HIM-Interchange by HIMAA.org.au

HIM-Interchange PROFESSIONAL PRACTICE JOURNAL OF THE HEALTH INFORMATION MANAGEMENT ASSOCIATION OF AUSTRALIA LIMITED

VOLUME 10 NUMBER 1 2020 ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

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Contents: Editorial: Letter from the Editor // Joanne Fitzgerald

Reports: ICD-11 review: toward implementation planning in Australia // Mardi Ellis

A comparison between Urgency Related Groups and the Australian Emergency Care Classification // Clare Searson, Laura Harris

The importance of clinical documentation improvement for Australian hospitals // Patricia Hay, Kathy Wilton, Jennifer Barker, Julie Mortley, Megan Cumerlato

A special year for health information management awareness in 2019 // Milla Krivozhnya, Sadiya Askar, Terri Fiorenza, Kara Pollard, Melinda Scott 20

Personal perspective: Managing health information in Cambodia: exchanging skills in a challenging environment // Julie Wilson 23 Year of a new graduate in the bush // Alexandra Van Gemert

Maybe Iâ&#x20AC;&#x2122;ll write to you from there: the journey of an undergraduate health information management student // Sadiya Askar

Life behind the pages of HIM-Interchange // Naomi Johnson, Danica Jong, Carol Loggie, Nina Palibrk, Dwayne Richards, Stella Rowlands

Update report: Report on the 19th World Congress of the International Federation of Health Information Management Associations // Julie Price

HIMAA International Special Interest Group: a community of practice empowering Health Information Managers with global voice // Suzette Dela Cruz Regalo

HIM-Interchange Editor Joanne Fitzgerald, Independent Hospital Pricing Authority

Letter from the Editor Joanne Fitzgerald

Associate Editors Stella Rowlands, Sunshine Coast Hospital and Health Service, QLD Jennie Shepheard, Shepheard Health Management Consultants, VIC Chair Maryann Wood, Queensland University of Technology, QLD Subcommittee Members Emma Barker, La Trobe University, VIC Kym Campradt, Lorica Health Patsy Catterson, Ballarat Health Service, VIC Naomi Johnson, ACHA Hospitals, SA Danica Jong, West Moreton Hospital and Health Service, QLD Carol Loggie, University of Wollongong, NSW Nina Palibrk, Catholic Negotiating Alliance, QLD Julie Price, La Trobe University, VIC Dwayne Richards, BreastScreen, VIC Deborah Yagmich, Joondalup Health Campus, WA Representative Members HIMAA Board of Directors: Sharon Campbell, Curtin University, WA HIMAA Administration: Philida Chew, Director of Finance and Operations Correspondence The Editor HIM-Interchange, HIMInterchange@himaa.org.au Advertising enquiries marketing@himaa.org.au Production Typesetting: Red Rabbit Creative Pty Ltd Electronic Production: Prateek Verma, HIMAA Printed by: SOS Print + Media Group Publisher: Health Information Management Association of Australia Limited Locked Bag 2045 North Ryde NSW 1670 AUSTRALIA Editorial Board Editor-in-chief: Joanne Callen, Macquarie University, NSW Editor, HIMJ: Joan Henderson, The University of Sydney, NSW Chair: Sue Walker, Queensland University of Technology, QLD Associate Editors: Kerin Robinson, La Trobe University, VIC Stella Rowlands, Sunshine Coast Hospital and Health Service, QLD Jennie Shepheard, Shepheard Health Management Consultants, VIC Sue Walker, Queensland University of Technology, QLD Members: Sharon Campbell, La Trobe University, VIC Deborah Debono, University of Technology Sydney, NSW Joanne Fitzgerald, Independent Hospital Pricing Authority Monique Kilkenny, Monash University, VIC Esther Munyisia, VIC Mirela Prgomet, Macquarie University, NSW Beth Reid, Pavillion Health, NSW Phyllis Watson, The University of Sydney, NSW Johanna Westbrook, Macquarie University, NSW Disclaimer The Editors, Editorial Board, HIM-I Subcommittee and publishers do not hold themselves responsible for statements by contributors. Opinions expressed in HIM-Interchange are those of the authors and do not necessarily reflect the official position of the Health Information Management Association of Australia Limited. Copyright © 2020 Health Information Management Association of Australia Limited

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Dear HIM-Interchange readers Welcome to the first issue for 2020 and a brand new decade! In this issue, Sadiya Askar (2020) shares her journey as a health information management student at La Trobe University over the past three years. Most of us can still remember that sense of trepidation and feeling out of our depth as students on our professional practice placements. It is not always easy to push yourself out of your comfort zone, but it sounds like Sadiya embraced the challenges, including travelling overseas and taking on a leadership role in the health information management student body. Another emerging health information management professional, Alexandra Van Gemert (2020), also shares her story of starting out in her health information management career, with a role in a regional New South Wales health service. However, it is not only students and new graduates who are capable of pushing themselves out of their comfort zones. If you are looking for some inspiration to take a chance or make a change in 2020, look no further than Julie Wilson’s (2020) article on her time spent volunteering at the Children’s Surgical Centre in Phnom Penh, Cambodia. I really enjoyed reading Julie’s account of her time at the hospital, the accomplishments of herself and her colleagues and the ongoing support she has been able to provide to make a difference to the staff and patients at the Children’s Surgical Centre. Her reflections show what a life changing experience it must have been. The article also reinforces that quality of clinical documentation is a universal issue. I wonder how Dr Jim’s strategy for ensuring doctors complete their operation reports would go down in Australia?

Knowing that clinical documentation improvement is a topic of interest to many of you, we have included an article from the current Health Information Management Journal Special Issue on Clinical Coding and the Quality and Integrity of Health Data. The article discusses the importance of clinical documentation improvement for Australian hospitals (Hay et al 2020). In the article, the authors consider the literature on the case for implementing clinical documentation improvement programs in hospitals and outline some of the challenges of implementation. I encourage you to have a look at the other articles in the special issue of the Health Information Management Journal, accessible through the Health Information Management Association of Australia (HIMAA) website. Julie Price (2020) also shares her insights on clinical documentation improvement gained from the presenters at the 19th International Federation of Health Information Management Associations Congress, which was held in Dubai in November 2019. Presentations at the congress provided delegates with tips on how to achieve clinician engagement and how to measure the success of your clinical documentation improvement program. For those interested in continuing the international flavour, check out the article on HIMAA’s International Special Interest Group by Suzette Dela Cruz Regalo (2020). Krivozhnya et al (2020) showcase some of the events organised by Health Information Managers to celebrate Health Information Management Awareness Month in 2019, including tours, open days, morning teas, audits and aerial photography. I hope the article gives you some ideas and inspires you to organise or take part in events for 2020. If you were not able to attend the HIMAA/National Centre for Classification in Health conference in Sydney in October 2019, or were in attendance but want to find out more, we have included papers from two of the conference presenters. Firstly, Mardi Ellis (2020) takes us through the Australian Institute of Health and Welfare’s International Classification of Diseases 11th Revision (ICD-11) review project, which aimed to provide evidence to support decision making and implementation planning for ICD-11. Next, Clare Searson and Laura Harris (2020) provide a more in depth analysis of the Independent Hospital

Pricing Authority’s development of the new Australian Emergency Care Classification. Lastly, I hope you enjoy reading what goes on behind the scenes at HIM-Interchange and the reflections of some of the HIM Interchange Subcommittee members. Please get in touch with us if you would like to be involved. Enjoy the issue. References Askar S (2020) Maybe I’ll write to you from there: the journey of an undergraduate health information management student. HIM-Interchange 10(1):31-33. Dela Cruz Regalo S (2020) HIMAA International Special Interest Group: a community of practice empowering Health Information Managers with global voice. HIM-Interchange 10(1):40-41. Ellis M (2020) ICD-11 review: toward implementation planning in Australia. HIM-Interchange 10(1):4-8. Hay P, Wilton K, Barker J, Mortley J and Cumerlato M (2020). The importance of clinical documentation improvement for Australian hospitals. Health Information Management Journal 49(1), 69–73. https://doi.org/10.1177/1833358319854185. Krivozhnya M, Askar S, Fiorenza T, Pollard K and Scott M (2020) A special year for health information management awareness in 2019. HIM-Interchange 10(1):20-22. Price J (2020) Report on the 19th World Congress of the International Federation of Health Information Management Associations. HIM-Interchange 10(1):37-39. Searson C and Harris L (2020) A comparison between Urgency Related Groups and the Australian Emergency Care Classification. HIM-Interchange 10(1):9-14. Van Gemert A (2020) Year of a new graduate in the bush. HIM-Interchange 10(1):29-30. Wilson J (2020) Managing health information in Cambodia: exchanging skills in a challenging environment. HIM-Interchange 10(1):23-28.

Joanne Fitzgerald Editor

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ICD-11 review: toward implementation planning in Australia Mardi Ellis

Background The International Classification of Diseases 11th Revision (ICD-11), was launched by the World Health Organization (WHO) in June 2018. In May 2019, the World Health Assembly adopted ICD-11 for implementation by Member States from 1 January 2022. The WHO will provide transitional arrangements for at least five years from that date, and as long as it is necessary, to support implementation. The Australian Institute of Health and Welfare (AIHW) undertakes a program of work relating to health classifications, including the management of the WHO Family of International Classifications Australian Collaborating Centre (WHO-FIC ACC), with funding support from the Australian Government Department of Health (the Department). The AIHW’s work program under the WHO-FIC ACC for 2018–20 included a review of ICD-11 and its potential implementation in Australian health information systems (the Review project). In Australia, ICD-10 and ICD-10-AM (the Australian Modification) are currently in use in vital statistics, hospital and some other health service patient statistical reporting systems, and in Activity Based Funding arrangements. A decision has not yet been made in Australia as to whether, when or how ICD-11 may be implemented in Australian health information systems to replace some or all of these statistical and reporting arrangements. The AIHW’s ICD-11 Review project aimed to provide evidence to support that decision making and implementation planning. The first phase of the Review project was a stakeholder consultation process, overseen by the AIHW’s Australian Health Classifications Advisory Committee (AHCAC) and led by Jennie Shepheard, from Shepheard Health Management Consultants.

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This article presents an overview of the stakeholder consultation process (stakeholders and resources), summarises the key findings (common themes, strengths, weaknesses, opportunities and threats) and describes the next steps for the Review project. The complete ICD-11 Review Stakeholder Consultation Report will be published by the AIHW in early 2020.

Stakeholder consultation process Stakeholders The Review commenced in 2018 with a stakeholder workshop to inform the consultation process. Twenty individual and group consultations were conducted between January and April 2019, with representatives from: Australian governments, the New Zealand Ministry of Health, the private health sector, the medical software industry and individuals with expertise in classification development and statistical reporting. The Review was overseen by the AHCAC, with members from the Commonwealth Department of Health, Australian Bureau of Statistics, Independent Hospital Pricing Authority, The Australian Digital Health Agency and two representatives nominated by the Australian Health Ministers’ Advisory Council (AHMAC) from New South Wales and Queensland. The AIHW’s National Health Information and Data Standards Committee (NHDISC) and Strategic Committee for National Health Information (SCNHI) were also consulted in the development of the ICD-11 Review and proposed work program. Resources AIHW advertised the consultation process, and ICD11, through the review flyer, published on the AIHW website and available at the 2018 Health Information Management Association Australia and National Centre for Classification in Health (HIMAA NCCH) conference.

Figure 1: The Review Flyer and Pre-consultation Paper

Stakeholders received a pre-consultation paper ahead of their consultation to provide background, context and the 22 questions framing the consultation process. These questions gathered insight on: • Current use of ICD-10 and ICD-10-AM, as well as other classifications and terminologies • Knowledge and understanding of ICD-11 • Current gaps and limitations that may be filled by ICD-11 • Impact of implementing ICD-11, including on current projects, workforce, systems and processes • Consequences of not implementing ICD-11 • The process, timeframes and resourcing required for implementation. The flyer and pre-consultation paper are available on the AIHW website, at https://www.aihw.gov.au/ourservices/international-collaboration

Key findings Common themes Six common themes emerged from the consultation process, from across the breadth of the stakeholder group: governance arrangements, workforce capacity and capability, infrastructure, resourcing, communication and education, and intervention classifications. In discussing governance arrangements for the ICD11, stakeholders expressed a need to understand arrangements at both national and international levels. There was a need for greater clarity on where the responsibilities lay for ongoing development, maintenance and local management of the classification. In relation to workforce capacity and capability, stakeholders with previous exposure to ICD-11 through WHO development processes understood the future

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workforce requirements. These stakeholders discussed the need for more data scientists, data brokers and documentation specialists to realise fully the benefits of ICD-11. The expectation that clinical coding will be largely automated within the next few years, and that this would lead the clinical coding workforce to transition to new roles in the electronic environment, was raised often. Infrastructure planning issues related to the fact that the full benefit of ICD-11 is realised when it is integrated into electronic health records. Stakeholders expressed concern that the roll out of electronic records is not consistent across Australia, that vendors have tenyear roadmaps with little or no provision for ICD-11 implementation and that these issues may prove to be a barrier to implementation in some settings. Another common theme was that resourcing requirements are currently unknown. There was insufficient knowledge among stakeholders about the technical developments in ICD-11 and the likely timeframes for implementation made it difficult for stakeholders to have any confidence in providing information on resource requirements. Stakeholders agreed that implementation of ICD-11 is not simply a matter of replacing one classification with another, as was largely the case when ICD-10 (and ICD-10AM) replaced ICD-9 (and ICD-9-CM) in the late 1990s. Stakeholders also noted that the different settings in which ICD-11 can be implemented may create different pathways to implementation with different resource requirements. Stakeholders were clear that communication and education are key to stakeholder engagement and acceptance of ICD-11 and that comprehensive communication and education should be provided as soon as possible. Education should initially focus on those who will contribute to decision-making about implementation. Stakeholders also commonly raised questions about the accompanying procedure/intervention classification to ICD-11, noting that the WHO’s International Classification of Health Interventions (ICHI) should be a complementary consideration. It was thought that significant investigation will be needed to ascertain whether there is a need to update Australia’s existing intervention classification, or whether ICHI will be a suitable replacement.

