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In 2010 I was provided an opportunity to work with the Dimensions Healthcare information technology team responsible for developing and implementing the comprehensive health information system (HIS) for the Palestinian National Authority Ministry of Health (MoH) as part of the U.S. Aid Flagship Project. The HIS links financial, administrative, patient records, referrals, equipment details, clinical standards/protocols and human resource data across the West Bank. All of the project planning and work was directed through the HIS vendor and the Palestinian office for the U.S. Aid Flagship Project, both working in coordination with the Palestine MoH. The purpose of the flagship project is multifaceted, but ultimately the objective is to improve overall patient care and optimize the utilization of resources.

Getting Started

Initial discussions centered on the purpose of my portion of the project, which was to capture all diagnoses and procedures in a classification system (as opposed to the manual log system then in use). We discussed ICD-9 versus ICD-10 as options. The decision was made to proceed with ICD-10 using the United States versions of ICD-10-CM and ICD-10-PCS, which are publically available. The Palestine MoH already was supplying information to the World Health Organization (WHO) in ICD-10 as abstracted by clerks from log books. The objective was to ensure complete and accurate capture of diagnoses and procedures via electronic media, eliminating the potential for error through third-party abstraction from those log books.

I was told from the start that the code sets for the U.S. ICD-10-CM and PCS were going to be too unwieldy, and that the code sets should be pared down to accommodate the medical practices in the West Bank. My primary question concerning this was simple: how would I know what was being treated? The conclusion was to travel to the West Bank, review medical records and abstract a minimal record set to determine a diagnosis and procedure code set from the extensive list of codes in ICD-10-CM and ICD-10-PCS.

Prior to my trip, I was instructed on how to dress and behave while in the West Bank. Dress and conduct were expected to be conservative, but I was not required to wear a hijab (a veil covering my hair) or an abaya (a loose outer garment covering everything except the face, feet and hands).

Another World

My journey first would take me to Tel Aviv, Israel, as a car service met me and drove me to the American Colony Hotel in Jerusalem, where I spent my first week of the project. Not knowing what my jet lag would be like, I purposely planned to arrive on a Thursday so I would have Friday and Saturday to acclimate to the new time zone. My work week would begin on Sunday. Each day a car met me at the hotel and drove me to the office in Ramallah and back through checkpoints I previously had seen during news coverage of skirmishes between Palestine and Israel.

I was surprised to find that not once upon entering the checkpoint was my car ever detained. We avoided that checkpoint at the end of the day because of long lines and the likelihood I would be required to leave the vehicle and pass through a metal detector. Instead, my driver took an alternate (and much longer) route into Jerusalem. By week two I had decided that the daily checkpoint ordeal was cutting into my work time, so I moved to a hotel in Ramallah. I then was able to walk to and from the office daily.

My first day consisted of an internal meeting at the IT company, where I met the team with which I would be working. I was given an overview of the EHR, which already had been implemented in Turkey and now was being revised to meet the needs of the Palestine MoH. Then we were off to our first hospital visit in Nablus.

During this visit, I found out just how hospitable the Palestinian people are. Coffee or tea was offered at the initiation and midway through every meeting. It didn’t take long to become a big fan of some of the varieties of teas offered. I’ve also always been a coffee lover, and the coffee I experienced, both Turkish style and drip, exceeded my expectations. In all I would visit six different hospitals and one primary-care clinic in the following cities: Nablus, Ramallah, Jerusalem, Hebron and Qalqilya. Each location welcomed me warmly and thanked me for my participation in the project.

Lost in Translation

Per my request, I was accompanied by a team member who could translate any Arabic text or information for data collection. I also was accompanied by one of two wonderful young female pharmacists; they proved invaluable as it pertained to my ability to capture the data I needed. Record reviews consisted of abstracting very basic information: gender, age, diagnoses, procedures, type of visit, etc. This was done for 872 records during a two-week period. Chronicling patient gender and age would have been a challenge if not for my companion pharmacists. All diagnoses and procedures were written in English, as were all other notes in the record. Given my 27-plus years in healthcare, both as a respiratory therapist and HIM professional, I found gathering diagnoses and procedures of no consequence – only two records contained handwriting I couldn’t decipher. Gender, however, was a different story. It’s not captured. The patient’s name was used to determine gender (not a perfect method, but adequate for this purpose). Age presented another challenge for me, but not for my companions. All demographic information was collected in Arabic. Their numeric system also looks very different from ours.

Once all the data was collected and analyzed, the ICD-10-CM diagnosis code set was pared down to around 1,000 codes. Many codes were in the non-specific range, but this was unavoidable in light of the primary objective of creating a code set that would meet data collection requirements. ICD-10-PCS proved to be more of a challenge, and the smallest set of codes for that version was around 3,000. In the end, the decision was made to use ICD-9 for procedures instead of ICD-10. Since there is no prospective payment system in the West Bank, using two different code sets (one for diagnosis, one for procedures) didn’t present any issues.

Once the code set was determined, a decision needed to be made as to who would be responsible for abstracting that information into the HIS. Since there is not a health information management field of study in the West Bank, the selection of both the diagnoses and procedures would need to be the responsibility of medical professionals. There would need to be ICD-10-CM/PCS training conducted with physicians and nurses once the HIS system was fully deployed. That training did take place around a year after the project began, and it was conducted by another individual.

What I realized after completing this project is that I am blessed with awesome healthcare coverage. Yes, it costs money to enjoy the coverage I do, but it’s worth it because I don’t have to go to my local hospital and register for the ED only to be triaged and told I’m not sick enough for the ED, but need to be seen in a clinic instead.

I then would need to stand in a queue in the specific clinic line in which I would be seen. This wait can stretch for hours on end, and I’m already not feeling well. Once I get to the clinic, which could be several days or even a week later, I am seen by a physician. That physician will need to wade through my “family” medical record (a single chart) – which has all visits documented for myself, my husband, my mother-in-law, father-in-law and two children – to find the information related only to me. Even worse, I may be seen in the ED but told I need surgery for an ovarian cyst rupture, then get sent back home to return in the morning for surgery. I want to point out that the healthcare providers across the West Bank understand the limitations and inefficiency of their system. They are dedicated to improving that system so they can provide quality healthcare to all of their citizens.

About the Author

Barbara Godbey-Miller is Vice President of HIM Client Development at QuadraMed. Previously she was the Director of HIM at Optum, where she secured an international assignment in Palestine for ICD-10 data reporting. She is an active member of the AHIMA, NYHIMA, and CNYHIMA, and has spoken at several state HIM associations on compliance, audit, and data analytics.

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