HIM- Interchange | Volume 10 Issue 3 Article

Page 1


VOLUME 10 NUMBER 3 2020 ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

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


Letter to the Editor // Cassandra Jordan


Reports: Residential aged care in crisis: using casemix to drive reform // Carol Loggie


International Classification of Health Interventions: the future of health intervention classification in Australia?// Megan Cumerlato and Nicole Rankin


Personal perspective: Where on earth is Tuvalu? My year as a Health Information Manager in a developing country // Kaye Borgelt 13 Health Information Manager opportunities in the digital transformation of the aged care sector // Janine Carter


The many roles of a remote Health Information Manager // Janine Wapper


Update report: Clinical coding and the quality and integrity of health data// Jennie Shepheard


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, Central Adelaide Local Health Network, SA Danica Jong, West Moreton Hospital and Health Service, QLD Carol Loggie, University of Wollongong, NSW Nina Palibrk, Royal Brisbane and Women’s Hospital, QLD Julie Price, La Trobe University, VIC Dwayne Richards, BreastScreen Victoria, VIC Deborah Yagmich, Joondalup Health Campus, WA Representative Members HIMAA Board of Directors: Sharon Campbell, WA Country Health Service and 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, WA Country Health Service and Curtin University, WA 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 third issue for 2020. What a year 2020 has been! Speaking for myself, I would be quite happy to never have to use the phrase ‘unprecedented times’ ever again. I look forward to the days when my standard email sign off does not need to be ‘stay safe’. I hope during the year HIM-Interchange has supported you to keep connected with your health information management colleagues and the profession. While many of us could not meet in person, we hope that you could keep up to date on some of the latest health information management topics through the articles in the journal. This issue is no exception, with a host of topical articles for you to enjoy. Aged care has been very much in the media recently. Firstly through the hearings and interim findings of the Royal Commission into Aged Care Quality and Safety (Royal Commission into Aged Care Quality and Safety 2019) and more recently due to the outbreak of COVID-19 in residential aged care facilities. Janine Carter (2020) reflects on the interim findings from the Royal Commission as they relate to data and information and advocates for the importance of Health Information Managers (HIMs) in the aged care sector. Loggie (2020) continues the aged care theme and describes the new residential aged care casemix classification and associated funding model developed by the Australian Health Services Research Institute, University of Wollongong, on behalf of the Australian Government Department of Health. It seems likely the aged care sector will undergo significant reform in the coming years, and in order to implement those reforms the need for HIMs will be critical. Given the current views on future health information workforce shortages, having sufficient HIMs for the aged care and health sectors would appear to a challenge.

Two HIMs share their stories of working in environments that may be foreign to many of us. Wapper (2020) recounts the many and varied roles she has had as a HIM working in a remote setting in the Northern Territory. However, even more remote than Alice Springs is the country of Tuvalu, where HIM Kaye Borgelt (2020) worked for 12 months as a volunteer as part of an international aid program. While the pictures of the beaches in the article may seem idyllic, the article outlines the significant challenges the country faces in managing health information and delivering health care. Borgelt illustrates how even in a short space of time and with limited technological solutions, health information management processes can make improvements to health care delivery. Also in this issue, Cumerlato and Rankin (2020) provide an overview of the International Classification of Health Interventions (ICHI) and reflect on how this could impact the Australian Classification of Health Interventions. The article provides a clear explanation of the structure of ICHI, how ICHI fits with other World Health Organization classifications and potential benefits. Lastly, if you haven’t seen the Health Information Management Journal Special Issue on Clinical Coding and the Quality and Integrity of Health Data, we have republished the editorial authored by Jennie Shepheard in this issue of HIM-Interchange. I encourage you to read the editorial and then check out the other articles in the special issue, which you will find through the Health Information Management Association of Australia (HIMAA) website.

The HIM-Interchange Subcommittee is always looking for ways to enhance the journal. The Subcommittee has been investigating ways to make the journal more accessible, easier for members to read, share articles with colleagues and search previous issues for relevant articles. The redevelopment of the HIMAA website has provided the tools to support this and from 2021 HIM-Interchange will be redeveloped and redesigned for online publication only. Keep an eye out for further information from HIMAA and for a new look HIMInterchange in 2021. References Borgelt K (2020) Where on earth is Tuvalu? My year as a Health Information Manager in a developing country. HIM-Interchange 10(3):13-16. Carter J (2020) Health Information Manager opportunities in the digital transformation of the aged care sector. HIM-Interchange 10(3):17-19. Cumerlato M and Rankin N (2020) International Classification of Health Interventions: the future of health intervention classification in Australia? HIM-Interchange 10(3):8-12. Loggie C (2020) Residential aged care in crisis: using casemix to drive reform. HIM-Interchange 10(3):5-7. Royal Commission into Aged Care Quality and Safety (2019). Royal Commission into Aged Care Quality and Safety Interim Report: Neglect. Available at: https://agedcare.royalcommission.gov.au/ publications/interim-report (accessed 14 August 2020). Wapper J (2020) The many roles of a remote Health Information Manager. HIM-Interchange 10(3):20-22.

Joanne Fitzgerald Editor

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Letter to the Editor Cassandra Jordan

Dear Editor I enjoyed reading the articles in the recent HIM-I (Volume 10 Number 2 2020), focused on education of our future Health Information Managers. The enthusiasm of the students, supervisors and educators shone through the readings, whilst at the same time the importance of ‘work integrated learning’ was emphasised. Collaboration between supervisors, educators and students must continue to be advocated as a significant branch of learning throughout the Health Information Manager journey. The benefit to supervisors is the opportunity to pass on one’s knowledge and experience whilst keeping informed of changes in the academic institutions; the benefit to educators is an opportunity to appreciate developments in industry facing Health Information Managers, either technically or as people managers, to foreshadow changes in teachings; and the benefit to students is to learn from keen and dedicated Health Information Managers, whilst at the same time taking steps in the evolution of their future career and identifying specific areas of interest.

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I would like to emphasise the value of a professional association in this evolution, so I encourage students to become active in their state branches. I would advise students to accept an invitation to be a mentee or to seek out a Health Information Manager to be their mentor. This relationship will prove invaluable, and often continues as students transition to positions in their career and network in their profession.

Cassandra Jordan MHM(UNSW), BAppSc(HIM), CertPersAdmin, AssocDip(MRA), JP Health Information Manager St Vincent’s Correctional Health Parklea Email: Cassandra.Jordan@svha.org.au

Residential aged care in crisis: using casemix to drive reform Carol Loggie

Introduction Residential aged care has recently been in the spotlight in Australia for all the wrong reasons. The Royal Commission into Aged Care Quality and Safety has highlighted many deficiencies in the provision of care (Commonwealth of Australia 2019), and the tragic impact of the COVID-19 pandemic has further laid bare the extent of the failings within the sector. Principal among the contributing factors identified has been insufficient and ineffective funding allocation along with inadequate staffing arrangements. Prior to the establishment of the Royal Commission in 2018, the Australian Government had begun investigating alternatives to the current funding model as a result of continual increases in the subsidy payments claimed by service providers in a system that lacked evidence to support or understand the escalating costs. Dissatisfaction with the status quo from care providers, care staff and care recipients was also gaining momentum (Aged Care Financing Authority 2020).

Background Funding provided from the Australian Government for a resident in aged care is currently determined using the Aged Care Funding Instrument (ACFI). The ACFI comprises three funding domains: activities of daily living, behaviour, and complex health care. Within each domain there are four levels of funding: nil, low, medium, and high. The domains are added together to calculate the subsidy paid by the Australian Government. The Australian Health Services Research Institute (AHSRI), University of Wollongong, was commissioned by the Australian Government Department of Health (the Department) in 2016 to review the current funding

model for residential aged care and develop alternative options for a future model. The study found that the ACFI tool was no longer fit for purpose as it was unable to adequately discriminate between residents and their associated care costs, with one third of residents assigned to just one of the 64 payment classes and many classes rarely used (McNamee et al. 2017). The design of the ACFI also creates perverse incentives for income maximisation by care providers. The recommended option from the study was a casemix based funding approach, including a purpose built casemix classification and resident assessment tool - representing a major overhaul of the current system. Following a process of stakeholder consultation, the Department proceeded with this recommendation and a major research and development project was commissioned. The Resource Utilisation and Classification Study (RUCS) commenced in 2017 and was completed by AHSRI over two years, culminating in the development of the Australian National Aged Care Classification (AN-ACC) (Eagar et al. 2019).