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Strengths, weaknesses, opportunities and threats Stakeholder consultation for AIHW’s ICD-11 Review project showed a number of strengths and opportunities for implementing ICD-11 in Australia, along with weaknesses and threats that need to be considered in implementation decision-making and planning. The Review project showed that the strengths of ICD-11 lie in: • Its digital design, enabling a common framework for integrated classifications and implementations to be developed to suit health information needs in different settings • The improved specificity and clinical currency of codes, applicable to multiple care settings and providing more detailed information for researchers and evidence to underpin policy analysis • The capacity to realise benefits of data not currently able to be collected, such as in primary care, community health or ambulatory care and aged care settings • Better mechanisms for research and for reporting healthcare safety and quality events, with a clustering mechanism that explicitly links characteristics of a patient’s condition, or cause of death. The opportunities of ICD-11 were seen to include the: • Impetus to change some of things about the way we operate currently, including streamlining existing update processes • Adoption of automated clinical coding tools, such as the WHO coding tool, to ensure the ongoing collection of clinically coded data and freeing up existing clinical coding skills to be used in evaluation and interpretation of data • Potential to introduce a new procedure/intervention classification, using the same change management committees and processes as for an ICD-11 implementation. The threats to implementation of ICD-11 were perceived by stakeholders to lie in: • The evolving governance frameworks and associated support mechanisms, at the national and international levels for the classification and its implementation, as well as a need for more clarity about the use of clinical terminologies in Australia, their governance, and relationships between digital health information and statistical health information

• Workforce issues, with shortages of appropriately skilled workforce to support eHealth applications and a lack of currently available education material to support workforce readiness • Different levels of electronic health record maturity in Australia, with particular concerns about differential timeframes for rolling out electronic health care systems, the associated costs with new ICD-11-ready systems, and the potential development of multiple clinical coding tools without proper regulation that could affect data integrity The weaknesses were revealed as: • Concerns about readiness for adoption, which largely related to a lack of clear information about the development of the classification and associated processes, and concerns about it being incomplete at the time of the Review. • The lack of accessible and detailed documentation about the differences between ICD-10 and ICD-11. • That mapping from the Sytematized Nomenclature of Medicine (SNOMED) is not yet available, and this is likely to be necessary to harness the benefits of ICD11 in an e-Health environment.

Next steps The Review showed that Australian stakeholders had limited knowledge of ICD-11, and that concerns related to threats and weaknesses of ICD-11 as raised by stakeholders would need to be addressed ahead of implementation. In this way, the Review revealed a suite of work that could be undertaken to address acknowledged concerns regarding the classification, leverage and realise the strengths of the classification as a digital enabling tool, advance understanding to inform decision making, and to facilitate transition to implementation following a decision to do so.

The AIHW developed a proposed work program based on the findings of the Review and with input and advice from AHCAC, NHDISC and SCNHI, in mid-2019. This program of work was endorsed for further prioritisation and work planning at AHMAC in October 2019. Proposed work program for prioritisation The AIHW proposed four broad areas of work to progress investigation of ICD-11 implementation in Australia, as described below. 1. A comprehensive review of how ICD-10-AM is, and ICD-11 could be, used in health information systems, including digital settings. This review would investigate the issues associated with ICD-10-AM and consider the way in which ICD-11 addresses these, to ensure that decision making about implementation covers all possible impacts. 2. Development of a national roadmap for classifications and terminologies and how they will be used together within health information arrangements. This would ensure that classifications and terminologies are used appropriately with consideration of their varied use cases. 3. Strategic communications activities to ensure that decision makers and their advisors can contribute to further work and decision-making over the next year about whether, when and how to implement ICD-11. 4. Continued planning for implementation in mortality data systems and to maintain and advance Australia’s current involvement in this international process.

... the Review revealed a suite of work “that could be undertaken to address acknowledged concerns regarding the classification, leverage and realise the strengths of the classification as a digital enabling tool, advance understanding to inform decision making, and to facilitate transition to implementation following a decision to do so.

”

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Figure 2: Broad areas of work and supporting activities

Broad areas of work Comprehensive review of how ICD is and could be used in health information systems

National roadmap for classification and terminologies

Strategic communication activities to support decision-makers

Implementation planning for mortality data systems

Supporting activities Governance arrangements for decision-making

International engagement for Australian input, collaboration and cooperation

AIHW proposed that these four broad themes of work be supported by three other activities: 1. Development of governance arrangements for decision making about ICD-11 implementation and for governance of any future implementation and maintenance activities. 2. International engagement to maintain current Australian input and advice on WHO ICD-11related processes and to support digital health interoperability. 3. Scoping of pilot projects to demonstrate value and inform implementation planning. Further planning and prioritisation of this proposed program of work will be undertaken in early 2020, with regular reporting to stakeholders and through the oversight committee structure.

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Scoping pilot projects to inform implementation arrangements

Further information The report of the AIHW’s ICD-11 stakeholder consultation review will be published and freely available on the AIHW website in early 2020. Information on the Review and ICD-11 is currently available at www. aihw.gov.au/our-services/international-collaboration. For further information, email the Australian Collaborating Centre at who-fic-acc@aihw.gov.au.

Mardi Ellis Senior Project Officer, Cardiovascular Diabetes and Kidney Unit (formerly Acting Head, Metadata and METeOR Unit) Australian Institute of Health and Welfare GPO Box 570 Canberra ACT 2601 Tel: +61 2 6244 1128 Email: mardi.ellis@aihw.gov.au

A comparison between Urgency Related Groups and the Australian Emergency Care Classification Clare Searson and Laura Harris

Introduction Emergency departments are dedicated hospital-based facilities specifically designed and staffed to provide 24-hour emergency care. The role of the emergency department is to diagnose and treat acute and urgent illnesses and injuries (Independent Hospital Pricing Authority [IHPA] 2019a). Annually, there is an increasing demand on emergency departments in Australian public hospitals. The average emergency department presentation growth from 2013-14 to 2017-18 was 2.7% per annum, which surpasses the average growth of the population over the same period. Total emergency department presentations have increased 11% over the past 5 years, and in the 2017-18 financial year presentations exceeded 8 million (Australian Institute of Health and Welfare [AIHW] 2018a, p.4). Consequently, national emergency department expenditure is increasing year on year. Due to an 8% increase from the previous year, the 2016-17 financial year expenditure exceeded $5 billion (IHPA 2019b, p13). While this increase in expenditure may be associated with improved costing processes in public hospitals, the trend correlates with the increased number of presentations and therefore resource utilisation required for service delivery. Due to an ageing population, increasing life expectancy and prevalence of chronic and complex diseases (AIHW 2018b) the number of presentations and therefore demand on Australian emergency departments will continue to rise. To ensure optimal resources are available for emergency department care delivery, the development of a new emergency care classification, which better accounts for patient complexity and cost variation, is required.

to an ageing population, increasing “lifeDue expectancy and prevalence of chronic and complex diseases the number of presentations and therefore demand on Australian emergency departments will continue to rise.

”

Currently, IHPA classifies care provided by emergency departments utilising the Urgency Related Groups (URG) system. The care provided by emergency services are classified according to the Urgency Disposition Groups (UDG) system (IHPA 2019c). For example, an emergency service in a small rural hospital staffed with an on-call visiting medical officer would classify patient activity utilising the UDG system rather than the URG system, due to limitations in data collection at smaller hospitals. The URG and UDG systems were adopted as an interim measure to classify emergency care for the purpose of activity-based funding (ABF), which was nationally implemented in July 2012. In 2013 IHPA commissioned an investigative review, conducted by Health Policy Analysis, to determine whether current systems appropriately classified emergency care and whether more suitable classifications were available. The review determined that current classification systems were not appropriate for ABF on a long term basis. This was due to the reliance on triage category as a proxy measure for patient complexity, restricted capacity for classification refinements, and limited clinical meaning (Health Policy Analysis 2014). The review explored alternative national and international emergency care classifications for use

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in Australia. However, none were deemed appropriate. The review concluded that development of a new national emergency care classification would overcome current system limitations and provide more accurate data on clinical profiles, cost variation and resource utilisation for ABF purposes. The following fictional case study will be referred to throughout the article: Case Study Name:

Albert Simms

Age:

Place of residence:

Holbean Residential Aged Care Facility

Transport mode of arrival: Ambulance Triage category:

Level 2

Symptoms:

Blood tinged mucus Chest pain worsens when coughing Fever 39.8

Emergency department principal diagnosis:

Pneumonia, bacterial (75570004 or J15.9)

Episode end status:

Admitted to hospital

Emergency care classification development comparison The URG system was developed using data from a Western Australia based study from three teaching hospital emergency departments (Jelinek 1992). IHPA adopted and modified the original URG system prior to its implementation for ABF, in order to meet national requirements. To ensure the URG system was meeting the demands of emergency care in Australia, the

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classification underwent several refinements. However, further improvements to the URG system would have required major structural changes to the classification. IHPA commenced classification development on a new Australian Emergency Care Classification (AECC) to replace the URG system in 2013. The AECC development stages included: • An investigative review of national and international classification systems for emergency care (Health Policy Analysis 2014) • Analysis of data from national activity and cost data collections to inform determination of cost drivers for emergency care • A national emergency department costing study and clinician time consensus study in 2016 to facilitate indepth data analysis of emergency department patient characteristics and costs • Development of a classification tree and draft classification structure • Public consultation on the draft AECC • Release of the classification for review by IHPA’s stakeholders, committees and health ministers. The systematic development process of the AECC facilitated increased data analysis and significant stakeholder engagement, which resulted in a robust, dynamic and clinically relevant classification which has several structural differences compared to the URG system.

AECC and URG comparison Structurally, the URG and AECC systems both have a three level hierarchical classification structure. Figure 1 and Figure 2 reflect how the classifications sort emergency department episodes into different end classes.

Figure 1: URG Classification Structure

Figure 2: AECC Classification Structure

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The AECC and URG system both utilise variables that are currently available in national datasets. The difference between the classifications are demonstrated through the structure and utilisation of those variables, as shown in Table 1. Table 1: Classification hierarchy and variables utilised by URGs and the AECC URGs V1.4

AECC V1.0

LEVEL 1

Episode end status (e.g. admitted to this hospital)

Type of visit (e.g. emergency presentation) or episode end status

LEVEL 2

Triage (e.g. 1 – resuscitation, 2 – emergency, 3 – urgent, 4 – semi urgent, 5 – non urgent)

Principal diagnosis (e.g. J18.9 pneumonia, unspecified)

LEVEL 3

Major diagnostic block (e.g principal diagnosis)

Complexity, using the following variables: Transport mode of arrival (e.g. ambulance, police/ correctional services vehicle, other), Age (e.g. 0-4, 5-9, 10-14, 15-56, 70-74, 75-79, 80-84) Triage Principal diagnosis (e.g. pneumonia subcategory) Episode end status

The main variables utilised by URGs include episode end status (the patient’s discharge destination at the conclusion of the emergency department stay, for example, admitted to hospital or discharged home), triage category and major diagnostic block (MDB). Whereas the AECC incorporates more specific categorisation of principal diagnosis along with patient complexity factors. The AECC classification structure and utilisation of variables has improved clinical relevance, reduced reliance on triage and better represents patient-based factors through greater use of diagnosis or presenting symptoms compared to the URG system. The first split for both the AECC and URGs is on the visit type or episode end status variables. In the AECC, some episodes are grouped to end classes at the first level and not further split based on diagnosis or complexity. These reflect circumstances such as where the patient did not wait for treatment, was dead on arrival or returned for a pre-planned visit. A diagnosis may not

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be available or relevant and these episodes account for a small proportion of all emergency department presentations. The majority of episodes for the AECC fall into the ‘all other emergency episodes’ category, which are further split into diagnosis categories, and in some cases complexity levels. Comparatively, all episodes within the URG system are grouped at the first level using episode end status. The URG system also has some end classes at the first level which are not split any further, for example, for dead on arrival or did not wait cases. The remainder of episodes are grouped into either admitted or non-admitted categories and then further split based on triage category and then MDB. The second level splitting variables differ for both classifications. The AECC second level groups by principal diagnosis, followed by a third split on complexity, whereas the URG groups at the second level through triage category, followed by a third split based on diagnosis through the MDB. Diagnosis The second level split for the AECC groups episodes into clinically meaningful diagnosis categories called Emergency Care Diagnosis Groups (ECDGs). ECDGs have subcategories that provide more specificity of diagnosis. ECDGs also have higher level groupings called Emergency Care Categories (ECCs), which are largely based on body system or aetiology. Applying the case study example, the ECC is respiratory, the ECDG is lower respiratory tract infection and the ECDG subcategory is pneumonia. ECDGs are based on IHPA’s International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD10-AM) emergency department principal diagnosis short list codes (Health Policy Analysis 2019). The diagnosis variable for the URG system is based on broad diagnosis categories of body systems or specialties, known as MDBs. These MDBs are more general in medical terms in comparison to the AECC ECDGs, which group episodes into major clinical conditions. Due to the greater specificity of ECDGs, ECDG subcategories and grouping at a higher level of ECCs, these variables can be mapped and analysed to provide more clinically meaningful information on the conditions

with which patients present to emergency departments and enhances the use of data for secondary purposes such as research or health service management. Table 2 reflects a comparison of the patient journey across both classifications with reference to the case study. Table 2: Components of URGs and the AECC URGs V1.4

Components derived from ED principal diagnosis

End classes

AECC V1.0 Emergency Care Category (e.g. E04 Respiratory)

Emergency Care Diagnosis (e.g. E0450 Lower Respiratory tract infections)

Emergency Care Diagnosis subcategories (e.g. E0451 Pneumonia subcategory)

132

Major Diagnostic Blocks (MDB) (e.g. respiratory system illness, or neurological illness)

Urgency Related Groups (URG)

114

AECC end classes (e.g. E0450B)

177

Error end classes

Complexity The third level split for the AECC involves grouping the ECDGs into end classes based on different levels of complexity, reflecting cost. The complexity splits are based on a score assigned to each episode, which is calculated using variables such as age, transport mode of arrival, emergency department principal diagnosis (based on ECDG subcategory), triage category and episode end status.

the AECC has significantly improved upon limitations of the URG system through reducing reliance on triage and application of complexity levels based on patient factors, such as diagnosis and age.

