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Leading the Way to Quality Data!

March 27, 2017

Health Information Professionals (HIP) Week is March 26th to April 1st!

HIP week provides an opportunity to showcase the thousands of Health Information Management (HIM) professionalswho perform their duties masterfully throughout the year. This year's theme is Health Information Professionals-Leading the Way to Quality Data. HIM at its core is all about maintaining the integrity and confidentiality of personal health information within four key domains of practice: Data Quality, Privacy, eHIM and Health Information Management standards.

This year we are taking a closer look at the important role Health Records Practitioners - Coding, also known as Coders, play in our Health Records Department!

Coders at HPHA are responsible for the accurate and timely coding and abstracting of acute care Inpatient, Day Surgery, Emergency Room and Chemotherapy/Dialysis Clinic visits. In 2016 approximately 83,000 visits across all HPHA sites were coded. Coders have education and certification in Health Information Management and maintain skills, knowledge and expertise through mandatory Continuing Professional Education.

Coding is the transformation of healthcare diagnosis and interventions into universal alphanumeric ICD-10-CA (diagnosis) and CCI (intervention) codes. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) is an international standard for reporting clinical diagnoses developed by the World Health Organization (WHO); CA represents the Canadian version. The Canadian Classification of Health Interventions (CCI) is a national standard for classifying health care procedures and is the companion classification system to ICD-10-CA. There may be 100+ codes for certain conditions such as anemia. Diagnoses codes are typically four characters in length, for example, Iron Deficiency Anemia secondary to chronic blood loss = D50.0. Intervention codes are usually 10 characters, for example, Hernia repair with synthetic tissue (mesh) using open approach = 1.SY.80.LA-XX-N. The coders also must adhere to Canadian Institute for Health Information (CIHI) Coding Standards and the Ontario Ministry of Health (MOH) directives.

Coders review medical record documentation, such as physician's notes, laboratory and diagnostic imaging results, etc. and assign appropriate ICD-10/CCI codes. They also verify a multitude of other data elements including demographic data, visit times, providers, discharge disposition, etc.

All of the data elements are included in an electronic “abstract” for each visit and is submitted monthly to CIHI databases (Discharge Abstract Database for acute care inpatients & National Ambulatory Care Reporting System for ER, day surgery and chemotherapy/dialysis clinic visits). The MOH and other research agencies use this data for tracking, monitoring, trending, funding and other purposes. The MOH has identified opioid use/misuse as an important public health priority and soon they will be using ER data to understand the incidence of morbidity and mortality associated with this. HPHA also uses the data internally for performance monitoring and other purposes. Because important decisions are made based on the data we submit, data quality is critical!

HPHA's Coders from L to R: Michelle Jeffrey, Tatiana Payne, Deanna Wiebe, Pauline Monden, Louise Gagan, Adele Russell, Haley Roth, Emily VanBakel (HIM Student/Health Records Clerk), Diana Klomp