Why use casemix? Casemix is well established across many Australian healthcare services, including acute and sub-acute admitted care, emergency care and non-admitted care. The development of a casemix system for aged care was seen as a major step towards the reform of the sector, as it would provide the evidence base to achieve equitable funding and drive improvements. A casemix system identifies consumers according to the characteristics that are known to drive care needs (i.e. care costs), meaning that funding can be appropriately distributed at the client level according to their predicted resource consumption. The branching structure of a casemix classification ‘splits’ into different classes using those characteristics, either individually 5 HIM-INTERCHANGE • Vol 10 No 3 2020 • ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

or in combination. This structure is superior to the ACFI design, which simply adds the different domain scores together without accounting in any way for the interactions of the different characteristics. Each casemix class is resource homogeneous as well as being clinically meaningful and funding is allocated according to the cost relativity of each class. Casemix systems can also be used to inform staffing requirements. Currently, the calls for the regulation of staffing levels and skill mix in residential aged care are often met by opposition that declares this a blunt instrument, given there is no ability to account for the variation in resident care needs. The classification of residents into casemix classes enables the adjustment of staffing levels to reflect the needs of the residents within a care home

consultation to determine the most influential cost drivers and to investigate the effect of different variables when combined. The AN-ACC Version 1.0 classification comprises 13 classes: one class for ‘admit for palliative care’, two classes in an ‘independent mobility’ branch, five in an ‘assisted mobility’ branch, and five in a ‘not mobile’ branch. The classification was found to be statistically sound with half of the variance in the cost of individual resident care explained, and a fivefold variation in cost between the least and most expensive class. Figure 1: The Australian National Aged Care Figure one Classification (AN-ACC) Version 1.0 The Australian National Aged Care Classification (AN-ACC) Version 1.0 CLASS 2

Independent Mobility

Other applications of casemix include planning and managing services, measuring quality and outcomes in meaningful ways, and benchmarking between comparable services.

Development of the AN-ACC casemix system The RUCS methodology comprised two major data collections from 30 participating care homes. Service use data (individual resident care time) were collected by a total of 1,600 care staff for one month using barcode scanning technology. Resident assessment data was collected for 1,877 residents over the same period by external assessors. The resident assessment tool was developed in consultation with expert clinical advisors. It incorporated assessment scales and measures to capture those variables that were considered to be the drivers of resident care costs. In contrast to the admitted acute care casemix classification where diagnosis primarily drives the use of care resources, the care burden characteristics in residential aged care were determined to be: mobility; palliative care needs; functional decline; frailty; cognition, communication and behaviour problems; wound care; and technical nursing needs. The effects of underlying diagnoses, such as dementia, are reflected in these cost drivers. After undergoing a series of data quality processes, the two data collections were linked to create the dataset for the classification development. This was an iterative process involving both statistical analysis and clinical 6 HIM-INTERCHANGE • Vol 10 No 3 2020 • ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

Without compounding factors


With compounding factors


Without compounding factors Higher cogni;ve Ability


With compounding factors


Assisted Mobility Medium cogni;ve ability

All Residents

Without compounding factors


With compounding factors


Admit for pallia6ve care


Low cogni;ve ability


Without compounding factors Higher func;on


With compounding Factors Not Mobile


Lower func;on & lower pressure sore risk


Lower func;on & higher pressure sore risk

Without compounding factors


With compounding factors

The AN-ACC funding model The casemix classification is one element of the AN-ACC funding model. Each care home resident is assigned to one of the 13 classes using the AN-ACC assessment tool and this class determines the ‘variable’ per diem payment from the Government for the resident’s individual care. There is also a ‘fixed’ per diem payment for the costs of care that are shared equally by all residents. This component is based on the care home characteristics that were found to drive fixed care costs: degree of remoteness, facility size in remote locations, Indigenous services and specialised care for the homeless. The funding model also includes a one-off

adjustment payment for each new resident into aged care to cover the additional resources required when someone first enters care. A number of recommendations were developed to support the implementation of the AN-ACC, including assessment for care planning being separate from external assessment for funding, protocols for reassessment of residents as their care needs change, and future quality and outcome studies to set national benchmarks.

What’s next? Since delivering the final report of the RUCS in early 2019, the Department has completed a public consultation process on the AN-ACC, and has recently undertaken a field trial of the AN-ACC assessment in readiness for implementation. The AN-ACC has also been presented in the hearings of the Royal Commission for consideration in their final recommendations. As the population in residential aged care continues to become older and frailer with increasingly complex care needs, more sophisticated information systems are needed to help transform the sector accordingly. The AN-ACC, incorporating a fit-for-purpose casemix classification, provides the means for addressing critical issues around care quality, including appropriate staffing and more transparent and equitable funding.

As the population in residential aged “care continues to become older and

References Aged Care Financing Authority (ACFA) (2020) Eighth report on the Funding and Financing of the Aged Care Industry. ACFA, Canberra. Available at https://www.health.gov.au/sites/default/ files/documents/2020/06/eighth-report-on-the-funding-andfinancing-of-the-aged-care-industry-may-2020.pdf (accessed 13 July 2020). Commonwealth of Australia, Royal Commission into Aged Care Quality and Safety (2019) Interim report: Neglect. Volume 1: Information gathered and some conclusions. Royal Commission into Aged Care Quality and Safety, Adelaide. Available at https:// agedcare.royalcommission.gov.au/publications/interim-report (accessed 13 July 2020). Eagar K, McNamee J, Gordon R, Snoek M, Duncan C, Samsa P, Loggie C (2019) The Australian National Aged Care Classification (AN-ACC). The Resource Utilisation and Classification Study: report 1. Australian Health Services Research Institute, University of Wollongong, Wollongong. Available at https://www.health.gov. au/resources/publications/resource-utilisation-and-classificationstudy-rucs-reports (accessed 13 July 2020). McNamee J, Poulos C, Seraji H, Kobel C, Duncan C, Westera A, Samsa P and Eagar K (2017) Alternative aged care assessment, classification system and funding models final report, volume one: The report. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong, Wollongong. Available at https://www.health.gov.au/sites/default/ files/documents/2019/11/alternative-aged-care-assessmentclassification-system-and-funding-models-report-alternativeaged-care-assessment-classification-system-and-funding-modelsfinal-report-volume-one-the-report_0.pdf (accessed 13 July 2020).

Carol Loggie AssocDip(MRA), GCertHlthServ(R&D) Research Fellow, Australian Health Services Research Institute University of Wollongong Email: cloggie@uow.edu.au

frailer with increasingly complex care needs, more sophisticated information systems are needed to help transform the sector accordingly.

Acknowledgements Thank you to the residents, care staff and management of the participating aged care homes, the clinicians involved in resident assessments and the expert advisors, as well as the RUCS project team. The project was funded by the Australian Government Department of Health.

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International Classification of Health Interventions: the future of health intervention classification in Australia? Megan Cumerlato and Nicole Rankin

Introduction The World Health Organization Family of International Classifications (WHO-FIC) has a suite of classifications that can be used in an integrated way to collect, compare and report health information at a local, national and international level (Madden et al. 2007). WHO-FIC contains three reference classifications: the International Classification of Diseases (ICD) (World Health Organization 2016), the International Classification of Functioning, Disability and Health (ICF) (World Health Organization 2001), and the International Classification of Health Interventions (ICHI), which is planned for finalisation in October 2020. This article will focus on ICHI and implications for health intervention classification in Australia. ICHI has been developed to classify interventions across all sectors of the health system including: • Acute care • Mental health

structure to which codes in national classifications can be mapped. A base for redeveloping the Australian Classification of Health Interventions The Australian Classification of Health Interventions (ACHI), like many national classifications of health interventions, was developed over 20 years ago and there are known shortcomings, especially with expanding the code structure to accommodate new interventions. Additional content to extend the scope of ACHI ACHI, like most national classifications, focuses on diagnostic, medical and surgical interventions, whereas ICHI has a much broader range of content. Australia could draw from ICHI to extend the scope of ACHI, for instance to include primary care, assistance with functioning, rehabilitation, prevention, and public health.

