Improving Human Rights Through Population Health in Conflict Zones Coleen Kivlahan MD, MSPH Medical...
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Improving Human Rights Through Population Health in Conflict Zones Coleen Kivlahan MD, MSPH Medical Director Alternative Payment Models, Health Care Affairs,
Improving Human Rights Through Population Health in Conflict
Zones Coleen Kivlahan MD, MSPH Medical Director Alternative Payment
Models, Health Care Affairs, American Association of Medical
Colleges
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Today, We Will: Understand the current state of forensic
documentation of sexual violence and torture in conflict zones
Actively review the recent work done by Physicians for Human Rights
to standardize forensic documentation Describe the relevance of
standardized forensic documentation to reduce variation and improve
outcomes to quality improvement work in health care settings
Integrate key learnings about the needs of torture victims and
populations in conflict into health care system access and quality
opportunities
Slide 3
Human Rights Violations Impact Health Care Access and Quality
Acute injuries and death in conflict zones Medico-legal
documentation of torture Investigation of mass atrocities
Identification and treatment of Sexual Violence Persecution of
health care workers
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Health and Human Rights Freedom from cruel, inhuman, and
degrading treatment is a fundamental human right established in
international law. Investigating and reporting on the devastating
consequences of torture on individuals, institutions, and society
is critical. Health professionals can detect signs of physical and
mental abuse that may not be otherwise evident. Health
professionals can serve as the validation of the survivor's voice.
While torturers may try to hide evidence of brutality, we can often
provide physical proof of the violation.
(http://physiciansforhumanrights.org/issues/torture/#sthash.sHxUnjOk.dpuf)
Slide 5
Health Professionals Roles The European Court of Human Rights
and the Inter-American Court of Human Rights have found that the
failure to mount an effective investigation is a violation of the
right to be protected against torture and inhuman treatment.
Investigations must be launched whenever there is reasonable
suspicion that torture has taken place. Since it is likely that
health professionals would be amongst the first to discover any
signs of abuse, the initiation of an investigation relies heavily
on our awareness, assessment and subsequent action.
Slide 6
International Standard for Documentation The Manual on
Effective Investigation and Documentation of Torture and Other
Cruel, Inhuman or Degrading Treatment or Punishment, commonly known
as the Istanbul Protocol, outlines international legal standards on
protection against torture, and guidelines for effective legal and
medical investigations into allegations of torture. The Istanbul
Protocol became a United Nations official document in 1999. The
guidelines apply to human rights investigations and monitoring,
political asylum, and care of survivors of torture.
http://phrtoolkits.org/wp-content/uploads/downloads/2011/12/ISTANBUL-
PROTOCOL.pdf
Slide 7
Prevalence of Torture Despite the absolute prohibition of
torture in international law, it continues to be practiced in more
than 100 countries, from totalitarian regimes to democracies Asylum
claims of 500,000 people in 44 industrialized countries in 2013.
320,000 in the EU, 75,000 in the USA; with USA, Germany and South
Africa being the three largest sites receiving new asylum claims
per year
Slide 8
Prevalence in Primary Care Among foreign-born patients
presenting to an urban primary care center in the United States,
approximately 1 in 9 met the definition established by the UN
Convention Against Torture. As survivors of torture, they may have
significant psychological and physical sequelae, and frequently
impact the health system with their needs. This underscores the
necessity for primary care physicians to screen for a torture
history among foreign-born patients and to effectively address
their trauma. Crosby SS et al. Prevalence of Torture Survivors
Among Foreign-Born Patients Presenting to an Urban Ambulatory Care
Practice. J Gen Intern Med. 2006 July; 21(7): 764768.