AECC structure allows for inclusion “ofThe improved measures of complexity as additional variables become available. ” End classes and numbering convention The number of end classes for the URG system is 122, whereas the number of end classes for the AECC has increased to 181. The increased number of end classes in the AECC supports more accurate funding and in depth analysis through further categorisation of data. The URG numbering convention is simply a numerical list, represented by a number 1 to 128. The numbers do not identify the placement or relationship between end classes in the classification structure. The numbering convention for the AECC is an alphanumerical code, comprised of three components as shown in Figure 3 (Health Policy Analysis 2019). Each AECC end class has the prefix of ‘E’ to identify the end class as belonging to the emergency care classification. There are three numerical components that represent the ECC, the ECDG and the complexity level. The AECC numbering convention conveys information on the placement of the end class within the classification hierarchy, whereas the URG numbering convention provides limited clinical meaning through a numerical value. Figure 3: AECC numbering convention

Comparatively, the complexity variable for the URG system is based on triage category, grouping patients from the first split into one of five triage categories depending on a patients need for medical or nursing care in an emergency department (triage categories are listed in Table 1). The AECC structure allows for inclusion of improved measures of complexity as additional variables become available (Health Policy Analysis 2019). Incorporating complexity through patient-based variables has been a key achievement of the AECC. The complexity split of

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Conclusion The increasing number of emergency department presentations, escalating expenditure, increasing pressure of an ageing population and prevalence of chronic, complex conditions compounds the demand placed on emergency departments. The underperformance of URGs is exacerbated by the reliance on triage category as a proxy measure of patient complexity, restricted capacity for classification refinements, and limited clinical meaning. The AECC more appropriately classifies patients in the current emergency department environment of increasing clinical complexity, increasing costs and presentations. The AECC has increased clinical relevance, and enables greater understanding of patient complexity and resource utilisation. The AECC has been developed to allow for future refinement and improvement and has utility beyond funding including health service management, epidemiology, research and service planning.

References Australian Institute of Health and Welfare (2018a) Emergency department care 2017–18: Australian hospital statistics. Health services series no. 89. Cat. no. HSE 216. Canberra: Australian Institute of Health and Welfare. Australian Institute of Health and Welfare (2018b) Australia’s health 2018. Australia’s health series no. 16.AUS 221. Canberra: Australian Institute of Health and Welfare. Health Policy Analysis (2014) Investigative review of classification systems for emergency care – Final report. Independent Hospital Pricing Authority, Sydney. Available at https://www.ihpa.gov. au/publications/investigative-review-classification-systemsemergency-care (accessed 24 January 2020). Health Policy Analysis (2017) Emergency care costing and classification project – Cost report. Independent Hospital Pricing Authority, Sydney. Available at https://www.ihpa.gov.au/what-wedo/development-new-emergency-care-classification (accessed 24 January 2020). Health Policy Analysis (2019) Australian Emergency Care Classification – Final report. Independent Hospital Pricing Authority, Sydney. Available at https://www.ihpa.gov.au/what-we-do/ emergency-care (accessed 24 January 2020). Independent Hospital Pricing Authority (2019a) Emergency care. Available at: https://www.ihpa.gov.au/what-we-do/emergencycare (accessed 10 January 2020). Independent Hospital Pricing Authority (2019b) National Hospital Cost Data Collection Report: Public Sector, Round 21 Financial Year 2016-17. Independent Hospital Pricing Authority, Sydney. Available at https://www.ihpa.gov.au/publications/national-hospital-costdata-collection-report-public-sector-round-21-financial-year (accessed 24 January 2020). Independent Hospital Pricing Authority (2019c) Urgency Related Groups and Urgency Disposition Groups. Available at: https:// www.ihpa.gov.au/what-we-do/urgency-related-groups-andurgency-disposition-groups (accessed 10 January 2020). Jelinek GA (1992) A Casemix Information System for Australian Hospital Emergency Departments. Report to the Commissioner of Health, Western Australia. Perth.

Clare Searson BBus (Marketing), MHSM (Planning) Manager, Classification Development Independent Hospital Pricing Authority Email: Clare.Searson@ihpa.gov.au Laura Harris BExPys, BSc Hons Neuro, MHIM Director, Classifications Independent Hospital Pricing Authority Email: Laura.Harris@ihpa.gov.au

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The importance of clinical documentation improvement for Australian hospitals Patricia Hay, Kathy Wilton, Jennifer Barker, Julie Mortley, Megan Cumerlato

Introduction When clinical documentation improvement (CDI) was first introduced in the United States (US), it emerged within the policy climate of the Bush administration, with a major focus on increasing the effectiveness of hospital care and reducing the cost of the healthcare system. The Deficit Reduction Act 2005 was a combination of withholding reimbursement (for hospital acquired conditions), assigning mandatory indicators (‘Present on Admission’ flags), and incentivising best practice (through ‘value-based purchasing) (Wilson, 2009). In order to achieve the requirements of the legislation, CDI programs in the US focused on improving the clinical documentation in the medical records so that resultant coded data submitted to internal and external agencies were as complete and accurate as possible, so as to manage the direct impact on reimbursement (Wilson, 2009).

The Australian clinical coding climate While there are not the same environmental conditions in Australia as the US, the two countries share the timeless issues of making the provision of health care more efficient and cost-effective, while improving patient outcomes. In the 1990s, public hospitals in Victoria moved from historically based block funding to activity-based funding, where reimbursement was based on the complexity of patients treated. In July 2012 a national activity-based funding model was introduced and those states not already operating activity-based funding models adopted the national model for their own purposes. The motivation to do this was to improve the link between hospital funding and the provision of service (Independent Hospital Pricing Authority [IHPA], 2011). In early 2017, the IHPA announced its upcoming pricing framework to focus on quality and patient safety by reducing funding for ‘unsafe care’. Pricing outcomes were to be directed toward three main areas: sentinel events; hospital acquired complications (HACs); and preventable readmissions (IHPA, 2017). With this trend towards increasing accountability placed on hospitals, there was pressure for clinical documentation to be as

accurate as possible since it has significant ramifications for patient care, casemix data reporting, and funding.

What is CDI? Hospital coded data are one of the building blocks of reporting for both public and private hospitals in Australia. These data are the result of a two-step process. Firstly, clinical documentation is generated by clinicians in the medical record. This documentation is then clinically coded or classified using the International Classification of Diseases (ICD-10-AM) and the Australian Classification of Health Interventions (ACHI) codes, which are then further classified into Diagnosis Related Groups (DRGs) to produce hospital casemix data. Unfortunately, the language used for clinical purposes, and that required by Clinical Coders (CCs) is often different. Clinicians frequently use generalised clinical terms, signs and symbols, and abbreviations. While this is meaningful for communication between treating healthcare professionals for managing patients, these terms are not always able to be translated into ICD-10AM/ACHI codes or coded to the required specificity that reflects the complexity of the patient. This disconnect can significantly affect the quality of hospital casemix data. For many hospitals, the results of clinical coding do not fully capture the activity and level of service that was provided, resulting in an under-representation of patient complexity leading to sub-optimal hospital reimbursement and incomplete reporting to external agencies. CDI is the process of reducing the ‘disconnect’ between what clinicians write in the medical record and what CCs need to produce quality casemix data. It achieves this by placing a CDI specialist or clinical documentation specialist (CDS) on the ward to review clinical documentation in a timely manner while the patient is still admitted. CDI specialists help clinicians to document using a format that is clear, complete, and accurate, to aid with patient management and also to be readily acceptable for clinical coding (Buttner et al. 2014; Lo 2014).

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A case for CDI in Australia

Communication and patient safety

Standard became the Communicating for Safety Standard, to broaden the Standard beyond clinical handover and to reflect the importance of effective communication throughout the entire delivery of health care. As Devkaran and O’Farrell (2014) pointed out, implementation and proof of compliance to Standards during accreditation processes are dependent on quality clinical documentation.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) has recognised the importance of the relationship between effective communication and patient safety, with evidence showing poor documentation can lead to adverse events. The Commission stated that documentation at the time of transition of care for patients with complex health care needs was a key safety and quality issue. Patient handover was the step associated with high negative risks and poor outcomes. The report noted that poor documentation often resulted from missing or miscommunicated information. Inconsistent use of abbreviations or standard terminology could also affect how the information was interpreted, leading to consequences such as higher readmission rates, lack of follow-up after discharge, increased costs, and medication errors (ACSQHC, 2017a;b].

The ACSQHC (2015) also introduced the national care, hospital-based outcome indicators for ongoing monitoring and review by hospitals. The rationale was that any significant variance can be a signal for issues such as data quality and consistency, resources, or quality of care. These indicators reflected: hospital standardised mortality ratios; death in low-mortality DRGs; and unplanned or unexpected hospital readmissions for: (i) acute myocardial infarction (AMI); (ii) stroke; (iii) fractured neck of femur; and (iv) pneumonia. A CDI program would naturally evolve to consider more quality improvement measures. The two are intertwined and improving documentation inadvertently impacts on its quality. In regard to outcome indicators, a death in a low mortality DRG can only be accurately interpreted if the DRG is correct, which is wholly dependent on accurate documentation and coding.

Roughhead and Semple (2009a, 2009b) conducted an extensive literature review to assess the extent of medication errors in Australia and the preventability of these errors. Their findings showed that medication errors represented an estimated cost of AUD$660 million to the Australian health care system. Australian researchers, Lamb and Henry (2004), investigated paediatric use of paracetamol to better understand prescribing practice. Out of 313 children, 231 (74%) were prescribed paracetamol during the study period. These researchers found that poor documentation between doctors and nurses commonly resulted in misunderstanding of the condition being treated and indication for use.

Implementation of an effective CDI program by a range of competent, trained personnel can be a powerful tool, the impact of which is, by its very nature, far reaching. Moje, Jackson and McNair (2006: 333) argued that “the usefulness of abstracted data for quality and safety purposes relies on good documentation in the medical record, thorough coding and periodic data audit”. From the literature and recent reports by the ACSQHC (2017a; b), there is little doubt that improving the quality of the clinical documentation in the medical record is a current area of focus and forms one of the strategies used to address the issue of patient safety and quality outcomes.

In 2012, the ACSQHC released the first edition of the National Safety and Quality Health Service (NSQHS) Standards to drive the implementation of safety and quality systems in Australia (ACSQHC 2012, 2017a). In 2011, the state health ministers had endorsed the NSQHS and a national accreditation scheme for health service organisations, and in 2017, the ACSQHC published the second edition of eight NSQHS standards (ACSQHC 2017a). The Clinical Handover

The ACSQHC’s (2017b) report summarised a table of minimum information content that should be documented for all complex patient types. Within this table very clear reference was made to documenting the principal diagnosis along with a clinical synopsis and relevant tests and investigations supporting that decision. Quality documentation should reflect evidence-based treatment plans, which can be linked

CDI is becoming an important strategic trend among hospitals in Australia due to its positive impact on clinical, financial, and epidemiological outcomes. This section discusses these three areas and summarises the Australian literature associated with each topic.

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Hospital reimbursement and funding

directly to the correct principal diagnosis and additional diagnoses. This then ensures accurate hospital coded data are abstracted and reported by CCs. Clinical coding gathers other information in the documentation, such as procedures and additional diagnoses to develop a picture of the patient’s admission and subsequently the allocation of DRGs (ACSQHC 2017b). Cheng et al (2009) investigated the ramifications of poor quality documentation on hospital funding in a major teaching hospital in Melbourne. From a 6-month period during 2004 to 2005 a sample of 752 coded inpatient cases from a surgical unit were audited for accuracy of the clinical coding. Of the total sample, 118 cases (15.7%) had a DRG change. Upon review, 57% of this subset was due to missing documentation of diagnostic information. The financial impact of the inaccurate hospital data from this study was significant and equated to a hospital shortfall in revenue of AUD$575,290 for this single unit over the 6-month period. Cheng et al. (2009: 43) concluded that “continuous improvement in the quality of the coding and DRG data outputs” and “routine and systematic internal clinical coding audits” are necessary. Their recommendations focused heavily on the role of CCs. While Cheng et al.’s recommendations are still applicable, clinical documentation improvement focuses on leveraging the role of a CDI specialist to increase the quality of the information provided to the clinical coder, ensuring the documentation in the medical record is complete, comprehensive, and legible before the patient is even discharged. The quality of clinical documentation in the medical record directly impacts clinical coding. Since clinical coding provides the building blocks for hospital data (which determine funding), the adoption of CDI initiatives in Australian hospitals is a legitimate strategy that can be applied to secure appropriate funding. Surveillance and burden of disease reporting From a disease standpoint, research conducted by Professor Peter Collignon’s group (Das et al. 2016) studied Staphylococcus aureus bacteraemia surveillance accuracy by comparing the number of laboratoryconfirmed episodes to the number of clinically coded episodes. From the 740 laboratory-confirmed episodes, only 408 were reflected in the coded data, representing only 55% (95% CI) of the total. This inaccuracy was most likely due to documentation issues by the medical practitioner (missing, inaccurate, or inconsistent data)

or misinterpretation of the documentation by the CCs. Das et al. went on to discuss the negative consequences resulting from poor clinical documentation, namely, any inaccurate burden of disease reflected in the coded data leads to sub-standard funding, impacts policy decisions, raises issues with tracking performance, and compromises trend data for national and international surveillance. This study highlighted the opportunity for improvement in the clinical documentation. Mitchell and Ferguson (2016: 32-35) pointed out that when the population being assessed is large in size and being observed over a long time period, using coded data has the advantage of being potentially more efficient for surveillance. To evaluate whether coded data were reliable for the surveillance of healthcareassociated urinary tract infections (HAUTI), Mitchell et al. reviewed 162,503 admissions from eight hospitals in one health district in New South Wales. Over the study period, 2,821 patients acquired a HAUTI. However, only 29.3% of laboratory-diagnosed HAUTI patients were assigned a UTI ICD-10-AM clinical code. In this study, had there been initiatives in place to improve the clinical documentation and resultant coded data it could have led to efficiencies for infection control surveillance, “a very time consuming and resource intensive process” (Mitchell and Ferguson, 2016: 35). Clinical coding occurs in every hospital in Australia. If the quality of hospital casemix data could be improved, the potential to increase the efficiency of surveillance and research toward quantifying the burden of disease would be greatly increased.