• Primary care

Universal health coverage

• Allied health

As an international standard, ICHI can provide a sound basis for developing and reporting indicators designed to track progress against the health-related targets communicated under the United Nations’ Sustainable Development Goals. It could also be used to capture country-level data on the delivery of interventions that are regarded by the World Health Organization (WHO) as essential to achieving universal health coverage (UN Statistical Commission 2017, World Health Organisation 2020a, World Health Organization and World Bank 2015).

• Assistance with functioning • Rehabilitation • Prevention • Public health • Traditional medicine.

Applications of ICHI International comparisons ICHI can provide a sound base for international comparison of data on health interventions, whether it is used directly for collecting data or as a common

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Patient safety and quality and health system performance ICHI, like ACHI, can be used as a key component of the information infrastructure needed for planning, managing and financing health services, including as part of a casemix system. Selected ICHI codes may be used to identify interventions that can flag safety and quality issues, as well as interventions commonly associated with remediation action. In the area of public health, ICHI can provide a basis for collecting, reporting and analysing data on population-level health promotion and disease prevention efforts.

In the area of public health, “ ICHI can provide a basis for collecting, reporting and analysing data on population-level health promotion and disease prevention efforts.

ICHI has the potential to support the improvement of the quality and availability of information on interventions for public health, and to raise the profile of public health in broader health system areas of policy and planning.

Structure and development of ICHI Development of ICHI began in 2007, in response to the recognised lack of a standard to support the collection of internationally comparable data on health interventions. Development has proceeded as an international co-operative process, with many members of the Network of WHO-FIC Collaborating Centres contributing to the work. Australia has been integral to the ICHI development process through the University of Sydney, led by Professor Richard Madden since 2007 and ICHI Managing Editors, Megan Cumerlato, since 2008, and Nicole Rankin, since 2016, as well as the Australian Collaborating Centre. ICHI defines a health intervention as ‘an act performed for, with or on behalf of a person or a population whose purpose is to improve, assess, maintain, promote or modify health, functioning or health conditions’.

ICHI’s tri-axial structure (Target, Action, Means) was finalised in 2010, and is outlined in Figure 1. The three axes of the classification are: • Target: the entity on which the Action is carried out • Action: the deed done by an actor to the Target • Means: the processes and methods by which the Action is carried out. Each axis consists of a coded list of descriptive categories, and each intervention is represented by a title and a unique seven character stem code denoting the axis categories for that intervention. Figure 1: ICHI axes Endoscopic biopsy of oesophagus


Oesophagus (KBA)




Biopsy (AD)

Per orifice endoscopic (AD)

does not include information about the Figure ICHI 1: ICHI axes

provider of an intervention or the setting where the intervention is performed. The reason(s) for an intervention, and its outcome, should be classified using ICD and ICF. ICHI contains approximately 8,000 interventions, grouped into four sections based on intervention Target: • Chapters 1-12: Interventions on Body Systems and Functions • Chapters 13-21: Interventions on Activities and Participation Domains • Chapters 22-26: Interventions on the Environment • Chapter 27: Interventions on Health-related Behaviours



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Examples of ICHI stem codes from each of the sections can be seen in Table 1 below: Table 1: Examples of ICHI stem codes Intervention

ICHI stem code




Implantation of device into hip joint


MLJ Hip joint

DN Implantation of internal device

AA Open approach

Training in self care


SM1 Self care

PH Training

ZZ Unspecified

Animal infection control measures


UBQ Animals of vectors of disease

VE Infection control measures

ZZ Unspecified

Awareness raising to influence tobacco use behaviours


VAB Tobacco use behaviours

VB Awareness raising

ZZ Unspecified

Extension codes have been introduced based on the ICD-11 model, and now play a key role in allowing flexible additions of detail where required; examples include: additional descriptive information about the intervention (e.g. laterality, revision and robotic interventions), telehealth, therapeutic products, assistive products, medicaments, and essential pathology tests. ICHI uses the same syntax as ICD-11 to post coordinate extension codes to stem codes (&) and to link interventions performed together (/). In addition, multiple stem codes (with or without extension codes) can be linked together (+) to describe interventions delivered as a package e.g. a rehabilitation program. WHO undertook formal testing during 2019 and 2020 with 22 countries from all six WHO regions participating and providing results either via the electronic testing tool, ICHI-FiT, (which was adapted from ICD-11 testing), via the ICHI Platform or direct country review reporting. The feedback received has been used to further develop and refine ICHI content. WHO proposes that ICHI will be regularly updated in a similar way to ICD-11 and ICF with a proposal and commenting tool to allow the public to make suggestions and discuss improvements to ICHI. The proposal platform will also provide notifications of changes that have been implemented.

Structure and limitations of ACHI ACHI has been a very useful classification, however, the structure is self-limiting due to the classification being based on a fee schedule (Medicare Benefits Schedule (MBS)). This has resulted in inconsistent granularity

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across the classification with some areas being very specific with multiple detailed codes and other areas not containing as much granularity. ACHI has been difficult to update or expand due to the sequentially numbered block structure and the restriction in being able to create new blocks has become more of an issue with increased use of minimally invasive techniques. This has resulted in the mixing of concepts within existing residual block categories. Many MBS item numbers contain diagnostic statements, and these were included in the ACHI codes during its initial development. In later editions there was an attempt to remove these, the rationale being that the diagnosis code should be classified by an ICD-10-AM code and it was therefore unnecessary to specify them within the ACHI, as it limited the classifications applicability when coding interventions. When reviewing and updating ACHI, the practice has always been to research other international classifications to see how they have dealt with the classification of the health intervention. This has included reviewing ICHI as part of the review process which has led to the broadening of certain block categories into one main concept, e.g. destruction procedures were implemented as a main axis rather than having individual codes for all the different destruction techniques such as cryotherapy, ablation, diathermy etc. This enables the classification to keep up to date with evolving techniques. The ICHI structure was used as the basis for this redevelopment of ACHI in this specific area.

It should be noted that solutions to address the limitations of ACHI to date, have been short term. A long term solution needs to be revisited. ICHI offers a solution based on a common international approach, and one that will be kept current as clinical practice changes over time.

Why is ICHI a possible solution for ACHI? The tri-axial structure of ICHI allows flexibility to meet user information needs in a wide range of situations, e.g. primary care, rehabilitation, public health, which ACHI does not provide. In Australia there is currently no system for the classification of interventions for public health and ICHI could fill this gap. ICHI’s broader structure allows new interventions to be easily classified without having to redevelop the existing code hierarchy. New intervention techniques would not necessarily be assigned to residual categories as is the current practice in ACHI. It is evident that ACHI is more granular than ICHI however, with the use of post coordination, i.e. ICHI stem codes plus extension code combinations, allows for the capture of finer detail which may be desired at a national level. It is an option that national extension codes could be developed to help maintain the current level of existing granularity seen in ACHI if required.

In this way, there is scope for some tailoring to meet Australia’s requirements, but this needs to occur in a controlled way to ensure that the international comparability of data is not compromised.

Bringing the classifications together WHO’s intent is that the three reference classifications, ICD, ICF and ICHI, where appropriate, be used together to paint a picture of an individual’s or a population’s health. Consistency between the three reference classifications has been a key principle of ICHI’s development. Body functions, activities and participation domains, and environmental factors from the ICF are included as targets in ICHI. These are used to describe investigative and therapeutic interventions that focus on the functioning of body systems, interventions to support people in activities and participation, and interventions that address environmental factors (e.g. assessment of or changes to the physical or social environment or provision of assistive products). It will be possible to use the three classifications together: ICD to describe health conditions, ICF to describe a person’s functioning, goals and need for assistance, and ICHI to describe interventions delivered, as illustrated in Figure 2 World Health Organization (2020b).

