A professional practice journal of the Health Information Management Association of Australia Limited
I hope you agree with me that it was worth the wait for the first issue for 2021. It has been in the planning and development stages for some time, and we are now ready to launch the new online platform for HIM-Interchange. Our aim is to upgrade the format of the journal to make it more accessible and functional for members, making it easier to share articles and search past issues and to modernise HIM-Interchange so that it keeps pace with the digital world we live in.
Members of the health information management profession will be deeply saddened to hear of the untimely death of our colleague, Jesse Gould. Jesse passed away in September 2019, aged 38 years, owing to complications of chronic illness.
Clinical documentation in medical records can be broadly defined as any notation made by medical practitioners and other health professionals relating to a patient’s symptoms, past history, test results or treatments provided during a clinical encounter.Clinical documentation is critically linked to accurate clinical coding and accurate generation of the diagnosis related group (DRG) resulting in appropriate remuneration to the hospital in a case-mix based funding model (Cheng et al. 2009). With the exception of DRGs ending in ‘A’ or ‘Z’, a proportionately higher level of funding may be generated for complications and comorbidities that have been treated, investigated or have required increased clinical care but have not been coded within an admitted patient episode. These complications/comorbidities have the potential to change the Episode Clinical Complexity Score (ECCS) (previously known as Patient Clinical Complexity Level (PCCL)) which influences the acuity of the DRG and resulting reimbursement. The ECCS is a measure of the cumulative effect of a patient’s complications and comorbidities and is calculated for each episode of care using the Diagnosis Complexity Level (DCL) value assigned to each diagnosis code (including principal diagnosis) as a complexity weight.Simple checklists or proformas have been shown to improve the accuracy of the principal diagnosis and procedure code resulting in a higher remuneration for the organisation (Clement et al. 2013; Naran et al. 2014; Murphy et al. 2017). Such checklists are completed by the medical team responsible for the patient in hospital. This task is usually delegated to the most junior member of the team. The clinical coding department at the Mater Health Services have developed such checklists for various specialties. The uptake of the use of these checklists during the inpatient stay is variable.This study aims to confirm the increased remuneration achieved by using checklists and to compare the remuneration generated by a junior medical person as compared to a senior doctor using these lists to help with chart reviews.
With advancements in digital health across Victoria and Australia – including the implementation of an electronic medical record in many major tertiary health services – an appropriate governance of the collection, use and access of patient and consumer health information is more pertinent than ever. As the custodians of health information, Health Information Managers (HIMs) are entrusted with managing, interpreting and protecting the use and collection of a health service’s health information, while operating in partnership with clinicians to support the provision of effective, integrated and comprehensive clinical care. This collaborative relationship fosters a shared responsibility for health information governance and is essential for harnessing the delivery of responsive care across the ‘creation to destruction’ life cycle of health information. A well-defined health information governance framework provides a basis upon which this partnership can be built and sustained and is of particular relevance for HIMs who are working in a space that is transitioning into a digital environment.
The COVID-19 pandemic has driven increased demands for timely, high quality statistics that can help governments to respond to the social, health and economic impacts of the disease. Data has also been critically important for informing the public during this time of high uncertainty. During the early stages of the pandemic, Australia relied on health surveillance systems to provide critical information on numbers of COVID-19 infections and deaths, with these systems continuing to play an important role in managing subsequent outbreaks. As the pandemic progressed, the need to understand the broader impacts on mortality, both direct and indirect, also became apparent. These impacts could not be measured through disease surveillance systems but could be captured through civil registration based mortality data. The Australian Bureau of Statistics (ABS) recognised both the challenge and opportunity in seeking to deliver rapid registration based mortality data, and after consultation with the Australian Health Protection Principal Committee, agreed to find a way to deliver the required data.
I have always thought of myself as an untraditional Health Information Manager (HIM). At the beginning of my career, straight out of placement, I worked in private health insurance. Working as a claims analyst and auditor, my role consisted of using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification and Australian Classification of Health Interventions (ACHI) codes to substantiate and verify the claims based on the admission.
Stella Rowlands has been a member of the HIM-Interchange (HIM-I) Sub-committee since its inception in July 2015 and we are sad to report that she has recently retired from the role of secretary and from the sub-committee. Before she got away, I managed to get some parting words of wisdom. Read on to hear from Stella herself about her journey with the journal and her thoughts about the future of the journal and the profession.
In November 2020 the Health Information Management Association of Australia (HIMAA) appointed a new Chief Executive Officer (CEO), Jae Redden. Jae comes to HIMAA with a strong background in publishing and with membership organisations. In her first month in the new role she made time to get to know and understand the HIMAA committees and interest groups, providing members of those committees and groups with an opportunity to get to know Jae. The HIM-Interchange (HIM-I) Sub-committee posed some questions for Jae so that members could get to know Jae further as well as provide an opportunity to understand what attracted her to the HIMAA CEO role.
Formal health classifications facilitate the collection of significant quantities of health data in the form of clinical codes. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) is used in Australia (and many countries around the world) primarily to report information about admitted patients’ diagnoses while the treatment provided to the patient is reported using the Australian Classification of Health Interventions. The Australian Refined Diagnosis Related Groups usethese clinical codes to group patients into like categories and represent another important health classification that is widely used by managers of health information in government departments, hospitals and health funds. In Australia, the Independent Hospital Pricing Authority is responsible for managing these classifications (IHPA, 2019). Health information managers (HIMs) and clinical coders (CCs) are responsible for the clinical coding of admitted patient records, thereby creating the bulk of these health data. The data are reported to state and federal government departments from where they are made available for use by multiple stakeholders, such as researchers, program managers and funding model developers. Within individual hospitals, researchers, funding managers and other stakeholders will also access these data to inform their work.