Slide 9
Purpose of the Medical Evaluation Medical evaluations involve a
careful and thorough clinical history and examination of physical
and psychological evidence. Clinicians must know the medical and
psychosocial consequences of torture and the established guidelines
for effective documentation Provide expert opinion on the degree to
which medical findings correlate with the alleged victims
allegation of abuse Serves to educate the judiciary, other
government officials, and the local and international community on
the physical and psychological sequelae of torture. Plays a key
role in effective corroboration of facts, providing redress to
victims and has a long term regulatory impact on prevention of
torture in a society. The UN endorsed Istanbul Protocol serves as
the model for effective documentation of torture and there is an
effort to create a systematic and uniform approach by adapting it
to the local medico-legal systems in less resourced countries.
Slide 10
Standard protocol, but non-standard documentation The Istanbul
Protocol is a guideline, much like care paths or clinical
guidelines. It sets out principles and is not a standard data
collection format The current state is that most of the
medico-legal documentation is in the form of a narrative affidavit
or report, subject to errors in omission, lack of consistent
terminology or conclusions, illegible handwriting, with limited
ability to review for quality or collect prevalence data Thus, just
as in other areas of medicine, we see the need for standardization,
both as documentation and training tools
Slide 11
Opportunities to learn from standardization efforts in
medicine
Slide 12
Sources of Documentation Variation include Some historical
points missed or overemphasized Some parts of physical exam not
completed or documented Critical diagnostic tests or referrals may
not be documented Logical flow may not be utilized Terminology
inconsistent between doctors but legal professionals unclear about
conclusions Failure to adequately document evidence upon which
conclusion depends Narrative forms do not increase training or
skill in users Result? At the least, the affidavit may not be
useful. At the worst, patient may not have a damaging report and
outcome.
Slide 13
Reducing unwanted variation IDEALLY. Develop standard form
which not only captures critical data in a flow that is intuitive
and consistent with legal standards, but also trains and improves
the skills of the user Form allows for continuous quality review
and feedback Form promotes peer review and group learning Form
allows both sophisticated and unskilled learners to use it Form
promotes legal colleagues understanding of basic medical
conclusions Consistently useful in legal proceedings
Slide 14
So How Do We Train Doctors To Document this Complex Work?
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Experience to Date Democratic Republic of Congo Kenya Syria
(Jordan/Turkey)
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Democratic Republic of Congo, South Kivu Low literacy
environment/multiple languages Few physicians with documentation of
experience or forensic training High level of interest in the work
and intense exposure Physician concerns with police/legal requests
to complete form, with payment and reputation Large number of
injured patients in some environments, few in others Slow
adaptation to standard form and IP language Now with 2000 forms
completed
Slide 27
Kenya Moderate literacy environment Existing national form but
inconsistent use Medical evaluator employed by police created
impartiality concerns Higher uptake of form in rural vs urban
areas
Slide 28
Syria/Jordan/Turkey High literacy environment Minimal
experience in torture evaluations but moderate expertise in
forensic medicine Intense, acute exposure to torture/trauma Health
professionals targeted Minimal past history with narrative
documentation form, adapted quickly to standard form
Slide 29
Interventions to Improve Documentation Basic Training Modules
Advanced Training Modules Simulated Patient Practice and Competency
Training In Vivo Observation Review of documentation best practices
and feedback on individual cases Cross-sectoral training and case
review by attorneys/police QI expert and peer review Victim
Impact
Slide 30
Role of the Medico-Legal Affidavit Critical importance in the
witness of torture Central role in the legal/judicial case
Opportunity to assist in access to medical care and treatment
Identify injury and population trends Opportunity to unite sectors
of the investigation and prosecution using a common language and
protocols Creation of a sustainable network
Slide 31
The End Game Our goal is to assure and improve documentation
quality, not to create new documentation forms. This goal could be
achieved in many ways: a standard form, guided narrative form,
voice recognition using a standard protocol, mobile app, EMR,
providing some narrative fields within template. Structured,
template based documentation systems can generate and store more
consistent patient data, yet the patient narrative must be
preserved. Complex ideas can be shared in an efficient manner
through a narrative, synthesizing disparate facts and providing
context. The hope is that we can improve consistency, maintain
context and assure positive outcomes for the patient and legal
system.