Figure 2: Using the WHO-FIC Classifications together





ATE.AA.ZZ Assessment of intellectual functions

b117 Intellectual functions

6A02.2 Autism spectrum disorder without disorder of intellectual development and with impaired functional language

ATE.RB.ZZ Practical support with intellectual functions

AUI.AC.ZZ Test of mental functions of language

b167 Mental functions of language

AUI.PH.ZZ Training for mental functions of language

JUC.AM.ZZ Observation of speech functions

b320 Articulation functions

JUC.PG.ZZ Assisting and leading exercise for speech functions

JUC.AC.ZZ Test of speech functions

b330 Fluency and rhythm of speech functions

JUC.PH.ZZ Training of speech functions

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ICHI has recently been migrated to the WHO-FIC platform which currently hosts ICD-11. This will result in the three reference classifications now sharing a common platform and tooling environment (browser, coding tool and proposal platform). Advanced searching of common extension codes across the three classifications will be available. Each ICHI category has a Unique Resource Identifier (URI) and back-end web services to provide easy access to ICHI content. Links to external terminologies can be facilitated using the URIs. Currently there are a number of countries reviewing ICD-11 and ICHI with the view to implement both classifications when ICHI becomes available. Development of a WHO Grouper is now being explored, based on ICD-11 and ICHI with possible inclusion of functioning using ICF.

Conclusion ICHI has been a significant achievement in the development of a standard international health intervention classification which encompasses a variety of health systems. Over the years of development the ICHI editorial team has ensured that the currency and scientific credibility of the classification has always been maintained. In future, this editorial work will transition to the WHO-FIC network for the review of update proposals and refining ICHI to strengthen its value to meet the needs of the users. As Health Information Managers we were in a unique position to be involved in the development of such a classification, which required liaising with clinical experts and representatives from many WHO regions. The broad scope of ICHI certainly provides the opportunity for Australia to review its current intervention classification and to think about the ability to capture information outside the traditional hospital infrastructure.

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References Madden R, Sykes C and Üstün B (2007) World Health Organization Family of International Classifications: definition, scope and purpose. Geneva: WHO. UN Statistical Commission (2017) 2030 Agenda for Sustainable Development: Report of the Inter-agency and Expert Group on Sustainable Development Goal Indicators. Available at: https:// unstats.un.org/unsd/statcom/48th-session/documents/2017-2IAEG-SDGs-E.pdf (accessed 31 August 2020). World Health Organization (2001) International Classification of Functioning, Disability and Health. Geneva: WHO. World Health Organization (2016) International statistical classification of diseases and related health problems. 10th revision, Fifth edition. Volume 1. Tabular list. Geneva: WHO. World Health Organization (2020a) Universal Health Coverage. Available at: http://apps.who.int/gho/cabinet/uhc.jsp (accessed 13 August 2020). World Health Organization (2020b) ICHI Beta-3 Education slide pack. Available at: https://hscic.kahootz.com/connect.ti/WHO_ FIC_EIC/grouphome (accessed 31 August 2020). World Health Organization and World Bank (2015) Tracking universal health coverage: first global monitoring report. Geneva: WHO.

Megan Cumerlato BAppScHIM Health Information Manager ICHI Managing Editor Email: megan.cumerlato@sydney.edu.au Nicole Rankin BAppScHIM Health Information Manager ICHI Managing Editor Email: n.rankin@sydney.edu.au

Where on earth is Tuvalu? My year as a Health Information Manager in a developing country Kaye Borgelt

What does an experienced Health Information Manager (HIM) do when they leave the Victorian public health sector after thirty years? I packed up my knowledge and suitcase and relocated to Tuvalu, one of the smallest and least visited countries in the world, to work for 12 months as a volunteer HIM with Australian Volunteers International, an aid program funded by the Australian Government. Tuvalu, which comprises nine small tropical islands, has a total population of just under 11,000 and only one hospital located on the island of Funafuti. My role as HIM was designed to assist in improving medical record documentation and building capacity and knowledge for local staff. It proved to be so much more.

The Nation of Tuvalu Tuvalu is one of the poorest and least developed of the Pacific Island countries. Diseases that are almost unheard of here in Australia – tuberculosis, leprosy, rheumatic heart disease and dengue fever – are real and ongoing health issues. The infant and under five mortality rates are very high, and life expectancy is estimated at 67.2 years (Central Intelligence Agency [CIA] 2020), more than 15 years less than our life expectancy in Australia, although with no accurate mortality and morbidity data that is a best guess, but more of that later. Tuvalu has the fifth highest obesity rate in the world at 51.6% (CIA 2020). Living on a coral atoll with no soil means that access to healthy food is extremely limited and the diet consumed by the population is largely processed food, very high in salt and sugar, brought to the island from Fiji every six weeks.

The Tuvalu healthcare system There is one hospital which is located on the main island of Funafuti, with health clinics on each of the outer islands. These clinics are staffed by nurses only, which given the furthest island is a 22-hour boat ride away, makes acute health care extremely difficult. The reality is that most people on one of the outer islands with an emergency condition will die. There is one General Surgeon, one specialist locum Anaesthetist and one specialist locum Obstetrician, who rotate from other Pacific Island countries. All other medical care is provided by General Practitioners (GPs) who are local Tuvaluans who travel to either Cuba or Taiwan for medical undergraduate training and then have one-year intern training before coming back to Tuvalu to literally run the entire health care system. In the seven years they are overseas the medical students may get to return to Tuvalu once to see family and friends. The hospital has 50 beds and one theatre. There is no access to intensive care, with the ward designated as high dependency different from the normal wards by having an air conditioner and at least some effort made in regard to infection control. Basic radiography and pathology services are available at the hospital although there is no access to Radiologists and Pathologists, leaving all diagnosing to be done either by the technicians or GPs. The hospital pharmacy is the only provider of drugs and medications in the country, with paracetamol only being sold in the ‘supermarkets’ from 2019 onwards. Previous to that citizens would have to come for a GP consult to even have paracetamol prescribed.

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Allied health consists of two physiotherapists and one nutritionist, which given the very high obesity rate and epidemic levels of diabetes and hypertension, is substantially less than what is required to make any meaningful change.

coming by boat from Fiji every six weeks, with extended delays common during cyclone season. For a period of three months only emergency surgery was able to be performed, in particular emergency caesarean section deliveries, due to a critical shortage of anaesthetic drugs.

There is an acknowledgement that public health is an incredibly important component of healthcare delivery in this developing country. A substantial public health department by Tuvaluan standards, consisting of environmental health, sanitation aides, non-communicable disease clinic, maternal and child health including antenatal clinics, tuberculosis/human immunodeficiency virus/sexually transmitted disease clinic and health promotion programs operate out of the acute hospital.

The main island of Funafuti is very densely populated with limited access to fresh water and generally poor hygiene creating a perfect environment for the spread of infectious diseases. Limited access to fresh fruit and vegetables and a heavy reliance on processed foods high in salt and sugar only adds to the generally poor health status of the population. This is one of our closest Pacific Rim neighbours and this is their everyday reality.

A universal healthcare system In contrast to most of the world Tuvalu has a truly universal healthcare system, with all care provided free of charge to all citizens. Nearly 62% of the total health budget is spent on the Tuvalu Medical Transfer Scheme whereby patients requiring care and treatment that cannot be provided in Tuvalu, are transferred overseas. Given the hospital is only the equivalent of a ‘district sized and equipped hospital’, this means a lot of people are transferred overseas. All cancer diagnoses are transferred and remain overseas for the duration of their treatment and there were about 25 patients with end stage kidney failure living permanently in Fiji with their families while they receive dialysis. All of this comes at an enormous cost – some $7 million in 2017 against a total national health budget of only $11.3 million (Borgelt 2019). Sadly, transferring patients to Australia or New Zealand is deemed to be too expensive so patients go to either Fiji, Malaysia or India.

Healthcare challenges Providing quality healthcare in Tuvalu is beset by a number of significant challenges. For patients living on outer islands, about 40% of the population, anyone requiring acute care must wait up to four weeks for the scheduled ferry to arrive and then travel up to 22 hours by boat back to the hospital. There is no such thing as ordering a road or air ambulance. Accessing even basic supplies such as anaesthetic drugs and gauze dressings is difficult with all supplies

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Kaye in the Nurses Station at Princess Margaret Hospital with Health Information Department staff Sisilia Pome’e and Tereinako Pakoa and Acting Director of Health Dr. Tuese Sinileta

Health information in Tuvalu Like many hospitals we had a hybrid medical record system with a combination of hard copy medical records stored in very rusty filing cabinets and an electronic system provided by the Republic of China (Taiwan) which was used for emergency and general outpatients and not much else. If you think it is hard logging issues with your in-house information technology department, try getting any changes made to a system which has been set up in Mandarin for use in a tertiary level hospital in Taiwan, translated into English for Tuvalu, and is operated from Taiwan (half a world away). When I arrived the Admission, Transfer and Discharge system was not used at all and there was no morbidity or mortality coding done. Birth and Death Registers were maintained in spreadsheets.

dying before their fifth birthday. The information was subsequently used to reallocate scarce public health funding and activities to these specific areas. The Medical Cause of Death Certificate was reviewed and revised to bring it in line with the WHO recommended standard and a national guideline on how to complete the certificate was implemented.

