythesis.typepad.com

Surgical Care of an Ophthalmic Surgery Patient

Cataract: Fading of the Light Cataract is generally defined as an opacity or loss of optical uniformity of the crystalline lens. Th...

Union Plastic surgery center becomes HIPPA complaint

Union Plastic surgery center becomes hippa complaint     Scenario This type of scenario will emphasize a situation that has led to the Union Plastic Surgery Center becomes a HIPPA complaint. The process undertook during a surgical operation of a woman clientele, aged 45 years old, working at a department store as she decides to undergo a liposuction in the center but the serious problem took place when the center failed to ask for authorization and permission consent in lieu to the HIPAA act of 1996 and failed to provide guidelines to consider upon the duration of the operation. The failure to insure the client in doing the process, the center then violates the guidelines of HIPPA and to always practice the profession in itself as well as in following the principles and provisions desired and included in the HIPPA guidelines. To simplify the situation, there is really a problem of implementing the HIPPA guidelines throughout the center respectively. Months after the operation, the client formally filed a complaint to the center, certain accounts for unsecured privacy information regarding health data and  the failure to incorporate health insurance because the center may have had an expire license and did not follow strict implementation of health care service rules and protocols in which the latter must be observed properly and careful assumptions are to be realized. The center failed to have committed as required by applicable federal and state law to maintain the privacy of the health information and did not give you notice about their privacy practices, legal duties and client’s rights concerning her health information.     The center has not used and disclose her health information in connection with their healthcare operations as it includes quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification and licensing activities. The client’s authorization: In addition to their use of health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose.   Description of Facility The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes a federal role for regulating the employer group and individual insurance markets (1997). Thus, HIPAA ensures access to insurance for some employer groups and individuals who previously were unable to purchase health insurance or unable to purchase adequate coverage. Moreover, variability among states in existing insurance legislation and the flexibility that states are given to implement the individual market reforms suggests that the answer to these questions will vary from place to place.           Develop Problem Statement   The problems in implementing HIPPA guidelines in the Plastic Surgery Center, in which a failure to adhere to the guidelines results into violation and certain form of malpractice of profession in providing stance for information about HIPAA and the provisions it contains, including: guaranteed issue, guaranteed renewal, portability, pre-existing condition exclusion limits and non-discrimination provisions. There could have possibilities of having the performance of state high-risk pools, one of the alternative mechanisms that states are allowed to adopt to meet the HIPAA provisions for the individual process reforms.   Problem Classification The problem of HIPPA implantation in terms of its guidelines for the center. HIPAA prohibits all group health plans – insured or self-insured from denying coverage or charging higher prices based on health status. It requires that health insurance companies guarantee renewal of all group plans, to both large and small groups. It also requires insurance companies that offer health coverage in the small group market to make all products available to all applicants and that small groups must be accepted and all eligible members of a group must be accepted.       Categorize the problem The specific provisions of HIPAA entail that health insurance issuers are required to guarantee renewability of coverage for all groups and guarantee issue all products for small groups. The group health plans must credit prior public or private insurance coverage toward preexisting condition periods, provided the coverage has not lapsed for days. The state must implement an acceptable alternative mechanism, to guarantee issue and apply no preexisting condition exclusions to individuals who had months of continuous coverage, the individual also must have exhausted all other sources of coverage – including COBRA coverage, Medicare or Medicaid. Individual health insurers must guarantee issue at least two different individual insurance products. These products may be either a) the two highest volume products b) a low and high policy option that represent individual policies offered by the insurer in the state that are subsidized, risk-adjusted, or covered by a risk-adjustment mechanism. Data Collection HIPPA’s group provisions were designed to eliminate insurer practices that discriminate against employer groups and their members on the basis of health status, industry, or other characteristics. Redlining, denying coverage to employees with poor health or to their entire group, and excluding coverage for pre-existing conditions are documented practices that can pose barriers that wish to offer health insurance as a benefit (1994). HIPPA eliminates the first two practices in the small group market, and limits the exclusion on pre-existing conditions for all group plans. Proponents of these reforms believe that they will expand coverage; critics argue that they will lead to increases in premiums that might in turn lower access to coverage ( 1997 Moreover, many states had already taken steps to eliminate discriminatory carrier practices and have standards that meet or surpass HIPAA standards. One empirical study using state data suggests that guaranteed issue legislation may result in an increase in the number of firms offering insurance ( 1995). This study’s estimate implies about a 10 percentage point increase in the number of small firms offering insurance in states in which availability is guaranteed, holding constant other regulations and market characteristics (1995). HIPAA does not provide for affordable coverage; it only ensures the continued right to purchase a plan.                       