Challenges to implementing CDI programs in Australia Implementation of a CDI program can deliver a wide range of advantages. However, because it requires behavioural change involving multiple stakeholders, it must be prioritised as a hospital-wide initiative. While many hospital staff are impacted by CDI programs, the major stakeholders are medical staff, CDI specialists, and Health Information Managers (HIMs) and CCs. Challenges to implementing a CDI program that impacts on stakeholder groups are discussed below. Classification and grouping Classification of diseases in Australian hospitals is aligned globally through the use of the World Health Organization International Statistical Classification of

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Diseases and Related Health Problems, 10th Revision, modified for use for Australian clinical practice (ACCD, ICD-10-AM 10th edition). Along with ACHI codes, the ICD-10-AM codes are the building blocks for classifying patients to DRGs. The classification process is complex and requires the CC to follow conventions contained within the classification, as well as ensuring compliance with Australian Coding Standards (ACS) and officially published national and state coding authority advice. While this ensures that casemix data are of a consistent quality, it also presents a challenge to those in the clinical coding profession. Changes to the base classification are also made biennially, presenting difficulties for a CDI program to maintain currency. Therefore, Cheng et al. (2009) suggested that CCs are best placed to deal with the complexities of the classification and advise on the necessary revisions. Moving from a retrospective to concurrent approach For many decades, HIMs and CCs have performed a vital role in reviewing the documentation and generating queries back to the treating clinician to clarify any concerns with the documentation. From a timing perspective, these queries are generated retrospectively, after the patient has been discharged. Aside from delaying the coding process, these queries will always have been negatively affected by the passing of time. With CDI, the objective is to improve the documentation concurrently, while the patient is still admitted (Chavis, 2009). Due to the complexity of the classification, grouping, and reporting requirements in Australia, as discussed, HIMs and CCs play an important role in guiding CDI specialists on the documentation required for casemix funding. When hospitals embark on their CDI journey, there may be a temptation to have the CDI specialist review medical records postdischarge. The challenge will be to leave the past behind and start working in the ‘here and now’ to improve the documentation going forward. This will take discipline, focus, and hospital-wide commitment. Doctor and clinician engagement The success of CDI programs relies on the ability to engage clinicians. Doctors are typically ‘time-poor and may require motivation to sustain their involvement in CDI over the long term (Leventhal 2014). Much of

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the literature on implementing CDI has stressed the importance of education as a means of increasing clinician engagement. To date in Australia, there has been no formal training on clinical documentation within the syllabus of medical courses at a tertiary level. As a result, doctors may not fully understand that their documentation has many uses that extend well beyond patient care. CDI education could facilitate doctors’ appreciation of why and how their documentation affects patient outcomes, reimbursement, casemix index, resource planning, decision making, clinical indicators, and benchmarking, just to name a few. When clinicians are better informed and realise the impact of changing the way they provide documentation, they are more likely to respond to CDI specialists and HIM and clinical coder queries. Towers (2013) suggested that the message to engage clinicians could be as simple as just informing them that CDI is a quality initiative. Patient complexity can also be used as an important driver to gain a doctor’s, other clinician’s, or a department’s commitment to CDI. If there is a perceived gap between the complexity of the patient’s treatment and what the casemix data reflect, then CDI could become the motivation to gain a doctor’s commitment to change the way the medical record is completed. Whatever the objective of adopting a CDI program, careful consideration needs to be given to clinician motivations for engagement as this is key to the success of the program. Each hospital has its own unique culture, resources, processes, and priorities and these factors all need to be taken into consideration to bring about the required change.

Recommendations for hospitals CDI is an important strategy that deserves increased consideration by hospital leadership. In a climate of increasing quality, patient safety, and reimbursement pressures, CDI programs aim to deliver more accurate data to help achieve operational, quality, and financial imperatives. CDI specialists, HIMs and CCs can all play an instrumental and important role in nurturing clinician engagement by providing continuous education on how and what to include in the documentation. In addition, concurrently reviewing the documentation for improvement ensures the medical record is complete, accurate, clear and appropriate for patient handover and clinical coding.

Understanding how the information in the medical record is consumed both inside and outside an organisation highlights the fact that CDI reduces hospital risk on many levels and also delivers multiple benefits that cannot easily be ignored. There is no doubt that the agenda to improve clinical documentation is one with a time-honoured vision. If CDI ensures quality data for better reporting, reimbursement, research, and provision of quality service, it should be every hospital’s foremost priority.

References (continued) Leventhal R (2014) Recognizing the value of clinical documentation improvement. Healthcare Informatics [online] Available at: <https://www.healthcare-informatics.com/article/ recognizing-value-clinical-documentation-improvement> [Accessed 30 November 2016]. Lo W (2014) Document like this, not that: CDI insights from the physician and CDI specialist perspective. Journal of AHIMA 85(7): 36-40. Mitchell B and Ferguson J (2016) The use of clinical coding data for the surveillance of healthcare-associated urinary tract infections in Australia. Infection, Disease & Health, 21(1): 32-35.

References

Moje C, Jackson T and McNair P (2006) Adverse events in Victorian admissions for elective surgery. Australian Health Review 30(3): 333.

Australian Commission on Safety and Quality in Health Care (ACSQHC) (2017a) National Safety and Quality Health Service standards, 2nd ed.) Sydney, NSW: ACSQHC.

Roughead E and Semple S (2009a) Medication safety in acute care in Australia: Where are we now? Part 1: A review of the extent and causes of medication problems 2002-2008. Australia and New Zealand Health Policy 6(1): 18.

Australian Commission on Safety and Quality in Health Care (ACSQHC) (2017b) Improving Documentation at Transitions of Care for Complex Patients. Sydney, NSW: ACSQHC [pp.3, 26]. Australian Commission on Safety and Quality in Health Care (ACSQHC) (2015) National core, hospital based outcome indicator specification. Sydney, NSW. ACSQHC. Australian Commission on Safety and Quality in Health Care (ACSQHC) (2012, October) Safety and Quality Improvement Guide Standard 6, Clinical Handover. Sydney, NSW; ACSQHC. Buttner P, Comfort A, Devrick J, Endicott M, Kohn D, Lo W, Ward M, Wiedemann L and Zender A (2014) Leading the documentation journey: A report from the AHIMA 2014 Clinical Documentation Improvement Summit. Perspectives in Health Information Management (Fall Issue). Available at: http://perspectives.ahima. org/leading-the-documentation-journey-a-report-from-theahima-2014-clinical-documentation-improvement-summit/#. VE_gzWeCM40 (accessed 23 May 2019). Chavis S (2009). Take documentation out of the dark. For the Record, [online] 21(6): 10. Available at: <http://www. fortherecordmag.com/archives/ftr_031609p10.shtml> [Accessed 27 Nov. 2015]. Cheng P, Gilchrist A, Robinson K, and Paul L (2009) The risk and consequences of clinical miscoding due to inadequate medical documentation: A case study of the impact on health services funding. Health Information Management Journal 38(1): 35-46. Das A, Kennedy K, Spyropoulos G and Collignon P (2016) Administrative data has poor accuracy for surveillance of Staphylococcus aureus bacteraemia. Infection, Disease & Health 21(4): 162-168. Devkaran S and O’Farrell P (2014) The impact of hospital accreditation on clinical documentation compliance: A life cycle explanation using interrupted time series analysis. BMJ Open, [online] 4(8): e005240-e005240. Available at: <http://bmjopen.bmj. com/content/4/8/e005240> [Accessed June, 2017].

Roughead E and Semple S (2009b) Medication safety in acute care in Australia: Where are we now? Part 2: A review of strategies and activities for improving medication safety 2002-2008. Australia and New Zealand Health Policy 6(1): 24. Towers A (2013) Clinical documentation improvement - a physician perspective: Insider tips for getting physician participation in CDI programs. Journal of AHIMA 84(7): 34-41. Wilson L (2009) The impact of a clinical documentation improvement program. Indiana University, USA: Master of Science in Health Informatics.

Kathy Wilton BHIM Clinical and Documentation Manager 3M Health Information Systems Building 2, 540 Springvale Rd, Glen Waverley, Victoria. 3150 Email: kwwilton@mmm.com Patricia Hay BCom 3M Health Information Systems Jennifer Barker BHIM 3M Health Information Systems Julie Mortley RN 3M Health Information Systems Megan Cumerlato B Sc (HIM) Health Information Management Consultant

Independent Hospital Pricing Authority (IHPA) (2017) National efficient price determination 2017-18. Sydney, NSW: IHPA. Independent Hospital Pricing Authority (IHPA) (2011) Activity based funding for Australian public hospitals: Towards a Pricing Framework. Sydney, NSW: Health Policy Solutions. Lamb S and Henry R (2004) Paracetamol pro re data orders: An audit. Journal of Paediatrics and Child Health, 40(4): 213-216.

This article was originally published in the Health Information Management Journal in volume 49, issue 1, 2020. It has been republished here with permission.

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A special year for health information management awareness in 2019 Milla Krivozhnya, Sadiya Askar, Terri Fiorenza, Kara Pollard, Melinda Scott

Health Information Management Awareness Week Milla Krivozhnya Health Information Management Awareness Week turned into the Health Information Management Awareness Month in 2019 as the Health Information Management Association of Australia (HIMAA) celebrated the 70 year anniversary of the profession. For the whole month of May our members were busy organising branch events and celebrations, lobby displays, Health Information Services (HIS) department tours and social functions, and making headlines in their health organisations’ newsletters.

of health services to recognise the worth of HIMs was identified as a priority for HIMAA’s Strategic Plan. This innovative idea to promote the profession through the annual Health Information Management Awareness Week has taken our members to the next level. The enthusiasm of the profession to be involved in one way or another is indicative of the right approach we have chosen for our self-promotion. As part of the strategy, HIMAA developed a Positioning and Advocacy Tool Kit, which is a collection of hints on how you can communicate the strengths and value of the HIM profession within your organisation. HIMAA National Office also supports all participants by providing Health Information Management Awareness Week Posters, suggested events lists, and merchandise that can be used as gifts and prizes. During the Health Information Management Awareness Month in 2019 our members showed us how innovative they could be, from posters to cakes, professional development days, meetings, open days and much more. HIMAA has been completely overwhelmed by the efforts of our participating members from both the public and private sectors.

Health Information Management Awareness Week has been on HIMAA’s annual calendar since 2016 when, in my role as the Marketing and Events Manager, I proposed the initiative to the HIMAA Board. The idea was to honour and celebrate the health information management professionals and to raise awareness that Health Information Managers (HIMs) have the knowledge, skills and motivation to contribute to and improve the health care system in Australia, together with the health and wellness of the nation. Positioning and advocacy has been a very difficult thing for the profession for many years and the neglect 20 HIM-INTERCHANGE • Vol 10 No 1 2020 • ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

Jenny Gilder and Phyllis Watson

Following are some of the events that took place in 2019, shared by active supporters of Health Information Management Awareness Month.

La Trobe University Health Information Management Student Association, Victoria Sadiya Askar The La Trobe University Health Information Management Student Association (HIMSA) organised an aerial photograph of the La Trobe health information management students and health information management academic staff forming the letters H I M on campus grounds. This event brought together health information management students from first year to final year along with the postgraduate students. Students who were passing by from other disciplines, such as biomedicine and physiotherapy, also happily joined in. The idea for the aerial photograph came from Jenn Lee, one of the health information management academic staff at the university. As a student association, it has been a great help to have the support of the academic staff, and the HIMSA executive team truly appreciate their advice and encouragement. The assistance from HIMAA allowed the event to be a great success, with the association providing of a number of goodies, such as t-shirts, pens and other merchandise to attract students to participate in the event.

The event was a great opportunity for the health information management students to meet and interact with each other, as they would not normally cross paths. I had the chance to speak with first year students who had chosen this degree, but were unsure about what was in store for them as they progressed through the course. As a final year student I was able to explain how professional placements in second, third and final year really help solidify the theory we learn to practice and enables you to develop a deep appreciation and passion for the industry. Health information management students who raised awareness of our profession to other disciplines enabled the health information management course to be acknowledged by non- health information management La Trobe students. Even if we did not convince them to enrol in the health information management course, at least we hope we made the clinical students aware of their clinical documentation practices and non-clinical students aware of the impact HIMs have within the health industry.

Central Coast Local Health District, New South Wales Kara Pollard Central Coast Local Health District celebrated Health Information Management Awareness Month with department open days on 22 and 23 May 2019. We focussed on the theme ‘Health Records through the Ages’ and displayed the different ways that medical records have been stored, back to the 1950s. All the staff enjoyed the day and we celebrated the great work done by all our HIS staff with a team lunch at each site.