The unspoilt tropical paradise of Tuvalu

Why health information is important in developing countries Why does a country like Tuvalu, with so many challenges, need a HIM? Put simply, data and information. How can a country improve its health outcomes if it does not have access to accurate data and information to inform discussion and decisions at all levels? The World Health Organization (WHO) regularly quotes health related information for countries throughout the world. Until now Tuvalu has not been in a position to report anything other than raw birth and death figures. Given that so much international aid is based on information relating to health outcomes, whether that is incidence and prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis rates, maternal and neonatal death rates, and sustainable development goals I suggest that for many developing countries information provided is at best a guess and worse whatever was reported last year, hence my hesitancy quoting life expectancy data previously. Given the little that was available in Tuvalu we had to decide what information was the most important and what was actually able to be collected and reported. As a result, we concentrated on four areas; births, causes of death, reasons for admission to hospital and reasons for transfer overseas for high level care. Mortality coding Mortality coding was introduced for all deaths and a review of mortality over a five-year period was completed and presented to the Tuvalu Government that highlighted emerging public health issues, including the high number of deaths due to non-communicable diseases and an uncomfortable number of infants

Mortality statistics is a fundamental measure used by the WHO to calculate many key performance indicators. Without accurate and timely mortality coding such indicators become problematic and potentially worthless. In Tuvalu, and possibly many other developing countries, the absence of even this most basic information is a real problem. Morbidity coding Local staff were provided with basic training in morbidity coding so that admissions to hospital could be accurately counted and categorised. The online WHO International Classification of Diseases, Tenth Revision (ICD-10) system was used, which unfortunately has no capacity to code interventions, a situation that will be rectified in the Eleventh Revision (ICD-11), a great step forward for developing countries relying on this free platform. The online training module was used to train staff and provided an excellent introduction to staff with no experience. Unlike in Australia where morbidity coding is now used predominantly for financial purposes, in a country like Tuvalu morbidity coding is important because it is the foundation for identifying public health priorities, and then monitoring whether public health programs make a difference over time. We were able to quantify the prevalence of diabetes and hypertension and the high number of diabetesrelated complications such as diabetic foot. Even better we were able to provide data that proved that early intervention at the non-communicable disease clinic had resulted in a dramatic decrease in the number of above and below knee amputations. Analysing admission, transfer and discharge data, including morbidity coding, we were able to identify priorities for specialist doctors – in particular the need for a Paediatrician. That position was subsequently advertised internationally.

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In addition to justifying health care expenditure as part of the national budget discussions we were also able to provide policy makers with accurate information to plan for future health services. These are truly big picture outcomes. Safety and quality At its core health information is about improving safety and quality in healthcare. I was able to introduce a number of basic processes to assist in making patient care at ward level safer and more effective, including using patient armbands to identify individual patients, printing patient labels to identify medical record forms and using printed progress notes rather than blank sheets. The medical record system already had a unique patient identifier. We worked hard to reduce duplicate unit record numbers and ensure that records were merged to ensure that important health information was not lost in multiple folders. Staff were made aware of the importance of using points of identification other than given name and surname to identify patients, which in a country where literally no one has an address, meant relying on the date of birth. Tuvalu has no private GPs which means that patients present to the hospital for all treatment and care. The introduction of an outpatient registration form to collect accurate administrative information to populate the Patient Master Index assisted in improving data quality. In common with many other developing countries Tuvalu has a relatively high birth rate. In 2018 there were 246 births, which compared to Australia is nothing but when the entire population is only 10,645 (Government of Tuvalu 2017), is quite substantial. A birth summary form was introduced to collect important birth information to facilitate analysis of deliveries which over time should lead to improvements in outcomes for mothers and babies, including a decrease in maternal and neonatal deaths. The introduction of booked outpatient clinics meant that medical records were able to be pulled in advance and provided to the specialist with important previous medical history, including investigations and comorbidities to assist in clinical decision making.

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In the health information department, we were able to introduce medical record clips so that loose pages did not fall out of the manila folders in which they were stored. Daily bed returns to count admissions and discharges commenced and handmade cardboard tracer cards using discarded manila folders reduced the number of misfiled medical records. Not all improvements involve sophisticated technology solutions.

The volunteering experience To be given the opportunity to live and work for 12 months in another country and culture is a tremendous privilege beyond anything I could have imagined. It is an opportunity to meet and become friends with people from many different cultures, countries and backgrounds. It is a chance to learn about who you really are and what is important, realign what truly matters, and appreciate the small things such as a beautiful sunset, receiving a bunch of bananas from your next door neighbour or finding apricot jam for sale in the supermarket. To be a HIM in a developing country is a chance to make a real and lasting improvement to the health outcomes of an entire population and reinforced to me that HIMs have skills that are incredibly diverse and valuable – we have so much more to offer than just maximising casemix and coding outputs. References Borgelt KD (2019) Tuvalu Medical Transfer Scheme (TMTS) Report – 2018. Central Intelligence Agency (2020) CIA World Factbook. Available at: https://www.cia.gov/library/publications/the-world-factbook/geos/ print_tv.html (accessed 12 August 2020). Government of Tuvalu (2017) Tuvalu Population & Housing MiniCensus 2017 – Preliminary Report. Central Statistics Division, Ministry of Finance, Economic Planning and Industries, Government of Tuvalu.

Kaye Borgelt MHSc; Grad Cert Org Chge; Ass Dip Med Rec Admin; GAICD

Health Data Analyst, Gippsland Primary Health Network 325 Francis Road, Glengarry West, VIC, 3854 Tel: 0427 537 400 Email: kayeborgelt@gmail.com

Health Information Manager opportunities in the digital transformation of the aged care sector Janine Carter

Back in the late 1980s I began my health information management career in the public aged care sector. After several years working in various health information management, information technology and project management roles in acute health, I have recently returned to the not-for-profit aged care sector at an exciting time, where the skills of a Health Information Manager (HIM) can contribute to supporting safe and effective care as technology develops into a key component of clinical practice.

given during the Royal Commission includes statements such as ‘Documentary assessment and monitoring was unsystematic, inaccurate and did not provide a clear picture of the care required or being given’ (2019b). As HIMs, we need to advocate for and facilitate a move to more integrated records across the continuum of care in the aged care sector. We also need to push for effective clinical documentation within aged care facilities through policies and best practice information systems designed in collaboration with clinical staff.

The value of data driven business in aged care has become more evident through the recent Royal Commission into Aged Care Quality and Safety (the Royal Commission), which has not only relied on verbal accounts from residents and their families and clinicians, but also historical data from manual and electronic medical, incident and complaints records. Data from aged care providers as well as the assessments stored on the My Aged Care portal, General Practitioner (GP) records and other health professional records have been referenced to evaluate the delivery of care and the flow of information throughout the aged care journey in the growing residential and community sectors.

Aged care providers manage a range of contracted care providers as well as their own skilled and unskilled workforce, making information management more complex to design and govern. HIMs can assist aged care providers in ensuring a single, integrated record can be accessed by all employed and contracted care providers, including GPs, geriatricians, nurses, personal carers, lifestyle assistants, pastoral carers and a wide range of allied health providers. Having experience with forms and system design, clinical workflow, information management processes and system administration is a perfect foundation for implementing best practice information governance in aged care.

The Royal Commission has made a number of observations about the quality and accessibility of data and information and the impact it has on care delivery. The Royal Commission Interim Report noted that ‘The person’s information does not always make its way from the assessment services to their My Aged Care client record, resulting in inconsistent screening or multiple unnecessary assessments’ (2019a). The lack of integration between My Aged Care records and aged care clinical applications has led to fragmented records that can cause difficulties in the flow of information from the aged care assessment process through to admission into community or residential services. In addition, evidence

The provision of care by GPs, who are not usually employed by aged care providers, often requires documentation in both the facility medical record and their practice management software, creating duplication and inefficiency as well as risk of gaps in either or both records. Giving evidence at the Royal Commission, Dr Tay, a GP, states, ‘I think you highlight an issue in relation to clinical notes for visiting GPs. We, at the moment, have an issue around duplication’ (2019b). In some cases, handwritten GP notes are scanned and uploaded and/or transcribed by a nurse into the resident’s clinical record, creating risk to clinical care and legal compliance.