Decision Making   If there is an authorization, the client may revoke it in writing at any time and the revocation will not affect any use or disclosures permitted by the authorization while it was in effect. The center cannot use or disclose her health information for any reason except those described from the notice. The center must disclose the health information to as it is described in the Patient Rights section. The use of health information for marketing communications without a written authorization is not allowed as required by Law that the center may disclose any health information when required to do so by law in accordance with the HIPPA guidelines, to the appropriate authorities if the center believe that the client is a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes as well as to avert a serious threat to your health or safety or the health or safety of others. The client may have the right to receive a list of instances in which the business associates disclosed health information for purposes other than treatment, payment, healthcare operations and certain other activities. The client have the right to request that the center place additional restrictions on their use or disclosure of the health information and are not required to agree to these additional restrictions, but if they do, they will abide by the agreement.           If the concerned believed that there was violation of privacy rights or you disagree with a decision made about access to the health information or in response to a request made to amend or restrict the use or disclosure of the health information by alternative means or at alternative locations, the client may file a formal complain to the U.S. Department of Health and Human Services. In the absence of guidelines from professional organizations then, it is necessary for each institution to examine their policies to determine whether they should consider requiring change in their requirement for patients and maximize cooperation with such policies.     Alternative solutions   Solution One The center and the HIPPA guidelines must adhere to a balanced coordination of their respective functions and must agree on such terms and conditions and avoid challenges to incorporate relevant information for the client’s security within the clinical clinical practice and every imaging data is stored digitally on easily accessible intranet systems and workstations. However patient confidentiality issues and HIPPA guidelines guide their appropriate use and dissemination           Solution Two There should have an in-dept understanding of the HIPPA guidelines in terms of authorization that implies, before the center begin to retrieve and save any images or clinical data, they have to ensure that they have privileges and authorization to do the operation  and will require the patients consent and approval of the center’s institutional review board   Solution Three Aside, it is critical to have a protected health information which refers to any information which may identify the background of the client and there is a need to integrate such provacy rules within the process as the HIPPA regulation require that such information be “de-identified” or removed in any communication if not needed  for direct care related issues.                   Solution Four (The best solution) Most importantly, the role of a permission and consent is vital for the center to follow carefully in terms of handling properly the client’s case and provide awareness of the services strengths and limitations promulgating its by-laws to the context of the guideline. There needs to adapt a generic disclosure and consent  upon admission top a clinic or hospital will cover the general use of  information in the course of treatment, discussion among consultations and multidisciplinary clinics. As the  HIPPA mandates that  reasonable caution be exercised in collecting storing and transmitting this information in an electronic form. Thus, this solution is essential to avoid references to any information that might easily identify a patient – particularly if the audience includes members not directly involved in the care of the patient. Moreover, it is rarely necessary to scan documents to highlight the clinical record. This is usually reserved for morbidity and mortality discussions and have to scan the client’s EKGs, EEGs, PFTs respectively before undergoing any form of surgery. The situation protocol would include what steps have been taken within the selected states to identify these and other problems that limit access to HIPAA coverage.             For example, the protocol would include specific questions to be covered in the site visit interviews. Has the state put in place routine compliance review mechanisms to identify how HIPAA is being implemented or do states wait for complaints? Has the state implemented a voluntary compliance regime that encourages firms to self-correct without sanctions? Once a problem limiting access to HIPAA is identified, what steps are taken to eliminate the barrier? The legislation requires that the center provide certification to the clients and dependents as they leave a group plan. It will be important to identify the specific roles played by the state, employers, and insurers and to identify problems in the notification process.   