Beyond the Frontlines: How MGH’s Health Records team tells the stories of our patients’ care

By Lucy Lau

Beyond the Frontlines spotlights the diverse teams at Michael Garron Hospital (MGH) that, as a patient or visitor, you may not see but are integral in our operations and provision of people-centred care.A respiratory issue brings you to Michael Garron Hospital’s (MGH) Emergency Department (ED), where, after being assessed by a triage nurse, you’re seen by a physician. They check your vital signs and ask you questions about the symptoms you’re experiencing, your medical history and any medications you’ve been prescribed, all while taking notes down on paper.

Your condition doesn’t require admission to the hospital, but the physician refers you to MGH’s respiratory clinic for a follow-up.

Later that week, you arrive for your appointment where a physician is able to access your health records electronically. There, they’re able to view the details of your past visits to MGH, including important information you disclosed to the physician in the ED, ensuring no time is wasted on a rehash of your medical history and you’re able to receive the next steps in your care.

This seamless flow of information is enabled by the collective work of MGH’s Health Records department, which consists of medical records transcriptionists and health information management professionals who are responsible for maintaining the accurate and holistic health histories of MGH’s patients. These histories make up what we call health records.

MGH uses a hybrid model of records, which requires the Health Records team to manage a combination of paper and electronic documents so physicians, nurses and other practitioners are able to access the information they need when they need it.

“I feel like a big part of the Health Records team — and health information management in general — is piecing a patient’s information together to create a story of their journey through the hospital,” says Nadia Stanichevsky, processing clerk in MGH’s Health Records department. “We ensure their stories are clear and legible so they can receive the best care possible.”

Health Records team pivotal to people-centred care

As a processing clerk, Nadia is responsible for collecting records from all clinical units at MGH and preparing these items for scanning and entry into Cerner, the electronic health information system used by MGH.

She meticulously conducts quality checks on paper patient charts, which have been barcoded and scanned by other members of the Health Records team. This ensures that information is being entered into the correct patient records and under the right document categories, so it can be easily retrieved by MGH’s healthcare teams during the patient’s next visit.

The task requires incredible attention to detail, as well as baseline knowledge of areas like anatomy and pathophysiology, so missing data or conflicting details in a patient’s care can be identified. Timeliness — ensuring that information is uploaded into a patient’s electronic record before their next visit to the hospital — is also important.

“It’s basically up to us to catch any errors, like misspellings or missing information, in a patient record before our clinical staff need to use it again for the patient’s next visit,” Nadia says.

The entry of these documents into MGH’s electronic health information system is vital in the continuity of care and minimizing patient risk, says Angie Panou, supervisor in MGH’s ED, a unit that works closely with the Health Records department. She says, without that team, it would be difficult to determine what the next steps in a patient’s care should be.

“A patient’s record needs to be available to the healthcare team involved with the patient or that will be following up with the care for this patient,” she says. “The physicians, nurses or members of the inter-disciplinary team, whether it’s Cardiology, Respirology, Ophthalmology or any other service, will rely on the health record to effectively navigate care.”

MGH’s transcription team, who convert physician voice recordings captured through speech recognition technology into written documentation, also play a role in the provision and continuity of care. Once a patient visit has been accurately documented in Cerner, MGH’s medical record coders spring into action.

'The funding we receive is 100 per cent dependent on the coding team'

Coders are responsible for translating different aspects of a patient’s journey within the hospital, including immunizations and laboratory and test results, into standardized alphanumeric codes developed by the World Health Organization (WHO).

These codes explain the story of a patient’s visit to MGH and are submitted to the Canadian Institute of Health Information (CIHI) and the Ontario Ministry of Health so MGH can receive the appropriate funding for the people-centred care it provides.

“The funding we receive is 100 per cent dependent on the coding team,” says Amelia Hoyt, chief information officer at MGH. “And, because they’re often more ‘behind the scenes’ at the hospital, I think many people don’t realize this or are not aware of the important work that they do.”

MGH’s finance and healthcare planning teams also use the coded data for purposes related to billing, research and resource allocation so the hospital can better support its patient population.

“Coding helps us manage our quality of care,” says Daisy Ferrigan, a health information management professional on MGH’s Health Records team who works in both Medical Coding and Release of Information, the latter of which responds to requests for patient information while ensuring patient privacy and following hospital policies and provincial legislation.

“It’s rewarding to know that we’re able to support our patients in their healthcare needs as well as for their personal matters.”

Identifying errors in records — and minimizing patient risk — like 'winning the lottery'

Daisy, who has worked at MGH for more than 20 years, says her role in coding can be challenging when she has to interpret scanned patient charts where handwritten notes present issues with legibility. But she says it’s gratifying to be able to successfully code a patient visit by reviewing both scanned and electronic documents to piece together a patient’s story.

“At times, I’ve been able to identify errors in the transcribed voice recordings while coding,” she says. “I’m able to inform the transcriptionist of the mistake and it’s then corrected. They’re usually small mistakes but it’s like winning the lottery when you find them because you know it’s helping to improve patient care.”

For Nadia, the errors that she and her team identify — and correct — on medical records have the potential to impact patient safety. It’s why she finds her work so meaningful.

“It’s really, really satisfying when I hear stories of people being grateful for our work or when our manager says that, thanks to what we do, an issue was caught and a patient was able to receive the care they need,” she says.

She feels a sense of duty in respecting patient stories and their time at MGH. “To someone else, my job may seem really tedious,” Nadia says, “but it’s our role to honour our patients and ensure that their story is as complete, accurate and accessible as possible for our healthcare teams.”