Guest Editor: JoAnne Fisher
Associate Editor: Jennie Shepherd
Managing Editor: Liz Morrison
Hospital Coding of Dementia: is it accurate?
Elizabeth Cummings, Roxanne Maher, Christopher Morris Showell, Toby Croft, Jane Tolman, James Vickers, Christine Stirling, Andrew Robinson & Paul Turner
Page: 05 - 11
This paper investigates the coding of dementia in the episode of care in a pilot study group (N=48) post hospital discharge and the possible implications of under-coding. The assigned ICD-10-AM codes and Diagnosis Related Groups were reviewed. Results demonstrate under-coding of dementia and of cognitive deficits; poor correlation between admission diagnoses and dementia codes on separation; and changes in individual patients’ cognitive status across forms and assessments in the same admission. The complexities of accurately coding dementias will impact upon planning for future treatments and service provision and will have a flow-on effect for patients, hospitals, and patient care in Australia.
How good is New South Wales admitted patient data collection in recording births?
Mary K Lam
Page: 12 - 19
This record linkage study aims to examine the coding concordance of delivery outcome and discharge status between the New South Wales (NSW) Midwives Data Collection (MDC) and Admitted Patients Data Collection (APDC) as well as factors that contribute to hospital births not being recorded in the APDC. Births recorded in the APDC and MDC datasets for the calendar year 2005 were used for analysis. Births registered in the NSW Registry of Births Deaths and Marriages for the same period were used as validation. Descriptive analysis was used to examine coding concordance between the APDC and MDC datasets for matched records, and logistic regression analyses were used to identify factors associated with hospital births not being included in the APDC. A total of 90,585 unique births were recorded in the MDC for the calendar year 2005. A total of 79,173 confirmed hospital births were matched to corresponding records in the APDC; 2,249 (3%) confi rmed hospital births were not found in the APDC. For unmatched records, logistic regression analyses showed that the level of obstetric hospital in which babies were born was a signifi cant factor associated with information not being recorded in the APDC. As compared with local, small isolated, and small metropolitan hospitals (Levels 1 to 3 hospitals), larger tertiary hospitals (Levels 4 to 6) and private hospitals had decreased odds of hospital births not being recorded in the APDC. For matched records, 95% and 99% of records were found to be coded consistently between the APDC and MDC datasets for outcome of delivery and discharge status respectively. With a high level of coding concordance between the APDC and MDC datasets and only a small percentage of hospital births not being recorded in the APDC, the obstetrics subset of the APDC dataset was found to be of good quality.
Dual vs. single computer monitor in a Canadian hospital Archiving Department: a study of efficiency and satisfaction
Thomas G Poder, Sylvie T Godbout and Christian Bellemare
Page: 20 - 25
This paper describes a comparative study of clinical coding by Archivists (also known as Clinical Coders in some other countries) using single and dual computer monitors. In the present context, processing a record corresponds to checking the available information; searching for the missing physician information; and finally, performing clinical coding. We collected data for each Archivist during her use of the single monitor for 40 hours and during her use of the dual monitor for 20 hours. During the experimental periods, Archivists did not perform other related duties, so we were able to measure the real-time processing of records. To control for the type of records and their impact on the process time required, we categorised the cases as major or minor, based on whether acute care or day surgery was involved. Overall results show that 1,234 records were processed using a single monitor and 647 records using a dual monitor. The time required to process a record was significantly higher (p= .071) with a single monitor compared to a dual monitor (19.83 vs.18.73 minutes). However, the percentage of major cases was signifi cantly higher (p= .000) in the single monitor group compared to the dual monitor group (78% vs. 69%). As a consequence, we adjusted our results, which reduced the difference in time required to process a record between the two systems from 1.1 to 0.61 minutes. Thus, the net real-time difference was only 37 seconds in favour of the dual monitor system. Extrapolated over a 5-year period, this would represent a time savings of 3.1% and generate a net cost savings of $7,729 CAD (Canadian dollars) for each workstation that devoted 35 hours per week to the processing of records. Finally, satisfaction questionnaire responses indicated a high level of satisfaction and support for the dual-monitor system. The implementation of a dual-monitor system in a hospital archiving department is an effi cient option in the context of scarce human resources and has the strong support of Archivists.
Smart use of data, information and communication: The INFORM-ed Best Local Practice Project - Grafton Base Hospital
Sheree Lloyd, Jean Collie, Alastair McInnes, Kevin King, Alison Lollback & Angie Garland
Page: 26 - 30
This paper describes current progress for an information management project in a medium-sized rural hospital after the fi rst four months of the one-year project. In particular, the article examines some of the project outcomes to date as these relate to the National Hospitals and Health Reform recommendations for the smart use of data, information and communication. The paper identifi es a number of important challenges and issues that have been addressed by the project and proposes that the project fi ndings may be used to inform similar projects in other settings. These findings relate to clinician requirements for reports, investment in human resources, development, and time for information management activities. An understanding of data collected, information systems, and presentation of clinician data are also important. The benefits of information sharing in assisting quality improvement activities are particularly relevant but, more importantly, they can engage and involve clinicians in the use of information. The importance of local data, information, and knowledge is described. Finally, issues for the health information management profession, such as working collegially and sharing knowledge and expertise, are outlined.
Who owns the information in the medical record?
Page: 31 - 37
As part of every private healthcare practice and healthcare facility, documentation of patients’ healthcare, diagnoses and treatment are an ongoing requirement with legal connotations. The question that may arise is whether copyright can subsist in patient medical records, and if so, what benefit may arise from ownership of such copyright.
Book Review: Health Law in Australia, edited by Ben White, Fiona McDonald & Lindy Willmott
Page: 38 - 39