This document discusses changes in clinical data collection and the role of clinical coders. It notes that data now comes from many sources through various mediums and is used for many purposes. Clinical coding translates medical descriptions into codes. While technology has improved coding efficiency, the role of clinical coders may change further as technology advances. In particular, widespread electronic health records could significantly impact current clinical coding practices and roles. The document urges clinical coders and organizations to consider how to prepare for and adapt to technological changes to ensure accurate and consistent health data collection into the future.

2. Change in the Data Collection Landscape
Clinical Coding
OPPORTUNITIES, POSSIBILITIES, POTENTIAL
H I N Z – O C TO B E R 2 0 1 5

3. Source Data:
Many authors
◦ Clinical and administrative
Many points of entry
◦ Hard copy and electronic health record
Many policies and procedures
◦ Difficult to formulate standards
◦ Obligations, responsibilities and accountabilities
Many sites of storage
◦ Formal and informal
Many users and use cases of data
◦ Interoperability and access

4. Clinical Coding:
The translation of diagnostic statements into alpha-numeric code
25 year old patient admitted with acute appendicitis.
Past History: Insulin dependent diabetic with poor control. Smoker.
Went to theatre for a laparoscopic appendectomy under general anaesthetic.
Developed atelectasis post operatively requiring physiotherapy.
Patient offered NRT and advised on the health benefits of smoking cessation

5. Background:
ICD-10-AM/ACHI/ACS 8th edition
Approximately 150 DHB Clinical Coders
◦ Inpatient events after discharge
◦ 21 day deadlines for submission to the NMDS
◦ Cancer registry, mortality registry and private hospitals
Primary use cases
◦ Funding (population based)
◦ Health care planning
◦ Risk management and clinical quality improvement
◦ Research

6. The Goal:
To collect accurate, consistent and timely health data
Inaccurate, inconsistent and late data is redundant

7. Data in = Data out
Clinical Coders
◦ Knowledge and expertise in classification
◦ Understanding of clinical and non clinical concepts
◦ Efficient abstraction skills
Clinicians
◦ Consistent, legible, specific documentation
Administrators
◦ Accurate entry of all administrative data elements

8. How much faith do you have in the quality of your clinical coded data?

9. Technology has improved things:
Change in operational model
Office based to coding in the clinical areas
Electronic coding resources
More reliable and accessible
Electronic quality tools
Comprehensive and holistic avenue to evaluate coding accuracy
Robust reporting
Intensive education and training
Face to face and electronic learning
Mentoring
Defining degree of difficulty
Engagement with clinical sector
Data education
Documentation Improvement

10. The Technology Factor:
2002 Melbourne NCCH Conference
….Clinical Coders, prepare for the future. The emergence of the electronic health record will
significantly change the way that data is collected, stored and retrieved thus current clinical
coding practice and the role of clinical coding in our health care organisations will become
obsolete.
Dr Kerin Robinson La Trobe University

11. As technology gains momentum do you think Clinical Coders will become
obsolete?

12. Business as usual:
No view that there might be other technology other than eHR that might have any influence at
all on the clinical coding workforce, role and practice
IF the electronic health record was to arrive
◦ Make things faster
◦ Legibility wont be a problem
◦ Code from home
No threat at all – we will always need clinical coders

13. The CDHB Clinical Coding Service:
Traditional Coding Practice2010
• Concerto, coding software
• Serious backlog pressures
• High FTE and resource requirements
New Operational Model2011
• Remote desktop
• Electronic coding resources
• Not so serious backlog pressures
The beginning of the next generation2015
• Updating and refining the new operational model
• Higher usage of electronic information
• Office ‘less’
• Almost no backlog pressures

14. Coding currently:
ACHIEVEMENT
Significant improvements in productivity and
timeliness of data
◦ 92% discharges coded for October at
Christchurch Hospital
◦ 100% discharges coded for October at
Christchurch Women's
◦ A significant reduction in resource
Direct access with clinical staff
◦ Education
◦ Clarification
◦ Advocacy for the health information
IMPACT
Less resource required to achieve improved
productivity outcomes
◦ More time to engage with education and quality
activities
◦ Development of the role into other areas of
health information
◦ Focus on documentation improvement activities
which again reduces coding time and improves
coding quality

15. Technology has arrived:
Transition hard copy, paper lite, paperless health records
Mature clinical information systems
Sophisticated mobile devices and internet capability
Evolving clinical coding software utilizing natural language processing tools
A cultural shift in our health data is collected, and managed
◦ Responsibility of quality on the clinician not on the coder
◦ Improved timeliness of data – collected at source
◦ Ownership of the data

16. The next generation:
Coding professionals for the future will become increasingly important
◦ Classification and standards development
◦ Health data dictionary and vocabulary development
◦ Research
◦ Activities related to health care funding
◦ Wider field of collaboration within an organisation – IT, Clinical, Corporate

17. 1. Workforce planning
◦ Less of what we currently employ
◦ Role development for new health information practitioners
2. Education and training
◦ Training tools and activities needs a different focus
◦ Allow them to come to HINZ!
3. Resources required for a clinical coding unit
◦ Is an office really necessary?
◦ Laptop’s v desktop’s
◦ What steps could be taken to make the transition smooth
Time to consider:

18. Final Messages:
Technology will have a significant impact on the way that health data is collected, stored and
retrieved
◦ Efficient, accurate, consistent
Clinical Coders will be required to make dramatic changes to the way they work
◦ Have a unique skill and knowledge set thus won’t become obsolete
◦ Exciting opportunities for growth and development
Now is the time to start considering the technological impacts on Clinical Coders and how to
harness their full potential for the future.