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Similarly, medications are recorded in the GP practice software and the aged care provider record, either in an electronic or paper-based medication chart. With the change in legislation supporting paperless scripts and increased integration in electronic medication systems, there are significant opportunities to streamline the medication management process and improve medication safety and efficiency. This is an exciting change that will allow seamless integration between GPs, pharmacies and aged care providers to improve efficiency and, more importantly, resident safety. The expertise of a HIM is a perfect fit for ensuring this progressive change is managed in a way that provides safe, efficient and legally compliant medication workflow from prescription to dispensing and administration.

strong change management, governance and expertise to ensure the benefits are realised. It also requires a strategic approach to ensure systems are implemented in a structured and integrated way.

The Aged Care Industry Information Technology (IT) Council is focused on research into the use of technology in the aged care sector and the implementation of innovative solutions to improve health and safety outcomes, such as artificial intelligence, sensor devices and closed-loop medication management solutions. The Aged Care Industry IT Council digital roadmap (2017) looks at a plan for the short, medium and long term strategies to strengthen the use of technology in the aged care residential and community sectors, including the importance of integrated systems These strategies provide exciting opportunities for HIMs to work actively with other clinical and technical professionals to improve the adoption and use of technology.

‘Unfortunately, the legacy systems that many aged care providers still use have poor design with little or no connectivity. It demands a framework that can provide the right information at the right time by unlocking and analysing all data.’

The process of adopting and use of technology is not easy, as noted by Barnett et al. (2019): ‘Sweeping aged care reform coupled with transformation and global acceptance of the internet has resulted in Government and Industry struggling to comprehend and adapt to the change brought on by the ubiquitous growth of data and information.’ While it grapples with technical infrastructure and clinical documentation challenges, the aged care sector is continuing to adopt electronic medical record software as well as smart technologies such as sensor and safety devices and clinical assessment and monitoring apps, transforming the way information is managed within facilities and between the aged, acute and community sectors. Although this is a positive venture and has significant potential to improve resident care, it requires

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In addition, the value of a good digitisation and information governance framework and robust systems is becoming clearer as privacy and data breach legislation continues to evolve and data breaches themselves become more prevalent in health. The pressure of clinical and financial accountability grows as organisations increase efficiency to reduce costs. Aged care publications are increasingly reporting on the need for better governance and design and it is important for HIMs to play an active role in that process. Nick Lambrou (2020) noted in the Australian Ageing Agenda that:

While the article is focused on technical connectivity, the implications for information flow are equally relevant. HIMs can contribute to the aged care sector by applying a similar skillset as those applied in an acute or community service, but the increased adoption of technology makes it the perfect time to be involved in the sector. HIMs have the required skills to ensure that data governance is considered as these technologies expand in the aged care sector and that effective information flow is supported within and across systems and services through integration and data standards. Involving HIMs in clinical software procurement ensures the evaluation is based on more than a technical perspective, resulting in more well-rounded and robust systems. Similarly, as aged care clinical software becomes more prevalent, HIMs can utilise their ‘forms’ design skills to contribute to software user interface design, ensuring information can be collected in a way that supports clinical practice by creating logical workflows, using structured and standardised responses where appropriate, applying logic within and between fields for example. HIMs can also represent aged care providers on customer advisory boards for software and other technology companies to ensure efficient design and workflow and legal compliance are considered with software development.

Despite International Classification of Diseases coding generally not being used in the aged care sector, the ability to adopt diagnostic code sets and provide mapping to the Aged Care Funding Instrument (ACFI) is a natural extension of the coding competency (ACFI is the current funding tool in the Australian aged care sector). Understanding diagnosis coding systems, funding models and casemix can be applied in the aged care sector to ensure quality diagnostic data can be collected and reported on in a meaningful way. The clinical coding skillset also provides insight into clinical workflow and disease management as well as having the clinical vocabulary to converse with clinicians in their language. This level of understanding facilitates decision making associated with information management, including what information is required, who needs to access it and how it needs to be presented. It allows HIMs to confidently evaluate how a clinical information system needs to be implemented in many environments, whether it is aged care, critical care or obstetric services. As the aged care industry moves away from the current ACFI funding model, HIMs can advise on how data can be used to support the new funding instrument and what the impact will be on documentation and data collection. The Department of Health is conducting trials of the Australian National Aged Care Classification (AN-ACC) funding assessment tool across Australian aged care facilities as a potential replacement for ACFI. HIMs can make a significant contribution to policies and procedures associated with information governance, including retention, storage and destruction of paper and electronic records, privacy policies and education, data quality audits, etc. As more information is being collected and systems become more complex, it is critical that aged care providers have well-structured processes that facilitate effective data collection, retention and retrieval to meet clinical and legal requirements. As HIMs have extensive knowledge of the data within their organisations, they can play an integral role in defining, analysing and writing reports to support clinical decision making, evaluate outcomes and plan future services. Although the reporting requirements will vary from the acute sector, aged care providers rely on information to identify clinical deterioration and demonstrate compliance with aged care standards.

This is becoming increasingly important as aged care providers are required to provide evidence of care given and justification for treatments, such as antimicrobial orders, chemical or physical restraint, etc. HIMs can ensure this information is readily available and monitored to identify anomalies or trends. There are many opportunities for HIMs in the aged care sector as information systems and smart technologies begin to transform the way data is collected and managed. The skillsets of HIMs can be applied to a range of roles within the sector and can have a positive impact on information governance to support safe and effective clinical care through collaboration with clinical and technical teams. It is an interesting, challenging and rewarding time to work in the sector with opportunities to drive some of the strategic change around information management that will come from the Royal Commission as well as from new technologies, standards and funding tools. References Aged Care Industry Information Technology Council (2017). Technology Roadmap for Aged Care in Australia. Available at: http://aciitc.com.au/wp-content/uploads/2017/06/ACIITC_ TechnologyRoadmap_2017.pdf (accessed 14 August 2020). Barnett K, Livingstone A, Margelis G, Tomlins G and Young R (December 2019) Aged & Community Sector Technology & Innovative Practice: A report on what the research and evidence is indicating. Aged Care Industry Information Technology Council. Available at https:// www.aciitc.com.au/ Lambrou N (2020). Can you demonstrate compliance? Australian Ageing Agenda. Available at: https://www.australianageingagenda. com.au/technology/can-you-demonstrate-compliance/ (accessed 15 March 2020). Royal Commission into Aged Care Quality and Safety (2019a). Royal Commission into Aged Care Quality and Safety Interim Report: Neglect. Available at: https://agedcare.royalcommission.gov.au/publications/ interim-report (accessed 14 August 2020). Royal Commission into Aged Care Quality and Safety (2019b). Statement of Dr Eric Tay. Auscript Australasia Pty Ltd. Transcript of Proceedings in the Matter of the Royal Commission into Aged Care Quality and Safety. Available at: https://agedcare.royalcommission. gov.au/sites/default/files/2019-12/transcript-10-july-2019.pdf (accessed 14 August 2020).

Janine Carter BAppSc(MRA), Dip(ProjMan), GradDip(Admin)

Clinical Systems Advisor, Uniting Agewell Email: jcarter3@unitingagewell.org

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The many roles of a remote Health Information Manager Janine Wapper

Twenty-five years ago I moved to Alice Springs. Like many who have moved to ‘The Alice’ I thought I would be in town for one or two years at most, then move on to bigger and better things. Instead I find myself working in an environment that continues to offer a wide range of professional experiences and challenges for a Health Information Manager (HIM). There are several remote health services around Australia that cover thousands of kilometres, with their hospitals hundreds of kilometres apart. The Central Australia Health Service (CAHS) is geographically one of Australia’s biggest health services covering 872,861 square kilometres - approximately 65% of the Northern Territory (NT), with one of the smallest populations around 48,000 people, of which 44% are Aboriginal. There are only two hospitals in the health service region – in the centre is Alice Springs Hospital (ASH), a typical regional hospital with over 200 beds, and 500km north is Tennant Creek Hospital, which has 30 beds. Yulara (the service centre for Uluru) has a clinic, and there are 28 more primary health care clinics scattered around the region. CAHS also provides mental health and alcohol and other drug services.

