Update report

Report on the 19th World Congress of the International Federation of Health Information Management Associations

Julie Price

The 19 th 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.

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

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). 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.

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