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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, 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

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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)

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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.

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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

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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

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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.

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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.

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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

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Opportunities to learn from standardization efforts in medicine

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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.

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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

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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

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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

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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

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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

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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

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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.

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https://www.youtube.com/watch?v=RI3I6oiVr58