Students at La Trobe University It was a great experience to get the health information management academic staff and health information management students together to share health information management experiences and participate in an event that essentially was just a simple photograph. It truly showcased the warm, inclusive and supportive nature of our profession as all involved enjoyed connecting with each other and working towards raising awareness of our industry.

Health Information Service Open Day at Central Coast Local Health District This is our third year running open days for Health Information Management Awareness Week, and staff really love the opportunity to show the rest of the hospital what they do and the variety of roles in the HIS department.

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Northern Health, Victoria Terri Fiorenza This year Northern Health held a morning tea in celebration of HIMs. An article was also written for the organisation’s iNews on the roles, responsibilities and achievements of HIMs. Health Information Management and Privacy Awareness Event at the Prince Charles Hospital

Health Information Management Awareness Week 2020

Morning Tea at Northern Health The Health Information Management Awareness event is a good initiative and it’s great for this to continue annually. It’s important to acknowledge the health information management profession in particular within health services, and it is a good opportunity for HIMs to promote the important work they do within their organisations. As a suggestion for future years, it would be great for social gatherings to be coordinated at a state level during Health Information Management Awareness Week in celebration of HIMs.

The Prince Charles Hospital, Queensland Melinda Scott The Prince Charles Hospital HIS team had lots of fun participating in Health Information Management Awareness Month and Privacy Awareness Week in May 2019. We partnered with the Office of the Information Commissioner to raise awareness about privacy and promote the important work that HIS undertakes. Living in the basement, next to the mortuary and kitchen, it was a great opportunity to get out and about and host a booth in the hospital canteen and hand out information sheets and goodies to interested staff, patients and visitors. As part of the week our HIMs also undertook a privacy audit across the clinical areas of the hospital. The team felt that it was very worthwhile participating in the Health Information Management Awareness Month as it was a great opportunity to promote our speciality services that embrace the overall commitment to the management and provision of quality patient information.

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The Health Information Management Awareness Week is back in 2020 and will be held as usual during the third week of May (11-17 May 2020) – so save the date! HIMAA welcomes all previous participants back and encourages everyone else to contribute by spreading the word about the profession. To order a promotion pack please contact HIMAA Events Team at events@himaa.org.au. Together we are stronger in actively promoting the profession that is at the heart of the health care system. Milla Krivozhnya BSBM Marketing and Events Manager Health Information Association of Australia North Ryde NSW 1670 Tel: 61 2 9887 5821 Email: millak@himaa.org.au Sadiya Askar BHlthSc, BHlthInfoMan Past President (2019), Health Information Management Student Association (HIMSA) La Trobe University Bundoora Vic 3086 Terri Fiorenza BHIM, GDipHlthInformatics Director, Health Information Services Northern Health Epping Vic 3076 Kara Pollard B.Hlth Sci (HIM), CHIM A/ District Health Information Manager, Health Information Services Central Coast Local Health District Gosford NSW 2250 Melinda Scott BBus (HIM), CHIA Director, Clinical Health Information Services The Prince Charles Hospital Chermside Qld 4032

Managing health information in Cambodia: exchanging skills in a challenging environment Julie Wilson

Introduction On a dull and cold Friday afternoon in August 2010 at the end of a busy but uneventful week, my colleague Jane and I were lamenting our feeling of doing a good job but not really feeling as though we’d ‘made a difference’. So, as we did on so many other Friday afternoons, we jumped onto the Health Information Management Association of Australia (HIMAA) website to check the job vacancies. Jane jokingly said, ‘Oh here’s a good one for you Jules, they’re looking for a Health Information Manager in Cambodia’. I laughed it off but was immediately intrigued and couldn’t wait to get home to check it out. By the time my husband arrived home, I was convinced that I really wanted, but more needed, to do this job.

unable to refuse my request but, for whatever reason, he agreed and was very supportive. When I told my staff, Jane was absolutely flawed and couldn’t believe that I had been quietly plotting since she first saw the advertisement several months earlier. I was feeling quite confident with my newly acquired knowledge but there was a lot to learn about Cambodia and even more to learn about CSC; I was off on a very steep learning curve.

What I learned about Cambodia It has a population of approximately 16 million people, mostly following Buddhist beliefs. Khmer Traditional Medicine is still widely practised especially in the more remote provinces, where Western medicine has been slower to infiltrate.

Many of us put things on hold while pursuing a career or raising a family and too many of us leave it so long that we either have a new set of commitments with ageing parents, or suffer our own health problems. It all gets too hard and there never seems to be a ‘right time’. So, with an eye on my ever-shrinking window of opportunity, and with my husband’s blessing, I started the application process for a three to six-month voluntary placement with Australian Business Volunteers (ABV), at the time funded by the Department of Foreign Affairs and Trade, to work at the Children’s Surgical Centre (CSC) in Phnom Penh. After passing the first stage of the application process, I began the very comprehensive and interesting online learning which covered cultural awareness and skills exchange. At the end of this stage, there was an assessment, which I passed, then a face to face interview. In December, I finally received the good news that I was the successful applicant. At the time I was the Manager of Health Information Services at Geelong Private Hospital and hoped that our General Manager would agree to me taking a few months’ leave. I like to think that my enthusiasm and determination were so persuasive that he was

Cambodian monks Cambodians mostly speak Khmer, with older Cambodians also speaking French and younger people now learning English at school. Once I arrived in Cambodia, I was determined to learn more Khmer so I could converse with my colleagues and the locals but it didn’t take long to realise that the neighbourhood kids were mostly teaching me swear words. 23 HIM-INTERCHANGE • Vol 10 No 1 2020 • ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

The weather is either hot and wet or very hot and very wet. Between 1975 and 1979 around two million people were killed under the Pol Pot regime and many more died from starvation and disease. Those with an education were particularly targeted and executed teachers, doctors, engineers. Many people were displaced, families separated and social structures were destroyed. Corruption became a way to survive and it is still a huge problem. During several conflicts, around 8-10 million landmines were laid in Cambodia and, despite extensive clearing programs, it is still one of the most landmine impacted countries in the world. By 1979 there were only 45 medical doctors for the 5 million people who survived. Consequently, the health system is still rebuilding.

What I learned about Children’s Surgical Centre CSC was set up by a British-American orthopaedic surgeon, Dr. Jim Gollogly, in 1998, originally to treat children with land mine injuries, post treatment for their acute injury. CSC is run totally by donations, with Australia being a huge supporter, both individually and on a corporate level. Most patients are poor Cambodians from rural villages with little or no formal education and many patients travel a long distance to be treated. All the care is free, including three meals a day for the patient and one carer. CSC has only Khmer medical and nursing staff, apart from Dr Jim. Specialist surgical teams from all over the world, including Australia, regularly visit to volunteer their time to treat patients with very complex and rare problems. There is a requirement that the foreign surgeons can only operate alongside Khmer surgeons so skills can be exchanged and the surgical skills of the Khmer surgeons are constantly improving.

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Congenital malformation As the incidence of land mine injuries has decreased, CSC now treats patients from 1 month old to over 90 years of age, with a wide range of post traumatic conditions, disabilities and congenital malformations and the numbers just keep increasing. Table 1: Number of operations and consultations at CSC 1998

2011

2015

2018

OPERATIONS

273

3567

4464

3921

CONSULTATIONS

2110

11840

24583

35202

Assignment Description

My assignment description was as follows: ‘It is hoped the volunteer will work alongside local counterparts to update CSC’s current medical record keeping system and develop a modern, practical, information technology (IT) based medical record system. It is expected the volunteer will engage in mutual skill transfer in order to build the capacity of local staff to effectively utilise and maintain the record keeping system’. Sounds simple enough, or so I thought! In 2011, I arrived in Phnom Penh, having never travelled to South East Asia before. My first day at CSC was quite confronting due to the sheer number of patients waiting to be seen in a seemingly chaotic, hot and crowded work environment. I would later realise that what seemed like chaos was perhaps the only way to provide care for so many patients and many of my Western ideas had no place in Cambodia.

Consultations

Patient database Working alongside my Cambodian colleagues, we reviewed the quality of patient data, such as the consultation notes made each time a patient attends CSC, and found it was often missing or lacking accuracy and detail. This posed a big problem for ongoing patient care, particularly when overseas specialists are consulted. We formulated a plan to: 1. Ensure all clinical care is documented. 2. Improve the quality of clinical documentation. We started with operation reports, as there was already a logical, simple template in place which just needed to be followed.

Waiting area I set about carefully observing people and documenting processes and I knew it would be important to find my key allies. I found the record keeping at CSC was basically sound and workable within the given conditions and the IT skills of the staff were most impressive. As with many of us, their main problem was their daily work schedule was so busy it didn’t leave much time for analysing what was working and how things could be changed to improve processes and efficiencies. I would be the fresh set of eyes to help them reach their objectives.

On day one, we found a 32% completion rate. We conducted an education session with the surgeons which increased the completion rate to 65% over the following few weeks, then our progress stalled. I discussed our lack of progress with Dr Jim who assured me he could improve on this with what he described as a very effective effective strategy he would dock the surgeons’ pay for every operation report not completed. Suffice it to say, the following week the completion rate had increased to 99% within 24 hours and 100% within 2 days. The good news was that no one had had their pay docked, just the threat of doing so was enough. In a nod to skills exchange, I wondered whether this was an idea I could take back to Australia with me?

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Other tasks

Assignment reporting and assessment

In addition to reviewing patient data, we completed an organisational restructure of the support staff to establish lines of authority and reporting and to provide an opportunity for promotion, with the intention of improving job satisfaction and staff retention. Som Chan Diman was identified as the Head of Patient Information as he already performed this role most capably. Formalising his position enabled him to manage staff with the authority to monitor performance and ensure compliance and accountability. It also provided him with a pay rate commensurate with his key role.

At the end of my placement, all stakeholders declared the assignment had been successful. We were able to complete all tasks identified in the revised assignment description, and some extra tasks as well, and we had made valuable professional connections.

We reviewed and documented processes and procedures to clarify task allocation, create accountability and assist with training. We recruited and trained new staff which allowed us to address the backlog of data entry and filing of patient notes, to cull old medical records and review and update medical record forms. I found the physical work environment was contributing to inefficiencies. For example, Diman was sitting at a desk on a chair propped up by a rock and he was constantly using a paper clip to release sticking keys on his keyboard. When I asked him whether he had asked for a new chair or a new keyboard he said ‘No, we need all our money for the patients, it’s no problem’. I explained that, in my opinion, his workplace safety was important and that he could provide a more efficient service if his equipment was in good condition. He reluctantly agreed to let me ask Dr Jim for a new chair and keyboard, which were promptly ordered and delivered, much to Diman’s delight, and mine.

Diman and his new chair

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I have returned to CSC most years since 2011, independent of ABV, to review the previous year’s projects and to assist with new projects and further changes. I’m always heartened to see the initial changes to processes still being followed and that further improvements have been made as part of an ongoing quality improvement program.

Some of the additional projects since 2011 Consultation notes There are often six or more doctors consulting with patients each day for either initial consultations or post-surgical follow up. The doctors were handwriting consultation notes which needed to be transcribed onto the patient data base, resulting in transcription errors and a backlog of notes to be transcribed. We devised a plan to have the doctors enter their notes directly onto the patient database using laptops donated by South Melbourne Rotary Club. We designed portable laptop trolleys and had the CSC Building and Maintenance staff construct them. We ran an education program for the doctors with the new system being generally well received and followed. The doctors realised that it’s usually quicker to type than handwrite, there are no transcriptions errors, no backlog and the notes are immediately available for ongoing patient care.

Laptop notes

Anaesthetic Syringe Labels During one of my visits, the anaesthetists expressed their concern regarding the poor labelling of anaesthetic syringes and identified this as a potential clinical risk. I investigated the universal colour coded standard labelling system for drugs and was able to arrange purchase of the labels from Australia. It is generally not advisable to post or freight goods to Cambodia as often goods ‘go missing’ or customs officials demand huge bribes to release the goods, so I organised the delivery of the labels in person by a group of students from a high school near me, who were travelling to Cambodia. While talking to my family members about CSC, my aunt kindly offered to support the supply of anaesthetic labels with an ongoing donation to cover the costs. Watsi Watsi is a United States based organisation crowd funding surgical procedures for patients in developing countries. Their strict criteria include requirements that the procedures must be low cost, have a big impact and a high rate of success. Additionally, any organisation they support must be financially sustainable and transparent. Watsi assessed CSC as meeting their criteria and offered ongoing funding through online donations. Initially patients were interviewed, and a report was hand written, later transcribed and uploaded to the Watsi website with the patient’s photo. It soon became apparent that it was quite time consuming to keep up with reporting to potential donors in order to maximise this revenue. To address this, we identified the staff most proficient in English, developed a template and trained staff in interviewing patients to ensure that reporting requirements for Watsi were met. With the patients’ consent, photos and information were then entered directly onto laptops and uploaded, allowing many more surgeries to be funded. If you’re interested, take a look at the Watsi website (https://watsi.org/) where you can donate as little as $5 toward life changing surgeries. All Cambodian patients on the website are from CSC so your donation will go towards helping CSC continue their vital work.

2016 visit – where to from here? By the time I visited CSC in 2016, I realised that I had reached the limit of what I could do from a health information management perspective. My Cambodian

colleagues had made many improvements to systems and processes and, while I could assist with further development of their future plans, I thought more specialist IT skills would be of more value. There are many opportunities for CSC’s medical and nursing staff to travel overseas to learn new skills but little opportunity for administrative and other staff. I tentatively suggested to Dr. Jim that we consider the possibility of my Cambodian colleagues coming to Australia to see how things are done here. He was incredibly enthusiastic and supportive, and we agreed that Som Chan Diman, Head of Patient Information, and Sok Menglong, Manager of Administration should make the trip. After a few months’ planning they arrived, and our health information management community came together to share their knowledge. At Barwon Health we looked at the scanned record, clinical documentation and processing of patients through the outpatient department. We spent a day at Deakin University Faculty of Health visiting virtual wards and methods for teaching nursing and medical students. At Melbourne University School of Medicine, we looked at online learning packages and at St John of God Hospital in Geelong we reviewed the scanned medical record, record forms, coding, admission process and environmental services.

