Change in the data collection landscape: opportunity, possibilities and potential

Change in the data collection landscape: opportunity, possibilities and potential

• 2.
  Change in theData Collection Landscape Clinical Coding OPPORTUNITIES, POSSIBILITIES, POTENTIAL H I N Z – O C TO B E R 2 0 1 5
• 3.
  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
• 4.
  Clinical Coding: The translationof 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
• 5.
  Background: ICD-10-AM/ACHI/ACS 8th edition Approximately150 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
• 6.
  The Goal: To collectaccurate, consistent and timely health data Inaccurate, inconsistent and late data is redundant
• 7.
  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
• 8.
  How much faithdo you have in the quality of your clinical coded data?
• 9.
  Technology has improvedthings: Change in operational model Office based to coding in the clinical areas Electronic coding resources More reliable and accessible Electronic quality tools Comprehensive and holistic avenue to evaluate coding accuracy Robust reporting Intensive education and training Face to face and electronic learning Mentoring Defining degree of difficulty Engagement with clinical sector Data education Documentation Improvement
• 10.
  The Technology Factor: 2002Melbourne 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
• 11.
  As technology gainsmomentum do you think Clinical Coders will become obsolete?
• 12.
  Business as usual: Noview 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
• 13.
  The CDHB ClinicalCoding 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
• 14.
  Coding currently: ACHIEVEMENT Significant improvementsin 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
• 15.
  Technology has arrived: Transitionhard 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
• 16.
  The next generation: Codingprofessionals 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
• 17.
  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:
• 18.
  Final Messages: Technology willhave 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.