Transcript Document

IFHRO Promoting Health
Records Standards
Lorraine Nicholson
President of IFHRO (International Federation
of Health Records Organisations)
2nd SE Asia Regional Conference, Perth, Australia
13th October 2009
2nd SEAR Conference 13/10/09
www.ifhro.org
A Vision for IFHRO
In 1948 Elsie Royle had a vision … of possible cooperation
between medical record personnel around the world and a
global linkage between medical record keepers
1952 1st International Congress on Medical Records held in
London
1956 Washington
1960 Edinburgh
1963 Chicago
In 1968 IFHRO was formed in Stockholm
16 years, 5 international congresses and thousands of
letters after the idea was initially discussed at the first
international meeting in London in 1952
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1968 Aims of the Federation
 To provide a means of communication between
persons working in the field of medical records in
the various countries of the world
 To advance the standards of medical records in
hospitals and other health and medical institutions
 Promote the development of techniques in order
to improve the quality of medical records
 To provide educational programmes and other
media for imparting information on techniques
& developments in medical record services
 Exchange ideas and experiences at an
international level
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In 1976 - 8 years on
The following Resolution was passed:
“That one of the main objectives of the
IFHRO was to work closely with WHO in
the promotion and extension of expertise
in health record services throughout the
world, with particular emphasis an
education and training”
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Working with WHO 2004 - 2009 (1)
 WHO-FIC-IFHRO Joint Collaboration
commenced 2004 – training & certification
for mortality & morbidity coders
 Mortality Coders
 ICD 10 web-based training tool
 A web-based training tool for ICF is under
development
 Information Sheets for mortality and
morbidity coding are under development
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Working with WHO 2004 - 2009 (2)
 Further pilots of the certification process in Korea
have been approved subject to the production of new
test questions
 Joon Hong (Korea) has convened a group to work on
an examination for morbidity coders
 Currently seeking funding for the certification process
 Next face to face meeting will be held in Seoul in Oct
09
 Thereafter in Cologne, Germany in February
2010
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Other IFHRO Collaboration
 IFHRO collaboration with the Royal College
of Physicians, London on Standards for
Record-Keeping and Guidelines for
Clinicians
 Paper produced by Sue Walker & Lorraine
Nicholson for WHO-FIC
“The relationship between Health Record
Documentation and Clinical Coding”
 Sue presenting at WHO-FIC Conference in
Seoul, Lorraine presenting in Perth
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“The Relationship between Health Record
Documentation and Clinical Coding”
 Clinical coding is the translation of medical
terminology as written by the clinician into a coded
format which is nationally and internationally
recognised
 i.e. It is the translation into code of what has been
documented by treating clinical staff
 Coders should not make assumptions but should only
code what is documented
 The accuracy of clinical coding is dependent on the
clinician recording clear and complete diagnostic and
procedural information
 Coding reflects the quality of the source
documentation as well as the skills and
knowledge of the coder.
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Primary Purposes of Health
Records (1)
 Health Records are basic clinical tools
 Accurate, complete and timely documentation
in the record is the responsibility of clinician
treating the patient
 The primary purpose of the Health Record is
to facilitate clinical care
 The record acts as an ‘aide-memoire’ for the
treating clinician & is an essential
communication tool for other healthcare
professionals
 It facilitates the patient receiving
appropriate treatment at the right time
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Primary Purposes of Health
Records (2)
 Records provide a permanent account of
diagnostic & treatment decisions & a means
by which a clinician’s treatment can be judged
 The record provides evidence of what was
done, when & why
 It also provides the means to answer
questions about diagnosis & treatment &
defend medico-legal claims where
necessary
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Secondary Purposes of Health
Records
To provide a dependable source of
clinical data to support clinical audit,
research, teaching, resource allocation
and performance planning
Clinical coding is the link between
the primary and secondary
purposes of the record
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Existing Standards for Health Records
There are two types of existing
standards for Health Records
1. Structure of the Health Record
2. Content and completeness of the
documentation within the record
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Structure of the Health Record
 Standards for organisation & configuration of
Health Records are needed so that records
are structured appropriately
 Records are a chronological record of
important events & need to be ordered
appropriately so that relevant clinical
information is recorded in the right place
to enable clinicians to locate it quickly
& easily when required
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Content and Completeness of
Documentation within the record
Content and completeness standards apply to the
format & definition of what is recorded in the agreed
structure to ensure that:
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Entries are legible
Authors of entries are attributable
Entries are dated, signed and timed
Amendments are made transparently
Entries are made contemporaneously whenever possible but
as soon as possible after the event/encounter
There is limited use of abbreviations and jargon
Personal or subjective statements are not recorded
There is no documentation of value judgements and
speculation
irrelevant documents are not included
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Importance of Standards for
Health Records
Both types of standards for records
are vitally important for clinical
coding purposes
1. STRUCTURE - so that relevant
information to determine complete &
accurate codes can be easily located
2. CONTENT - because the
completeness and accuracy of
the coding relies on content
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NHS Standards (England)
 The Health Informatics Unit at the Royal College of
Physicians (RCP) in London has coordinated the
development and piloting of nationally agreed
standards for the structure and content of Health
Records that have been agreed for all hospital
specialties
 The project was funded by NHS Connecting for
Health and the standards were ‘signed off’ in April
2008 by the Academy of Medical Royal Colleges
 The standards were passed as fit for purpose
 Psychiatry and Paediatrics - although the information
that they require is different from and additional
to that covered by the standardised headings, the
requirements for these specialties can be
accommodated within the proposed standards
structure
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On-Going Use of the Standards
 The standards developed by the RCP have been
submitted to NHS Connecting for Health which is
responsible for the development of the national
Electronic Health Record in England
 Work on definitions that will meet the rigorous
requirements for IT implementation is currently
underway
 The definitions will then be submitted to the NHS
Information Standards Board for Health & Social
Care for approval
 All IT system suppliers to the NHS will be required
to use the standards for their EPR solutions
 Many hospitals & IT suppliers are already
implementing them in both paper & electronic
format
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Supporting the Use of the RCP
Standards Operationally
The NHS Digital & Health Information Policy
Directorate in England has published a two
part clinician’s guide to the standards:
Part 1 - Rationale for developing and
introducing the national professional record
keeping standards &s the expected benefits
Part 2 - Generic Health Record Keeping
Standards & the structure & content
standards for admission, handover &
discharge documents
AVAILABLE ON THE IFHRO WEBSITE
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Benefits of Standards for HIM’s &
Coders
Improves HIM’s & Coders ability to
abstract comprehensive and relevant
clinical information on which to
assign the most complete and
accurate set of codes to describe the
clinical encounter
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Standards & Coding Quality
 ICD-10 contains recommended format for
medical certificate of cause of death but many
of the mortality coding rules have been
developed to address issues caused by
inadequate documentation of cases
 Instructions for morbidity coding have been
developed to manage poor documentation
 Having standards for record structure and
content would go some way to addressing
poor documentation before it becomes a
coding problem
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Improving Coding Quality Globally
 Availability of standards for Health Records
(& potentially other source documents, such
as death certificates) for use internationally
would assist with the provision of high quality
coded data
 Most countries with well-developed health
information systems already have their own
standards
 Small and developing countries in which
there are few trained Health Record
professionals may not have access to
such standards
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Improving Coding Quality Globally
The authors of this paper suggest that a
discussion about the development of
simple, but comprehensive, standards
for source documents be considered as
another means to improving coding
quality around the world
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Thank You
Lorraine Nicholson
President of IFHRO
[email protected]
+44 01706 355957
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