Change in the Data Collection LandscapeClinical CodingOPPORTUNITIES, POSSIBILITIES, POTENTIALH IN Z – O C T O B E R 2 0 1 5

Source Data: Many authors

◦ Clinical and administrative

Many points of entry◦ Hard copy and electronic health record

Many policies and procedures◦ Difficult to formulate standards◦ Obligations, responsibilities and accountabilities

Many sites of storage◦ Formal and informal

Many users and use cases of data◦ Interoperability and access

Clinical Coding: The translation of diagnostic statements into alpha-numeric code

25 year old patient admitted with acute appendicitis.

Past History: Insulin dependent diabetic with poor control. Smoker.

Went to theatre for a laparoscopic appendectomy under general anaesthetic.

Developed atelectasis post operatively requiring physiotherapy.

Patient offered NRT and advised on the health benefits of smoking cessation

Background: ICD-10-AM/ACHI/ACS 8th edition

Approximately 150 DHB Clinical Coders ◦ Inpatient events after discharge◦ 21 day deadlines for submission to the NMDS◦ Cancer registry, mortality registry and private hospitals

Primary use cases◦ Funding (population based)◦ Health care planning◦ Risk management and clinical quality improvement◦ Research

The Goal: To collect accurate, consistent and timely health data

Inaccurate, inconsistent and late data is redundant

Data in = Data out Clinical Coders

◦ Knowledge and expertise in classification ◦ Understanding of clinical and non clinical concepts◦ Efficient abstraction skills

Clinicians◦ Consistent, legible, specific documentation

Administrators◦ Accurate entry of all administrative data elements

How much faith do you have in the quality of your clinical coded data?

Technology has improved things:Change in operational model

Office based to coding in the clinical areas

Electronic coding resourcesMore reliable and accessible

Electronic quality toolsComprehensive and holistic avenue to evaluate coding accuracyRobust reporting

Intensive education and trainingFace to face and electronic learningMentoringDefining degree of difficulty

Engagement with clinical sectorData educationDocumentation Improvement

The Technology Factor: 2002 Melbourne NCCH Conference

….Clinical Coders, prepare for the future. The emergence of the electronic health record will significantly change the way that data is collected, stored and retrieved thus current clinical coding practice and the role of clinical coding in our health care organisations will become obsolete.

Dr Kerin Robinson La Trobe University

As technology gains momentum do you think Clinical Coders will become obsolete?

Business as usual: No view that there might be other technology other than eHR that might have any influence at all on the clinical coding workforce, role and practice

IF the electronic health record was to arrive◦ Make things faster◦ Legibility wont be a problem◦ Code from home

No threat at all – we will always need clinical coders

The CDHB Clinical Coding Service:

Traditional Coding Practice2010•Concerto, coding software•Serious backlog pressures•High FTE and resource requirements

New Operational Model2011•Remote desktop •Electronic coding resources•Not so serious backlog pressures

The beginning of the next generation2015•Updating and refining the new operational model•Higher usage of electronic information•Office ‘less’ •Almost no backlog pressures

Coding currently:ACHIEVEMENT

Significant improvements in productivity and timeliness of data

◦ 92% discharges coded for October at Christchurch Hospital

◦ 100% discharges coded for October at Christchurch Women's

◦ A significant reduction in resource

Direct access with clinical staff◦ Education◦ Clarification◦ Advocacy for the health information

IMPACT

Less resource required to achieve improved productivity outcomes

◦ More time to engage with education and quality activities

◦ Development of the role into other areas of health information

◦ Focus on documentation improvement activities which again reduces coding time and improves coding quality

Technology has arrived: Transition hard copy, paper lite, paperless health records

Mature clinical information systems

Sophisticated mobile devices and internet capability

Evolving clinical coding software utilizing natural language processing tools

A cultural shift in our health data is collected, and managed◦ Responsibility of quality on the clinician not on the coder◦ Improved timeliness of data – collected at source◦ Ownership of the data

The next generation: Coding professionals for the future will become increasingly important

◦ Classification and standards development◦ Health data dictionary and vocabulary development◦ Research◦ Activities related to health care funding◦ Wider field of collaboration within an organisation – IT, Clinical, Corporate

1. Workforce planning◦ Less of what we currently employ ◦ Role development for new health information practitioners

2. Education and training ◦ Training tools and activities needs a different focus◦ Allow them to come to HINZ!

3. Resources required for a clinical coding unit◦ Is an office really necessary?◦ Laptop’s v desktop’s◦ What steps could be taken to make the transition smooth

Time to consider:

Final Messages: Technology will have a significant impact on the way that health data is collected, stored and retrieved

◦ Efficient, accurate, consistent

Clinical Coders will be required to make dramatic changes to the way they work◦ Have a unique skill and knowledge set thus won’t become obsolete ◦ Exciting opportunities for growth and development

Now is the time to start considering the technological impacts on Clinical Coders and how to harness their full potential for the future.