Deakin University, Geelong 2017 We also spent some time immersing Diman and Menglong in our culture and lifestyle by travelling the Great Ocean Road, attending a play at the Geelong Performing Arts Centre, shopping and cooking together, including the delicious meal of the traditional Cambodian Beef Lok Lak they prepared, and meeting up with various friends and family members, intrigued and delighted to meet our international guests.

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Diman and Menglong benefitted enormously from their visit, taking back information on online learning packages and a better understanding of clinical documentation and processes. The entire time they were here I could see them carefully analysing and diligently trying to work out how they could replicate the things they had seen. Our Aussie beef is highly regarded in Cambodia and, with the help of their ex-pat friend, Lina, now living in Melbourne, they were able to cram a large amount of frozen beef into their suitcases.. They were so impressed with the cleanliness of our hospitals, they took back a microfibre mop and dusters, on the recommendation of Environmental Services staff. From all reports, once Diman and Menglong returned to CSC, they began implementing many of the ideas they had seen in Australia and, with their newly acquired skills and confidence, they became even more pivotal in the administration of CSC. While planning my visit to CSC in 2018, I began as usual with a discussion with Diman and Menglong. We would usually identify a small project we could work on or finish a previous project, but this time it was different. They assured me that their visit to Australia had provided them with a wealth of information and they were confident in their ability to maintain patient information and clinical documentation at a high standard. In effect I was no longer needed and, much like a mother whose child can now tie their own shoelaces, I was feeling a little superfluous but overwhelmingly proud and pleased to have been able to pass on my skills to my colleagues and support their further education.

During subsequent visits, the focus has been much less on work and more on socialising, attending weddings and festivals and just spending time with our wonderful Cambodian friends.

On Reflection When I reflect on my connection with CSC and Cambodia, I feel a sense of gratitude for the things I have and sometimes take for granted: • The opportunities I have because of my formal education • The choices I can make about where and how I use my skills • The generosity, friendship, mutual respect and admiration I have enjoyed with my Cambodian colleagues • Not fearing landmines when we farm our land, or our children go out to play • Having a relatively safe health care system available to all • Having workplace health and safety protections in place. I have been deeply affected and changed by my time working in Cambodia in so many ways: • I feel a deep commitment to living a bigger life with a smaller footprint • I believe small actions can have huge impacts • I see redundancy as a good thing and I’m proud to have passed on my skills to my colleagues at CSC to a point that they no longer require my guidance • I know I’m capable of things far greater than my formal training or my job description • I can survive, indeed thrive, outside of my comfort zone • Our community can be as big or as small as we want it to be, the main thing is to connect and to contribute to it.

Julie Wilson AssocDipMRA Health Information Manager St John of God Geelong Hospital and iMedX Australia Tel: +61 439 761 630 Email: toulies@hotmail.com Thearan’s wedding

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Year of a new graduate in the bush Alexandra Van Gemert

Traditionally, the first choice for most new graduates has been to obtain jobs in metropolitan hospitals. I can honestly say that my decision to go against convention and move over 1,000 kilometres away from home to rural New South Wales (NSW) to work as a regional Health Information Manager, has been an enriching and worthwhile experience. My position manages the Clinical Information Services across two activity-based funding sites, and four block funded health services, covering a population of roughly 80,000 residents. I thought I would share some of my experiences and challenges. Day one and we are off to the local pub for lunch with the General Manager, District Clinical Coding Manager and my team of six staff (Clerks and Clinical Coders). What a great way to meet some of the staff who have worked at the hospital for many years, some since they were teenagers, and have a wealth of knowledge. The hospital is their home. As they share their experiences and stories, I begin to reflect on what lies ahead, having already seen records piled on the floor and shelving exploding out the door. After being thrown into presenting at the Junior Medical Officers Orientation during my first few weeks, I started to feel much more confident and settled having met the other new kids on the block. My mission was to ensure they all know where the medical record department is located within the hospital and to encourage them to become frequent visitors, even using our 9am coffee runs from the local cafe as a potential lure. Of course, only for work related purposes and to assist with discharge summary completion and clinical coding queries. The presentation went well, although more of a practice run for future sessions. I am pleased to say the content has since improved, now that I have a better

understanding of the expectations of doctors and their knowledge on clinical coding and documentation. A month in and thinking I am on track having successfully streamlined and updated some of the old processes, I am greeted by our local police. There has been an unfortunate death on the operating table in theatre and I am confronted by the detectives, carrying out a patient’s original hardcopy medical record bagged up as evidence. Hospital security are called, and I intercept this. Not only are they taking hospital property off site, they haven’t even bothered with any paperwork or official court order to seek release of the information to them. The detectives proceed to make numerous calls to our local court but of course it is lunch break and phone lines are shut. An hour is too long for them to wait around, so the detectives are back upstairs with the intention of taping off the operating theatres as a ‘crime scene’ until the medical records are released to them. ‘Crime scene’ – was there a murder? No one told me. You can imagine the adrenaline rush. I can confidently say my expectations are now very clearly known to the local police, including the chief superintendent, who made a special visit the following day to hand over necessary paperwork. Following this incident, all staff involved and nurse managers were debriefed to ensure a similar situation did not happen in the future. The meeting included some education regarding privacy and release of information, with reference to district and NSW Health policies and procedures. All hospitals have those ‘big dreamer’ medical consultants who want everything. I have never come across one as enthusiastic as our own, who expressed to me his dreams of developing an electronic health record that charts observations electronically and automatically triggers rapid responses. Highly

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advanced for our little site, but when the consultant states he would be happy to go to Harvey Norman and buy all the equipment to build it, you know he is being serious! Space and storage issues appear to be never ending for most health services that are still utilising paper medical records. After realising the hospital had not culled a medical record for at least 10 years, the implementation of a culling program presented as top priority. The lack of culling is largely due to the hold on destruction during the Royal Commission into Institutional Sexual Abuse in NSW. Challenge in this project includes identifying records that are dating back to a last attendance in 1975 and are pre the current patient master index (PMI), so you cannot look them up anyway. The frustration then of course comes to sourcing additional staffing to complete the project. For context, it is estimated there are over 80,000 records stored onsite for a 100 bed hospital, excluding those pre current PMI. Roughly 9,000 new records are created each year made up of new patients or volumes. The next project was to set up a record barcoding system at one of the smaller sites that currently use tracer cards to track records. Having never heard of a tracer card, I knew this task was going to be a challenge. It was a matter of setting up the technology, training staff to use other areas of the patient administration system and some change management, all fundamentals to implementing an electronic medical record, such as our ‘big dreamer’ medical consultant’s idea. Working in a regional area with limited resources can be challenging and difficult. Some days I experience firsthand the frustrations of doctors and nurses, with medical records being thrown at my feet, complaints about the new electronic medication system and clinicians wanting information to be entered for them or charts printed off to avoid using the electronic system. Other days I was able to scrub up and go into theatre to observe some exciting procedure being undertaken or join ward rounds with the doctors to assist with ‘live documentation’.

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At times it has been daunting; trying to explain to executive why we need to purchase the new clinical coding books for 11th Edition as a backup reference or why there may be a potential drop in National Weighted Activity Units as a result of the new Australian Coding Standard 0002 Additional diagnoses. However, it is most satisfying when you gain the respect of staff and become supported and viewed as an expert in your field. I would encourage all new graduates to consider rural and regional opportunities. The unique experiences and broad skills that can be gained while increasing your confidence in your abilities, even after 12 months, will prepare you well for your future career. The country social life is also very different; quiz nights at the local pub, rodeos, country races, playing sport. All unique experiences of their own and great ways to meet the locals, who are even friendlier when they find out you aren’t a passing tourist.

all new graduates “ I wouldtoencourage consider rural and regional opportunities. ” I have thoroughly enjoyed the past 12 months in rural NSW. It has been a big learning curve and I am thankful to those who have provided support and mentoring along the way. My advice to any new graduate would be to take opportunities that offer a challenge and be flexible with the location, as this often leads to great experiences. You should never feel isolated, knowing our professional association Health Information Management Association of Australia is there to provide support with being able to meet and network with likeminded colleagues. Acknowledgements to La Trobe University for providing a solid grounding in health information management basics and to my District Coding Manager for her ongoing mentoring. Alexandra Van Gemert BHlthSc(MedClass), BHlthInfoMgt

Manager, Clinical Information Services; Tablelands Sector Email: Alexandra.VanGemert@health.nsw.gov.au

Maybe I’ll write to you from there: the journey of an undergraduate health information management student Sadiya Askar

For the past three years, I have been studying health information management at La Trobe University in Bundoora, Victoria. In December 2019, I graduated with a Bachelor of Health Sciences (Medical Classification)/ Bachelor of Health Information Management. This double degree course is a four-year undergraduate program which I joined after completing my Associate Degree in Health Sciences at RMIT University. Over those three years, along with many late nights, numerous assignments, and several stressful exams, I have had the opportunity to complete three professional placements, study abroad, be elected President of the Health Information Management Student Association (HIMSA) and last, but not least, made numerous lifelong friends and professional networks.

Professional placements My first placement was in a hospital with a paper-based medical record, my second in a hospital which used a hybrid medical record and my final placement involved the implementation of a new electronic clinical system, across several hospitals in Sydney, New South Wales, to replace paper medication charts with a fully functional electronic system. I was able to experience the full circle of records management, from paper to electronic, during my time as a student. My first professional exposure to the health information industry was from my first placement in second year. Here I learnt the basics of medical records management within a hospital where I first used a patient administration system and filed paper medical records (by terminal digit filing). This placement provided me with the foundation of hospital workflows from admission to discharge and solidified my learnings from university.

For my second professional placement, I was placed within the Clinical Information Systems Support Team within a large public hospital. I was involved in a project where I migrated test plans from a word document to an electronic testing system, while simultaneously running the test scenarios on the scanned medical record information system itself. This task was initially very daunting as I had no experience in conducting systems testing, leading me to question whether I would be able to complete the task independently. However, I approached the experience with an open-mind and took on the challenge, as any health information management student would, and completed the task to a high level, which surprised my placement supervisor. This placement experience sparked a deeper appreciation of the health information management industry. I had this ‘light bulb’ moment where I was extremely proud and excited about my choice of career. Final year placement projects are 11 weeks long and take place in second semester of fourth year. I took myself out of my comfort zone and requested to go interstate for three months so I could experience the health information management profession outside of Victoria. The placement project assigned to me involved the implementation of a new hospital clinical system, which was an additional module to the existing electronic medical record within the organisation. My tasks revolved around change management, project management and staff training. Throughout the placement project, my project team and I faced many unforeseeable challenges, as expected with any largescale electronic medical record project. I was able to apply my education, knowledge and skills to real-world situations and overcome the challenges and difficulties that arose, enabling me to be a key member of the project team, even as a student.

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This placement made me realise that the La Trobe health information management course had well and truly equipped me with all the necessary tools and skills I needed to excel in assigned tasks during this project. Furthermore, this gave me confidence that my learning will be applied to my future health information management career. As part of the final placement project, students deliver a 20 minute presentation about the activities and tasks they engaged in during their respective projects, which mimics a real-life professional conference. Out of the 32 students presenting, I was the only one who went interstate and worked on the implementation of an entirely new electronic system. As a bonus, I was a recipient of one of three best speaker awards.

International study I wanted to seize every possible experience I could during my time at university (before the reality of the real-world hit me!), so why not go abroad? After consulting with my course coordinator, and due to my previous high academic performance, I was able to partake in an international study experience. I attended the Copenhagen Business School in Copenhagen, Denmark, during the semester break between June to August 2018. I studied Change Management and The Values-Driven Organisation, which I believe is vital within the health information industry as change is ever-occurring. The course covered the frameworks and principles surrounding value-based leadership, organisational change and resistance to change, and provided students with skills and strategies to become change agents within a business environment. I was among 44 undergraduate and postgraduate students from various parts of the world and differing academic disciplines. Interestingly, I found myself being the only one from a health information management background, allowing me to bring a different and unique perspective to class discussions and group-work. Living and studying in Copenhagen for eight weeks was an amazing experience which I will never forget. Denmark is such a beautiful and serene country – well deserving of its title; ‘Happiest Country in the World’. The lessons and skills I learnt on my exchange assisted me during my final year placement in Sydney, where the organisation was undergoing massive change. I know I will continue to re-visit these lessons throughout my future career as the health information management industry continues to change. 32 HIM-INTERCHANGE • Vol 10 No 1 2020 • ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

Leadership I have always had a passion for leadership and mentorship. My strong communication skills and the ability to build rapport easily, has drawn me to various leadership and mentorship roles. I was a Global Peer Advisor for La Trobe International, mentoring international students to settle into university life in Australia, along with providing advice and support for local students looking to study abroad. In 2019, I had the honour to be elected as President of HIMSA. My vision was for health information management students to be better connected and provide opportunities for students to engage in more than just their academic studies while at university. The HIMSA Executive Team and I (all very talented and passionate) aimed to build a stronger health information management community within La Trobe University, enabling students to connect with each other across all year levels, form long lasting friendships and make industry connections. In 2019, HIMSA organised multiple study sessions, an industry professional guest speaker and a health information management awareness event. We represented La Trobe health information management students at the 2019 Health Information Management Association of Australia (HIMAA) and National Centre for Classification in Health (NCCH) National Conference and established a link with HIMAA (which helped the student association grow). We also organised social events such as a pizza night and an end of exams event for both academic staff and students to enjoy after the stresses of exams. Leading and organising a student association was a great experience and has improved my connection with all current La Trobe health information management students. It also provided me with many opportunities to network with industry professionals and meet previous HIMSA executive members. Through my Presidency, I have been involved with the health information management industry and recognised as a leader among my peers. My involvement with HIMSA has provided me with amazing opportunities; I was a guest speaker at industry events, attended the HIMAA NCCH National Conference and I am now actively part of industry committees and special interest groups.