The Decision Matrix     Criteria 1 Criteria 2 Criteria 3 Criteria 4 Total   Weight Weight Weight Weight   Option 1 25 25 25 25 100 Option 2 25 25 25 25 100 Option 3 25 25 25 25 100 Option 4 25 25 25 25 100         Furthermore, to gain enough perspectives, those involved from the following entities would have these four decision options to make 1) state officials involved in HIPAA implementation; 2) a sample of large and small surgery centers 3) health insurers  and 4) a sample of HIPAA eligibles . The desired strategy is to triangulate in order to obtain more than one voice for the client’s interest, and interviews should be coded to ensure that every responses are included in synthesizing outcomes to solutions. For instance, using high-risk pools as an alternative HIPAA mechanism, the interview would include questions about risk pool funding, the premium schedule, and the methodology for determining premiums. In states that have adopted guaranteed issue, the interview would focus on the number and characteristics of guaranteed issue plans, risk adjustment or risk-spreading mechanisms, marketing practices, and enforcement. In advance of the interviews, the evaluator should collect available documentary evidence. A data checklist should be developed and distributed requesting that documents be provided or made available to the site visit team for review.   Criteria for selecting the best solution Criteria 1: Integration Criteria 2: Relevance Criteria 3: Substance Criteria 4: Applicability The implications for the solution The implication for each solution is to focus on the privacy and security measures to be adapted by the center as the client may be in high risk industries within the key outcomes to monitor include the availability of group coverage, the cost of group coverage and mobility and compare what would have happened over time without reforms to the changes that we observe in states in which the HIPPA provisions lead to the changes of ways and reforms prior to the HIPAA legislation and for the control measure that the center should have.   Implementation HIPAA provides for substantial state flexibility in implementing the intent of the individual market reforms to ensure that those who leave a group health insurance plan are able to maintain coverage and are not denied individual insurance if that is the only coverage option available. To meet the requirements of an acceptable alternative mechanism – a state program must provide all eligible individuals with a choice of coverage, including one providing comprehensive benefits, and not impose pre-existing condition exclusions to meet the requirements, in most cases expanding on an existing risk pool (1998), other alternative programs include mandatory group conversion policies, or guaranteed issue of designated individual policies.     The HIPAA group provisions ensure access to coverage for groups and individuals in those groups, but also place some limits on insurers ability to segment risks. Insurers cannot charge higher prices to high risk individuals in a group; they cannot exclude entire groups from the risk pool. Risk segmentation results in lower premiums for the healthy than the sick; greater pooling of risks may result in adverse selection and increasing premiums that will cause the healthy to drop coverage. However, HIPAA does not place any restrictions on the manner in which insurers can set premiums, and so insurers retain substantial ability to segment the market (1996). Thus, the HIPAA provisions are unlikely to result in substantial premium increases for those individuals currently purchasing insurance (1992). HIPAA imposes new requirements that may increase the administrative costs of insurance. HIPAA requires employers to provide certification of creditable coverage to employees and their dependents as they leave a group plan; in subsequent contracts, employers are likely to place this responsibility on insurers (1996). Insurers view this as costly and unnecessary, favoring certification on demand. They note that state portability rules have been successfully implemented without global certification requirements (1998). The necessity of certifying periods of coverage for spouses and dependents may pose special problems and require costly new record keeping systems. Employers and insurers currently do not have records to track this coverage (Humo, 1997).         Evaluation The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Department of Health and Human Services to report on the effectiveness of the provisions of HIPAA in providing access to health insurance and ensuring coverage security for the currently insured. This document describes components of a design for undertaking such an evaluation. The design builds on the literature review and database review described in earlier parts of this report, and on the policy database developed by the Institute for Health Policy Solutions The approach to evaluation design is to identify the key outcomes address on changes brought about by the HIPAA legislation. In doing this, there must have designs to measure the effects of reform packages that have been adopted to conform to HIPAA that have been produced that are subsequent to the HIPAA legislation. According to a recent  report, state insurance regulators have encountered implementation barriers resulting in part from the lack of federal guidance before policymakers and stakeholders can take action to address the perceived weaknesses in the HIPAA structure, there must accurately assess how HCFA and the states are enforcing HIPAA provisions, what seems to be working, what the potential barriers to implementation are and what covered populations or services have been most affected by the implementation process. (1998)         Feedback HIPAA was targeted to address the most important insurance abuses and not to ensure affordable coverage ( 1997). But, there are many implementation issues and problems facing employers, insurers, and regulators that also need to be addressed in the evaluation. One observer notes that HIPAA may appear modest in scope to public policy makers, but it is anything but simple for the private sector (1997). Monitoring employer and insurer efforts to document creditable coverage, insurer benefit design practices and the characteristics of products available to HIPAA eligible and state practices to insure compliance with HIPAA requirements, are all important issues that will need to be addressed as a part of a qualitative assessment of HIPAA.                   ________________________________     Credit:ivythesis.typepad.com

Union Plastic surgery center becomes HIPPA complaint

Union Plastic surgery center becomes hippa complaint Scenario This type of scenario will emphasize a situation that has led to ...

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