Early years My first role was as a HIM, working on clinical coding backlogs at ASH while the incumbent HIM – Jill Burgoyne – was on maternity leave. I found the clinical coding in a remote health service quite different to that on the heavily populated east coast where I had worked previously: not so much ischaemic heart disease, cancer and methamphetamine related episodes; a lot more renal disease, infectious disease (including rheumatic heart disease, ear, eye and skin infections), bronchiectasis, advanced type 2 diabetes, and alcohol related episodes. While the burden of renal disease is growing seemingly exponentially, there are good news

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health stories too. When I first came to ASH there were three paediatric wards – a regular ward, a child health unit that ran a nutrition program for underweight infants and their mothers, and a ward for patients with infectious gastroenteritis. Now we only have a regular paediatric ward – thanks to primary health initiatives in the remote clinics such as the ‘Strong Women-Strong Babies’ program and the introduction of the rotavirus vaccine. The Patient Service departments at the two CAHS hospitals incorporate the medical records service, switchboard, admissions service, outpatient clerical service, and in the past, the patient travel service. Over the years the Patient Service Managers, who usually came from a nursing or operational services background, often sought advice from the HIMs regarding: • Medical record forms management: in the early years the forms were managed through a Patient Services based committee, but now medical records forms design and approval for publication is managed by the Safety and Quality Unit through the Policy Advisory Committee (of which the Director of Health Information is a member) • Privacy and release of information: when there were policy updates or patient information requests that did not seem to follow protocol, the HIM’s opinion was sought • Department design and layout: - The medical records department moved four times and the secondary storage area twice in my first ten years at ASH. During that time the onsite HIMs provided advice regarding flow of work through various areas and the standards to be met for

medical record storage. One of our biggest wins was the compactus shelving being removed and never again used for onsite file storage at ASH. The compactus had a history of work-health safety and maintenance issues with parts requiring sourcing from interstate. The new storage areas were big enough to accommodate free standing shelving. - The clinical coding has in the past been performed in six different locations around the hospital. Less successful venues included coding on a high bench and stools in a closed off corridor during renovations, and an attempt at ‘on ward’ coding (that was actually single-coder-in-a-room-nearthe ward coding). The current Health Information Service (HIS) office was set up four and a half years ago and has comfortable open-plan space for eight staff (including six coders) and a manager’s office. • Relocating medical record filing areas: during the many departmental relocations it was the HIM who was tasked with coordinating the moving of thousands of terminal-digit filed records to new locations. This experience taught me that laundry trolleys are very useful for moving and maintaining bulk records in filing order. The last big move was in 2009 when I led a project to relocate over 116,000 patient files to a more spacious secondary storage area.

From these sessions evolved what is now the NT Coders Forum, where all NT clinical coders meet every six to eight weeks via teleconference...

In those early years I also became engaged in clinical coding staff education. With the implementation of first edition of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification, Australian Classification of Health Interventions and Australian Coding Standards came the opportunity to attend the ‘train-the-trainer’ sessions in Sydney, and spread the good word about the new classification to my NT coding compatriots in Darwin. It was great to meet face-to-face with other NT coders. From these sessions evolved what is now the NT Coders Forum, where all NT clinical coders meet every six to eight weeks via teleconference (those shy clinical coders aren’t keen on videoconferencing), and up until recently a yearly face-to-face coding workshop in Darwin. Jill Burgoyne became our NT-wide Coding

Auditor and Educator for a few years, but with her retirement the two NT health services now have their own strategies for staff education. CAHS now has a Health Information – Coding Manager, Isabel Hayes, who is the local clinical coding guru and auditor.

Recent years Five years ago, I was appointed to a newly created position – Director of Health Information of CAHS, reporting to the Chief Finance Officer. The Director manages the HIS, which consists of the Coding Manager, two ‘advanced’ clinical coders (with over 10 years experience), two clinical coders and our trainee ‘associate’ clinical coder position (an attempt to grow our own clinical coders locally). The service also has a data integrity officer who is responsible for making episode data corrections in our ancient Patient Administration System (PAS) – an often laborious process as some episode data must be removed then re-entered, after the correction is made. There is also the newly created position of activity-based funding (ABF) non-admitted data project manager who will review our non-admitted data in the current PAS system and make changes and improvements in preparation for a new PAS system to be rolled out in the next two to three years. The roles of the Director of Health Information include: • Human Resources Manager: essentially this is complying with NT Public Service requirements to recruit and retain suitable clinical coding and data staff to supply timely, accurate ABF data for CAHS. With executive approval I can create new roles that will enhance CAHS ABF data. This requires writing job descriptions and completing job assessment questionnaires to determine salary levels for the new positions. Currently clinical coders are part of the administrative salary stream, but with executive support I am working towards moving clinical coders into a professional or technical salary stream. • Staff advocate: identifying issues for staff and finding and implementing resolutions for those issues. For example, it was identified that some workstation desks within the office were old and unsound and required replacement. An independent workplace assessment was commissioned with the outcome that sit-stand workstations were recommended for all staff within the Health Information office. Sit-stand workstations were sourced and installed in the workplace within two months of the recommendation. 21 HIM-INTERCHANGE • Vol 10 No 3 2020 • ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

• Educator of clinical staff – by providing targeted group education about: - Clinical Documentation Improvement (CDI). - ABF and how this relates to CDI Clinical staff education sessions can vary in size from a presentation in a lecture theatre to 30 new clinical staff to a tea-room chat with three to four midwives. I was averaging two education sessions every month, but this has dropped away with COVID-19 meeting conditions. Online self-education is now the favoured mode of delivery so there will now be a focus on developing online education about ABF and CDI. • Data Analyst: interrogating health data sets for audits, management reporting and research. While I can produce simple data reports for local audits, our local data analysts are experts at extracting data. I liaise regularly with our analysts about report setups – particularly those that require data sourced from coded diagnoses and procedures. Our analysts regularly send me reports to review to check their validity from an ABF or clinical coding perspective. • Data Governance: I am a member of several departmental committees concerned with the data governance process. Some of the committees are concerned with data policy and procedure issues, and others are designed to keep abreast of ongoing data governance issues and projects. Over the last three years I have also been involved in the NT’s Core Clinical System Renewal Project (CCSRP). From the project’s information website: ‘CCSRP is developing a single, secure, Territory–wide, electronic patient record that integrates multiple systems currently used by NT Health, and replaces current aging clinical systems.’ This includes in the initial stages, replacing the three separate PAS used in acute, community and primary health care centres. The NT does have a bit of a headstart regarding the PAS, as for the last 30 years every

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NT health client has been allocated a unique identifier (known as the Health Record Number or HRN) that is used across the remote clinics, the urban health centres and the Territory’s five hospitals. As one of the patient administration leads for the CCSRP, I provide ‘expert knowledge’ on our old acute care (hospital) PAS, concerning how the patient registration data is captured and reported. My advice includes: • Which current PAS processes are useful and should be part of the new system • Where PAS data capture processes can be improved using the new system’s existing program or requiring program development • Where reporting processes can be improved using the new system’s existing program or requiring program development. The next two years will be very interesting for patient service departments and health information work units as the PAS program is developed and implemented across the NT. I consider myself fortunate to be employed in a remote health service where the knowledge of a HIM is respected and regularly sought by other health service managers and clinicians. My roles have evolved over the years and will continue to transform with the everchanging health environment.