Future direction Over the past three years, I have developed a deep appreciation and passion for our industry. I have had the best university experience while completing the health information management course at La Trobe University. I have grown so much, learnt so much, experienced so much and to think it is only the beginning of my journey as a health information manager. The support, encouragement and guidance from the La Trobe health information management academic staff have shaped me into the person I am today. They have truly inspired me and made me fall in love with this profession. I will continue developing my leadership and mentoring skills after my graduation as I value these aspects of my character most. I will actively seek opportunities throughout my future career which allow me to engage with the health information management community as a leader in order to continue spreading awareness of our underappreciated profession. I hope to spark this passion in the next generation of students. I want to work in dynamic and challenging projects and roles like that of my final placement and be at the forefront

of our industry. I will continue to seize opportunities to work interstate or internationally; possibly even one day work in Copenhagen, where I studied. The World Health Organization headquarters for the European region is in Denmark… maybe I’ll write to you from there.

I want to work in dynamic and “ challenging projects and roles like that of my final placement and be at the forefront of our industry.

”

Sadiya Askar Fourth Year Health Information Management student La Trobe University (graduating 2019) Email: sadiya.askar12@hotmail.com

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Life behind the pages of HIM-Interchange Naomi Johnson, Danica Jong, Carol Loggie, Nina Palibrk, Dwayne Richards, Stella Rowlands

The HIM-Interchange Subcommittee The HIM-Interchange Subcommittee was formed in 2015, with the primary responsibility at that time being the co-opting of articles to fill the pages of HIM-Interchange. Today the role of co-opting articles remains a key responsibility of the members, however the scope has been extended to include the mentoring of authors and the end-to-end functions associated with the publication of the journal. The subcommittee members are responsible for reviewing all articles for compliance with the editorial standards of HIM-Interchange. This process involves the review by the author’s mentor, followed by a second review by another member of the subcommittee, with the final review by the editor. Maintaining the professional standard of the health information management profession underpins this process that can sometimes involve a back and forth with the author. This process is undertaken respectfully recognising that the authors are frequently tapped on the shoulder to write for HIM-Interchange. In turn each article must be proof read. The process of liaising with the typesetter and development of the journal format is the responsibility of the editor. The editor is also responsible for the writing of the editorial that pulls the content of the issue together. Finally, the Health Information Management Association of Australia (HIMAA) office completes the printing of HIM-Interchange and the online publication. In between getting the journal out, the subcommittee is considering the HIMAA members and ensuring that the journal has street appeal to ensure that HIMInterchange is read and not filed. In 2018 the artwork on the cover of HIM-Interchange was updated. Do you like the new cover? The subcommittee has also reviewed the HIM-Interchange webpages and have developed a proposal for HIM-Interchange to be online only. The collective brains of the subcommittee members, and their individual professional network is the

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genesis of most articles. However, occasionally we are delighted to receive an out of the blue email from a HIMAA member indicating they would be interested in writing an article. It goes without saying that we never refuse a budding writer. The HIM-Interchange Subcommittee are members of HIMAA who are committed to the advancement of the profession through the publication of HIMInterchange. Given the size of the profession it is truly amazing that we can produce not one but two journals. The Health Information Management Journal (HIMJ) is a peer-reviewed journal publishing primarily research within the field of health information management. HIM-Interchange is a journal for the people, that being you, we encourage you to support the health information management profession by reading HIM-Interchange, volunteering to write for HIM-Interchange, providing feedback and promoting HIM-Interchange and individual articles through your networks. Finally, there is really no limit to the number of members of the HIM-Interchange Subcommittee. The following are thoughts from the members of the subcommittee that we hope will inspire you to join the subcommittee or write an article. Happy reading!

HIM-Interchange Subcommittee “ The are members of HIMAA who are committed to the advancement of the profession through the publication of HIMInterchange.

”

Why did you join the HIM-Interchange Subcommittee? Dwayne Richards: As a member of the health information management profession a resource such as HIM-Interchange, where learnings and professional practise experiences can be shared, is highly valuable. I believe that it is important that Health Information Managers (HIMs) have somewhere to showcase the

work, experience and skills they are developing to the wider profession so that others may benefit, with readers potentially finding things they can add to their own toolsets as health information management professionals. Our roles in the health information management profession are highly varied and what better way to support communication and awareness on the different types of work being undertaken, and the different skillsets we have than through our professional practice journal. On a personal level, I was seeking to further develop my writing and editing skills and found joining the HIM-Interchange Subcommittee an excellent avenue to combine this goal while also supporting an important resource for HIMs in Australia.

Looking back, you were recruited to the HIM-Interchange Subcommittee as new graduates. How has being a member of the subcommittee contributed to your professional development? Danica Jong: When I was first approached to join the HIM-Interchange Subcommittee, I saw it as an opportunity to become more actively involved and a way to advocate for the health information management profession. Joining the subcommittee as a new graduate helped me feel better connected to the profession of which I was now newly a part. The subcommittee is made up of members across the country with a wide variety of roles and levels of experience and this has helped to develop my network of colleagues from all over Australia. As a member of the subcommittee, I act as a mentor for potential authors of articles for HIM-Interchange. Through this, I have further opportunities to make connections and help share the stories, perspectives and insights from the wonderful work of health information management professionals. I’m also able to learn about the many different hats a health information management professional can wear as we hear about how health information management professionals are able to provide their expertise in so many ways and in many different roles. Finally, I’ve been able to learn about the editing process, from approaching potential authors through to final publication and everything in between, which has helped to keep my written communication skills intact post-graduation.

Nina Palibrk: Shortly after graduating from the health information management degree I was tapped on the shoulder by a HIM-Interchange Subcommittee member and asked if I would be interested in joining. I thought this would be a fantastic professional opportunity to broaden my exposure to the health information management profession and contribute to our profession’s literature. Being a member of the HIM-Interchange Subcommittee has allowed me to meet a range of health information management professionals from across Australia and learn about the many opportunities the profession offers. The subcommittee allowed me opportunities to engage with and support those interested in writing for the journal, which has contributed to my professional development in leadership and mentoring. Through the mentoring program you support authors to communicate their experiences and ideas to the broader health information management community. Through this role I am continuously learning and developing skills in journal publication, article writing and proof reading and continuously learning from the experiences and knowledge of others. This allows me to be informed and up-to-date with what is trending in the health information management profession and the broader health industry.

As a HIM working in South Australia (SA), with most of the profession working in Eastern Australia, what motivated you to join the subcommittee? Do you feel that your membership of the subcommittee has or will contribute to the profile of the profession in SA? Naomi Johnson: I was motivated to join the HIMInterchange Subcommittee as I wanted SA to have a presence on the journal and in the greater HIMAA community, as the concentration of HIMs in the current environment is very focused on the eastern states. In having a South Australian representative, my hope is to encourage more active and equal participation in national health information management activities and and support people to find their voice regarding issues about which they are passionate. There is so much happening in SA that could provide opportunities for discussion or research. Opening discussions, contributing to research

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and increasing engagement in the wider health community of SA would go a long way to raising the profile of the health information management profession.

What do you consider to be the greatest challenge associated for you as a member of the sub-committee? Carol Loggie: HIM-Interchange provides the opportunity for the profession to showcase the amazing work that is being accomplished in the very broad ranging and ever-changing world that is health information management. The major challenge as a member of the subcommittee is to encourage people to take up this opportunity and contribute an article for publication. As we all know, resources are tight, deadlines are ever looming, and we move on to the next big thing very quickly, but it is crucial that we take the time to share our experiences on a platform such as the HIM-Interchange, not only for the continuing development of the profession at large, but also for each of us as professionals navigating our way through such diverse and dynamic work environments.

Naomi Johnson BSc HIM, Certificate of External and Internal Clinical Coding Auditing

Clinical Coding Auditor/Educator; ACHA/ Healthscope SA Email: naomi.johnson.him@gmail.com Danica Jong BHlthInfoMgt Health Information Manager, West Moreton Health Email: Danica.Jong@health.qld.gov.au Carol Loggie AssocDip (MRA), GCertHlthServR&D Research Fellow, Australian Health Services Research Institute, University of Wollongong Email: cloggie@uow.edu.au Nina Palibrk BHSc (HIM), BHSc (Nutrition), CHIA HIM Lead, Royal Brisbane Women’s Hospital Email: Nina.Palibrk@health.qld.gov.au Dwayne Richards BSc (HIM), CHIM Project Lead – Electronic Records Management (Vitro), BreastScreen Victoria Branch Convenor, HIMAA Victorian Branch Committee Email: drichards@breastscreen.org.au Stella Rowlands PhD Health Information Manager, Sunshine Coast Hospital and Health Service Email: Stella.Rowlands@health.qld.gov.au

Cyberscience develops powerful and intuitive Clinical and Business Intelligence software. Cyberquery (CQ), our flagship product may be leveraged for many areas within your organisation, from improving internal operations, reducing costs and improving quality to network strategies of integrating care, peer benchmarking and population health management. Pymble Corporate Centre | Level 2, Building 2 | 20 Bridge Street | Pymble | New South Wales 2073 healthcarebi@cyberscience.com

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Report on the 19th World Congress of the International Federation of Health Information Management Associations Julie Price The 19th International Federation of Health Information Management Associations (IFHIMA) Congress was held in Dubai, United Arab Emirates from Sunday 17 to Thursday 21 November 2019, with the major theme being ‘empowering health information management professionals through a global voice’. The congress was hosted by the Saudi Health Information Management Association with many representative attendees from countries in the region as well as representatives from Australia, United States of America (USA), Canada, England, Korea, and Indonesia to name a few. On Sunday there was a series of pre-conference workshops that focussed on the congress topics of health information management, healthcare transformation, research, healthcare finance, value based healthcare, educating for the future, health information management survival, health informatics, digitisation of health, healthcare quality and patient safety, clinical coding, classification and terminologies and workforce development. Over the next three days there were many conjoint sessions on these topics and on the final day there was an International Classification of Diseases Eleventh Edition workshop, including some clinical coding activities as well as a hospital visit for some of the attendees. Our final evening in Dubai involved a four-wheel drive adventure in the desert, followed by camel rides, entertainment and dinner under the stars. Through the sessions I attended, the message I took away from the congress is that data quality should be at the centre of everything we do as health information management professionals. An editorial in the Health Information Management Journal of Australia by Kilkenny and Robinson (2018) entitled Data Quality: ‘Garbage in – garbage out’ reminds us of this point and with a focus on data analytics across many industries including health, data quality will become a focus for anyone trying to answer questions from their data.

There were many interesting and engaging presentations held throughout the congress. However, I wanted to highlight a couple of sessions that I found very engaging. The first one was on capacity building in countries that are not capturing cause of death certification. In thinking about this session, I asked myself ‘How could Health Information Managers (HIMs) get involved?’ as I have previously lectured on the death certification process. It dawned on me that the information from this certificate is vital in public health planning on a global level. As custodians of the data and with a focus on quality, HIMs should get involved, at least within the hospital context, so that we are always looking for ways to continuously improve the quality of the data used for so many purposes. For example, by developing a poster to assist clinicians with the certification process. The second session I want to highlight is clinical documentation improvement (CDI), an area of increasing interest in the Australian context. There were a number of excellent speakers during this session presenting on different aspects of CDI.

Cause of death certification – The ultimate morbidity statistics Dr Azza Badr from the World Health Organization presented an engaging session in the coding and classification session entitled ‘Importance of Mortality and Cause of Death Statistics’. This session on capacity building in countries with poor mortality data collection systems discussed a series of simple steps from death to documenting cause of death and underlying conditions, coding the documented causes, checking and validating data quality and then reporting. She reminded all member countries in the audience about the importance of collecting accurate mortality statistics she described as the ultimate ‘morbidity statistics’. Having, complete and accurate global statistics on mortality and the underlying causes are the foundation of public health interventions and health promotion activities. As described by Brooke et al. (2017), the ultimate public health interventions prevent the factors that lead to death. 37 HIM-INTERCHANGE • Vol 10 No 1 2020 • ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

Dr Badr presented a series of graphs to demonstrate the importance of mortality data. Examples included measuring the reduction in maternal mortality rates over the last 100 years and measuring health inequalities within a country such as average life expectancy to check for outliers. The data can then be analysed to identify factors leading to significantly lower life expectancy, and then look at trends between countries when public health interventions have been implemented. Examples of public health interventions include reduction in motor vehicle accidents from interventions such as mandatory wearing of seat belts and air bags. Mortality data can be used to assess the impact of natural and manmade disasters. The example used was a newspaper report of 64 deaths after a hurricane hit Puerto Rico, however more detailed analysis of mortality data in the following months suggested many thousands may have died due to delayed medical care. In an article for general practitioners on how to complete a death certificate, Bird (2011) describes the purpose of death certification as being for legal purposes; for statistical and public health purposes; and for family members to know what caused the death. The cause of death and underlying causes is auto coded by the Australian Bureau of Statistics (ABS), which is then used to produce Australia’s mortality statistics. These data are evaluated so that public health and health promotion interventions can be developed to improve overall health of Australians. When researching this topic I noted there were a number of articles describing inconsistencies in mortality data collections even from the auto-coded data (Bugeja et al. 2010; Churruca et al. 2016; Daking and Dodds 2007; Walker et al. 2008). I also found it interesting that across each state and territory there are differences, in the death certification form that the doctors complete and for coroners’ cases there are different practices in reporting cases where suicide is suspected (Walker et al. 2008). I wondered how HIMs could get involved in trying to improve these data. For HIMs that work in hospitals, is there any validation, checking or auditing of the completeness and quality of the certification against the guidelines provided by ABS (2008)?

Clinical documentation improvement – An emerging role for HIMs Another session I found interesting was on CDI, an emerging field in Australia and well established in the USA. A range of speakers provided similar messages to

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the audience about the steps to take when considering implementing a CDI program, including Laurie Prescott, Nicole Draper, Diann Smith, and Gwen Blough. Planning for CDI implementation When planning for CDI implementation, consider things such as: • Setting goals about why your hospital wants to implement CDI and align these with organisations strategic goals • Finding out where the gaps are by conducting a clinical documentation audit • Identify barriers (undertake strengths, weaknesses, opportunities, threats analysis) • Conducting a risk assessment on the risks of not implementing CDI, for example the risk of mortality • Identifying the scope of the program, for example, inpatient and emergency department • Identifying measures of success, which must align with the goals of the organisation • Developing metrics for quality measures, for example, - Patient safety indicators - Hospital acquired complications - All cause readmissions and potentially preventable readmissions - Severity of illness and risk of mortality measures - Present on admission status • Developing a framework governing the CDI program. How to engage with clinicians This is an area that is potentially the most difficult to implement, therefore needs planning, strategy, consistency and support from senior management as it involves cultural change management. Suggestions include: • Develop a framework for engaging with clinicians, using simple messages • Educate clinicians on documentation and get clinicians to educate HIMs and Clinical Coders about new procedures – lunch and learn sessions, webinars, podcasts, documentation tip cards – try to link it to continuing education scheme • Identify a clinician champion who supports CDI

• Develop a script to engage with them, pick a time when they are not busy, be friendly and confident, be seen and present, build relationships • Focus on all the uses of quality data (other than funding), for example, quality assurance, epidemiology, benchmarking, clinical research, government reporting, patient safety • Consider engagement strategies, such as education, awareness, accountability, reward • Look at technology options, for example, voice recognition, artificial intelligence. How do you measure success of the program? Finally, it is important to measure the success of your CDI program to demonstrate the benefits and the return on investment in resources. Strategies include: • Measuring the impact of the CDI program, for example, change in the Diagnosis Related Group causing increased reimbursement, improvements in hospital performance can lead to pay for performance payments, improvements in quality outcome scores for the organisation in areas such as hospital acquired complications and patient safety indicators, measuring patient outcomes (observed to expected ratio), capture of social determinants of health that informs potential readmission and mortality risks • Reducing the practice of ‘copy and paste’ in the electronic health record • Reporting on results, compare and share the analysis – graphs, tables, dashboards

As the next congress will be held in Brisbane in 2022, there is a great opportunity for more Australian HIMs and Clinical Coders to attend, participate and even think about presenting a paper. The sessions I attended were well received by the audience with opportunities to meet the presenters in the breakout sessions to exchange business cards for further collaboration and to discuss ideas.

References Australian Bureau of Statistics (ABS) (2008) Information Paper: Cause of Death Certification 2008. ABS Cat. No: 1205.0.55.001. Canberra: Australian Bureau of Statistics. Bird S (2011) How to complete a death certificate: A guide for GPs. Australian Family Physician 40: 446-449. Brooke HL, Talbäck M, Hörnblad J, Johansson LA, Ludvigsson JF, Druid H, Feychting M and Ljung R (2017) The Swedish cause of death register. European Journal of Epidemiology 32: 765-773. Bugeja L, Clapperton AJ, Killian JJ, Stephan KL and Ozanne-Smith J (2010) Reliability of ICD-10 external cause of death codes in the National Coroners Information System. Health Information Management Journal 39: 16-26. Churruca K, Draper B and Mitchell R (2016) Varying impact of comorbid conditions on self-harm resulting in mortality in Australia. Health Information Management Journal 47: 28-37. Daking L and Dodds L (2007) ICD-10 mortality coding and the NCIS: A comparative study. Health Information Management Journal 26: 11-22. Hay P, Wilton K, Barker J, Mortley J and Cumerlato M (2019) The importance of clinical documentation improvement for Australian hospitals. Health Information Management Journal 49: 69-73. Kilkenny MF and Robinson KM (2018) Data quality: ‘Garbage in garbage out’. Health Information Management Journal 47: 103-105. Krauss G (2019) When CDI fails: the unrelenting pursuit of reimbursement. ICD 10 Monitor.

• Evaluating the program through capture and measurement of key performance indicators.

Shepheard J (2018) What do we really want from clinical documentation improvement programs? Health Information Management Journal 47: 3-5.

The overall message from each speaker is to focus on the quality of the data within the medical record and the money will follow, a viewpoint support by Shepheard (2018). Hay et al. (2019) also recommended to hospitals in Australia that CDI will support communication and patient safety, surveillance and burden of disease reporting and hospital reimbursement and funding. They (Shepheard 2018, Hay et al. 2019) noted however that there were many challenges that hospitals would need to overcome to implement a successful CDI program. A prime focus on the funding has been shown to lead to the failure of the program (Krauss 2019).

Walker S, Chen L and Madden R (2008) Deaths due to suicide: the effects of certification and coding practices in Australia. Australian and New Zealand Journal of Public Health 32: 126-130.

Julie Price BHSc, BHlthInfoMan (Hons), Grad Cert E-Health, CHIM, CHIA

Casual Lecturer Health Information Management, Latrobe University Kingsbury Drive, Bundoora VIC 3086 Email: Julie.Price@latrobe.edu.au

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HIMAA International Special Interest Group: a community of practice empowering Health Information Managers with global voice Suzette Dela Cruz Regalo

Communities of practice Since the recognition of communities of practice (CoP) as a key concept in knowledge creation, acquisition and resource sharing, they have become increasingly popular, with a growing number of healthcare organisations investing in them to manage knowledge and improve performance. As a concept, CoP have featured in the academic discourse as early as the 1990s. The notion was developed by Lave and Wenger (1991 cited in Li et al. 2009a, p. 2), who defined CoP as ‘a group of people who decide to deepen their knowledge and expertise in an area by interacting on an ongoing basis’. As Bertone et al. (2013) indicated, this fundamental purpose of CoP has remained the same over time. They defined CoP as a group of like-minded individuals who interact regularly to deepen their knowledge on topics of collective interest (Bertone et al. 2013, p. 11). Underpinning CoP is the idea that learning can take place through social relationships, in addition to traditional acquisition of knowledge through books or in a formal learning environment (Lave and Wenger 1991 cited in Li et al. 2009a, p. 2). Furthermore, these social relationships are characterised by mutual respect and trust. The interactions can occur in voluntary informal networks, conferences or work-supported formal training meetings, wherever people come together to share and exchange ideas (Li et al. 2009a, p. 1). Given CoP can take shape anywhere and in any form, they facilitate the sharing of both explicit and implicit knowledge. There are many reasons that explain the increasing popularity of CoP. Woodgate et al. (2018) and Barnett et al. (2013), found that CoP help break down professional barriers by creating an environment for novices and

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experts to meet and interact on a regular basis in order to create and enhance their professional identities. Hoffman et al. (2011) suggested that because the informal nature of networks present many opportunities for peer-to-peer knowledge sharing, they enhance connectedness and sense of belonging among members. Last, a growing number of healthcare organisations invest in CoP because they improve organisational culture and promotes individuals’ personal and professional growth (Li et al. 2009b, p. 1).

International Special Interest Group The Health Information Management Association of Australia (HIMAA) International Special Interest Group (SIG) is an example of a CoP. The SIG is a constituent of the HIMAA National Board and is one of six special interest groups under the HIMAA umbrella. In the International SIG, members come together to celebrate and deepen their shared passion for contributing to the overall enhancement of the health information management profession, as well as in advancing the health information management profession in Australia and at an international level. Members collaborate, connect and engage with experts on health information related activities that are being undertaken internationally. The SIG has members who come from different parts of Australia, and different parts of the world. There are Australian Health Information Managers (HIMs) who work overseas, and culturally diverse HIMs who call Australia home. The International SIG works in collaboration with similar organisations within the Eastern Mediterranean and Western Pacific Region. More recently, the group has adopted a ‘transnational’ membership with the use of modern technology, welcoming members from New Zealand, Hong Kong, Qatar and Saudi Arabia. Page et al. (2019) advocate for

the use of technologies, such as videoconferencing, as it promotes attendance and involvement among members who could perceive distance as a barrier.

Activities of the International SIG The International SIG offers members with a wide range of activities that enable networking, informal mentoring, and the creation and sharing of knowledge. Activities include: • Sharing knowledge, personal and professional skills, expertise, experiences and lessons learned to other HIMAA members • Providing a platform for regular interaction, as well as sharing of international news, events and activities through a website • Providing opportunities for members to meet, connect and interact with one another through regular quarterly teleconference and videoconference meetings; • Promoting HIMAA credentials and certifications • In partnership with the National Board, promoting HIMAA’s role in the advancement of health information management in other countries in the Eastern Mediterranean and Western Pacific regions • Supporting HIMAA’s contribution to International Federation of Health Information Management Associations and other international organisations as appropriate. In summary, the HIMAA International SIG is a CoP that enhances the professional development of members, not only because it provides opportunities for networking and knowledge sharing, but because it also empowers HIMs with a global voice.

References Barnett S, Sandra C, Bennett S, Iverson D and Bonney A (2013) Usefulness of a virtual community of practice and web 2.0 tools for general practice training: Experiences and expectations of general practitioner registrars and supervisors. Australian Journal of Primary Health 19(4): 292-296. Bertone MP, Meessen B, Clarysse G, Hercot D, Kelly A, Kafando Y, Lange I, Pfaffmann J, Ridde V, Sieleunou I and Witter S (2013) Assessing communities of practice in health policy: A conceptual framework as a first step towards empirical research. Health Research Policy and Systems 11(39): 1-13. Hoffmann T, Desha L and Verrall K (2011) Evaluating an online occupational therapy community of practice and its role in supporting occupational therapy practice. Australian Occupational Therapy Journal 58(5): 337-345. Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC and Graham ID (2009a) Use of communities of practice in business and health care sectors: A systematic review. Implementation Science 4(27): 1-9. Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC and Graham ID (2009b) Evolution of Wenger’s concept of community of practice. Implementation Science 4(11): 1-8. Page R, Hynes F and Reed J (2019) Distance is not a barrier: The use of videoconferencing to develop a community of practice. Journal of Mental Health Training, Education & Practice 14(4): 12-19. Woodgate RL, Zurba M and Tennent P (2018) Advancing patient engagement: Youth and family participation in health research communities of practice. Research Involvement and Engagement 4(9): 1-6.

Suzette Dela Cruz Regalo RN, BSN, PgDip ICD, MHIM Principal Planning Officer, Health Sector Planning, Digital Health Department of Health and Human Services Melbourne VIC 3000 Tel: +61 3 9096 2106 Email. suzette.delacruzregalo@dhhs.vic.gov.au

To those who are interested in joining this vibrant and exciting Special Interest Group (SIG), please email the SIG Convenor, Suzette Dela Cruz Regalo at suzette.delacruzregalo@dhhs.vic.gov.au or interhimsig@himaa.org.au.

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Competencies Generic professional skills Communication skills; Organisation and engagement; Information communication technology (ICT) literacy and knowledge management skills; Teamwork – within the work unit and as part of a multidisciplinary team; Problem-solving and decision-making; Lifelong learning; Ethical behaviour; Social and cultural awareness. Health information and records management Health data and records; Healthcare information standards and governance Language of medicine Medical science; Medical vocabularies Healthcare terminologies and classification Code systems, clinical terminologies and classification such as ICD-10-AM, ACHI, DSM, SNOMED CT; Clinical coding; Casemix management and activity based funding methodologies Research methods Healthcare statistics and research Health services organisation and delivery Healthcare delivery systems; Quality and safety management and performance improvement management Health information law and ethics Healthcare privacy, confidentiality, disclosure, legal and ethical practice E-health Information and communication technologies; Data security; Health information systems and health informatics Health information services organisation and management Human resource management; Business/operations management; Project management; Financial and resource management

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Information for Contributors Contributions are invited in the form of Reports, Case Studies, Personal Perspectives, Sounding Board, Professional Profiles, Professional Practice Placement Profiles, Conference Reports, Reviews, HIMAA Reports, Letters to the Editor. Recommended word limit ~ 2,400 words. Submitting a manuscript for review All contributions are reviewed by an editorial panel made up of two editors and at least one other member of the HIM-I Subcommittee. Manuscripts are to be submitted electronically, saved in Word format, and with no headers and footers. Do not submit papers in PDF format. Digital photographs only should be provided as separate files, clearly identified and captioned. Subject’s permission to publish may be required. Data for tables and graphs should be provided in separate Excel files as well as in their final form. Formatting of the document should be kept to a minimum. Further information may be sought by contacting Stella Rowlands, Associate Editor, at HIMInterchange@himaa.org.au. Submission of manuscripts: Please email manuscripts to: Stella Rowlands, Associate Editor email: HIMInterchange@himaa.org.au © 2019 Health Information Management Association of Australia Limited

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Notes

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Notes

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Health In f

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A Strategic Asset

HIM-Interchange

Articles inside

Update report

HIMAA International Special Interest Group: a community of practice empowering Health Information Managers with global voice // Suzette Dela Cruz Regalo

Life behind the pages of HIM-Interchange // Naomi Johnson, Danica Jong, Carol Loggie, Nina Palibrk, Dwayne Richards, Stella Rowlands

Reports

Personal perspective

The importance of clinical documentation improvement for Australian hospitals // Patricia Hay, Kathy Wilton, Jennifer Barker, Julie Mortley, Megan Cumerlato

Terri Fiorenza, Kara Pollard, Melinda Scott

A comparison between Urgency Related Groups and the Australian Emergency Care Classification // Clare Searson, Laura Harris

Maybe I’ll write to you from there: the journey of an undergraduate health information management student // Sadiya Askar

Contents

Year of a new graduate in the bush // Alexandra Van Gemert