Janine Wapper Ba App. Sci. Health Information Management

Director, Health Information Central Australia Health Service Alice Springs, Northern Territory Email: Janine.Wapper@nt.gov.au

Clinical coding and the quality and integrity of health data Jennie Shepheard

This guest editorial was published in the Health Information Management Journal Special Issue on Clinical Coding and the Quality and Integrity of Health Data (Volume 49, Issue 1, January 2020). It can be accessed at https://journals.sagepub.com/toc/ himd/49/1 It is a pleasure to provide the guest editorial for this Special Issue of the Health Information Management Journal (HIMJ). The Journal has had a long and interesting history that can be traced back to the 1970s with humble beginnings, being manually produced with a stencil and duplicating machine by volunteers (Watson, 2019). The fact that we are now publishing a special issue through SAGE Publishing speaks volumes about how far the Journal has come and the title of this Special Issue, Clinical Coding and the Quality and Integrity of Health Data, speaks volumes about how important clinical coding has become to the management of health information in Australia and around the world. In Australia, as the Health Information Management Association of Australia celebrates its 70th anniversary, clinical coders are facing challenges on many fronts. Clinical coded data influences diverse aspects of our health systems, from quality and safety monitoring and funding models to health service planning and infrastructure development. In addition, we have technological developments that will change the clinical coders’ roles substantially over the next 5–10 years. The articles published in this Special Issue reflect these challenges and illustrate the far-reaching consequences of data that lack integrity and are of poor quality. Campbell and Giadresco (2020), through a literature review, investigated the effect of computer assisted coding on the accuracy and quality of clinical coding and its impact on clinical coding professionals. The articles, dissertations and case studies they reviewed

demonstrated value in improving clinical coding accuracy and quality through computer assisted coding. Campbell and Giadresco concluded that clinical coders should view computer assisted coding as an opportunity to develop new skills, particularly in monitoring and auditing coding outputs, and that sound change management strategies are needed to ensure a successful transition of the clinical coding workforce to new roles. Improved clinical coding accuracy will benefit our health system enormously but it would be naїve to think that computer assisted coding is the complete answer. Clinical coders will be needed in different roles to help realise the benefits of computer assisted coding. To that end, Hay et al. (2020) discussed the role of documentation improvement specialists and how they can ensure adequate documentation that can be translated into clinical codes. This is a potential role for clinical coders who understand both the clinical documentation and the needs of the end users of the coded data. Hay et al. (2020) also outlined the work of the Australian Commission on Safety and Quality in Health Care, which has promoted improved documentation through its National Safety and Quality Health Service Standards and the use of coded data for monitoring patient safety through its hospital-based outcome indicators. The development of the hospitalbased outcome indicators has further elevated the need for high-quality clinical coding. However, barriers exist to achieving quality clinical coding outcomes. Canadian authors, Doktorchik et al. (2020), discussed these barriers in their article ‘A Qualitative Evaluation of Clinically Coded Data Quality From Health Information Manager Perspectives’. Their interviews with health information managers and clinical coding managers revealed that expectations were increasing for high-quality data collection 23 HIM-INTERCHANGE • Vol 10 No 3 2020 • ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)

but without additional resources to support this endeavour. They also found that incomplete and disorganised clinical documentation and lack of good communication with clinicians impacted on the quality of clinical coding. These same issues exist in Australia, and I am sure in many other countries around the world. The integrity of clinical coding depends fundamentally on the quality of the patient record. The Portuguese study by Alonso et al. (2020), ‘Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders’ perceptions’, highlights that clinical records are not just for patient treatment but that the data derived from them are stored in administrative databases and used for many downstream purposes. To that end, the authors conducted focus groups to elicit from clinical coders the problems they face in the health records that influence the quality of the coded data. They identified several issues including missing or incomplete discharge and/or surgical notes, the use of abbreviations, variability in documentation between specialties and lack of specificity in diagnosis descriptions. They also identified that in spite of electronic health records solving illegibility problems, they have created problems of their own, notably the copy and paste facility that results in errors being repeated throughout the record and very large volumes of notes to be perused by clinical coders. Importantly, they also found that no solutions are being found for these issues. Australian clinical coders would sympathise with these comments, as would many others. Three recent articles, two in this Special Issue, have focused on the congruence between the clinical codes assigned to the case and the clinical documentation in the medical record. Given that clinical coders are governed by guidelines and standards that limit the assignment of codes in certain circumstances, very important questions are raised by these papers. Australian authors, Nguyen et al. (2019), studied the level of agreement between documentation in the medical records and ICD-10-AM coding of mental health, alcohol and drug conditions in trauma patients. These authors concluded that despite documentation in the medical record, these conditions are not always coded, rendering incomplete the administrative databases on which epidemiologists and other researchers rely. Sveticic et al. (2020) from Queensland, Australia, conducted a medical record review to assess the validity of data on suicide and self-harm. They concluded that

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suicide and self-harm are under-enumerated in the administrative data and issued a warning that the data should be used with caution. In the third paper, the UK authors Handley and Emsley (2020) studied medical records that had been identified by the allocation of specific codes for intracranial venous thrombosis (ICVT). They concluded that ‘the coded data reported a higher incidence of ICVT than previously thought’. This goes to the question of specificity of clinical codes in the international classification of diseases and its various modified forms around the world. The problem of classification keeping up with current clinical definitions was outlined by Phillips et al. (2020) in their article from the United States, ‘Malnutrition Definitions in Clinical Practice: To be E43 or Not to Be?’ When the definitions used by clinical coders are out of step with the latest clinical definitions, the integrity of the coded data is compromised. Should the classification be updated more regularly, or does that compromise the stability that many processes need? Perhaps the most high-profile use of the clinical coded data is as a foundation for diagnosis-related groups (DRGs), which are used by many funding models. Two articles in this Special Issue have raised issues associated with the coding of co-morbidities, which are important for determining complexity splits in DRGs. In a study based on Portuguese data, Souza et al. (2020) argued that all co-morbidities, preexisting or newly diagnosed, should be coded in order to achieve optimum severity splits in the all patient refined diagnosis related groups (APR-DRGs). Following the publication of an Australian report that stated the complexity model in Australian DRGs did not correlate with cost, Kim et al. (2020) undertook a study of the complexity model in Korean DRGs concluding that ‘if highly accurate coding data and cost data become available the performance of secondary diagnosis as a variable to reflect the case complexity should be re-evaluated’ (p. 6). This Special Issue of HIMJ will help to raise awareness of how important the clinical coding function is to the quality and integrity of our health data. Across the spectrum of documentation improvement, clinical code assignment and end uses of the data, such as for funding models based on DRGs, the articles in this issue challenge us all to find solutions that will improve the quality of coded data, protect its integrity and support the clinical coding workforce.

References Alonso V, Santos JV, Pinto M, et al. (2020) Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders’ perceptions. Health Information Management Journal 49(1): 28–37. Campbell S and Giadresco K (2020) Computer-assisted clinical coding: A narrative review of the literature on its benefits, limitations, implementation and impact on clinical coding professionals. Health Information Management Journal 49(1): 5–18. Doktorchik C, Lu M, Quan H, et al. (2020) A qualitative evaluation of clinically coded data quality from health information manager perspectives. Health Information Management Journal 49(1): 19–27. Handley JD and Emsley HCA (2020) Validation of ICD-10 codes shows intracranial venous thrombosis incidence to be higher than previously reported. Health Information Management Journal 49(1): 58–61. Hay P, Wilton K, Barker J, et al. (2020) The importance of clinical documentation improvement for Australian hospitals. Health Information Management Journal 49(1): 69–73. Kim S, Jung C, Yon J, et al. (2020) A review of the complexity adjustment in the Korean Diagnosis-Related Group (KDRG). Health Information Management Journal 49(1): 62–68. Nguyen TQ, Simpson PM, Braaf SC, et al. (2019). Level of agreement between medical record and ICD-10-AMcoding of mental health, alcohol and drug conditions in trauma patients. Health Information Management Journal 48(3): 127–134. Phillips W, Doley J and Boi K (2020) Malnutrition definitions in clinical practice: To be E43 or not to be? Health Information Management Journal 49(1): 74–79. Souza J, Santos JV, Canedo VB, et al. (2020) Importance of coding co-morbidities for APR-DRG assignment: Focus on cardiovascular and respiratory diseases. Health Information Management Journal 49(1): 47–57. Sveticic J, Stapelberg NCJ and Turner K (2020) Suicidal and selfharm presentations to Emergency Departments: The challenges of identification through diagnostic codes and presenting complaints. Health Information Management Journal 49(1): 38–46. Watson P (2019) The Australian health information management profession: Journal history. Health Information Management Journal 48(3): 111–112.

Jennie Shepheard RMRL, GDipHlthAdmin, CertHlthEco, MPH

Shepheard Health Management Consultants 14 Violet Street, Essendon, Victoria 3040, Australia. E-mail: jennie@shepheardhealth.com.au

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Production Schedule




Volume 11 Number 1, 2021


Volume 11 Number 2, 2021


Volume 11 Number 3, 2020


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