Best practice in the management of clinical coding services: Insights from a project in the Republic of Ireland, Part 2.

INTRODUCTION: This is the second of two articles about best practice in the management of coding services. The best practice project was part of a year-long project conducted in the Republic of Ireland to review the quality of the Hospital Inpatient Enquiry data for its use in activity-based funding. METHODS: The four methods used to address the best practice aspect of the project were described in detail in Part 1. RESULTS: The results included in this article are those relating to the coding manager's background, preparation and style, clinical coder (CC) workforce adequacy, the CC workforce structure and career pathway, and the physical and psychological work environment for the clinical coding service. CONCLUSION: Examples of best practice were found in the study hospitals but there were also areas for improvement. Coding managers would benefit from greater support in the form of increased opportunities for management training and a better method for calculating CC workforce numbers. A career pathway is needed for CCs to progress from entry to expert CC, mentor, manager and quality controller. Most hospitals could benefit from investment in infrastructure that places CCs in a physical environment that tells them they are an important part of the hospital and their work is valued.

Casemix systems and their applications.

Casemix systems are used in many countries around the world. The reasons for the popularity of casemix systems will be clear once their design features and applications are explained. The specific design issues for acute and other health care settings are discussed, along with their application to paying for care, utilisation review, quality assurance and clinical governance. The quality of the data is important to the integrity of these systems, and the chapter closes with a discussion of the causes of errors in the data and how the quality can be improved.

Comparing diagnosis-related group systems to identify design improvements.

The objective of this research was to compare the casemix systems used in the United Kingdom (UK), Australia and the United States of America (USA) to identify possible improvements in the design of the UK Healthcare Resource Groups. The data consisted of over 12 million inpatient and day case discharge records from 574 National Health Service acute hospitals in England for 2001-2002. These data were grouped into four casemix systems, namely Versions 3.1 and 3.5 of Healthcare Resource Groups, the United States-based All Patient Diagnosis Related Groups, and the Australian Refined Diagnosis Related Groups. The statistical performance of the groups was measured using the reduction in variance (RIV) statistic. The Australian Refined Diagnosis Related Groups produced the best RIV overall but this grouper had the advantage of more groups than the others. The comparison of the performance of the chapters within each grouper showed that each had some chapters with a better RIV than the other groupers. Comparing the performance of these groupers was successful in identifying changes to the Healthcare Resource Groups that improved its performance. Further revision of the Healthcare Resource Groups should be focused on the chapters with the best potential for improved performance.

Perceptions and behaviour of access of the Internet: a study of women attending a breast screening service in Sydney, Australia.

OBJECTIVES: To describe the perceptions and behaviour in accessing health information from the Internet by women attending a BreastScreen, New South Wales (NSW) Service in Northern Sydney. DESIGN: Cross-sectional study. SETTING: A BreastScreen NSW Service in Northern Sydney. MAIN OUTCOME MEASURES: Behaviour and perceptions of accessing of the Internet for breast health and screening information and other related health information. PARTICIPANTS: Four hundred and fifteen women aged > or =40 years who had a screening mammogram at a BreastScreen NSW Service in Northern Sydney. Data were collected from 1 October to 22 December 2004 (study interval). RESULTS: Four hundred and sixty-one eligible women were invited to participate in the study and of these 415 women agreed to participate in the study (participation rate=90%). Of the 415 women enrolled in the cohort, 80% (333/415) of women accessed the Internet in general and 62% (205/333) of the women who accessed the Internet also accessed health related information from the Internet, but only 7% of the total women accessed breast health and screening information from the Internet. Two hundred and eighty (70%) women in the cohort expressed their intention to access the Internet if they were diagnosed with breast cancer. Age (OR=0.94; 95% CI=0.91-0.97), marital status (OR=2.65; 95% CI=1.45-4.83), educational status (OR=3.26; 95% CI=1.77-6.02) and behavioural intention of accessing the Internet if diagnosed with breast cancer (OR=3.31; 95% CI=1.83-5.98) were found to be associated with access of Internet for general information. Furthermore, behavioural intention (OR=2.43; 95% CI=1.30-4.55), rating of computer skills as 'average' (OR=0.42; 95% CI=0.22-0.79) and 'not good to poor' (OR=0.23; 95% CI=0.11-0.49) were found to be associated with access of health related information from the Internet. CONCLUSIONS: Information searching from the Internet is common among women having a screening mammogram. There is potential to provide guidance to women regarding accessing the BreastScreen NSW website and other reliable sources of Internet information on breast health, breast screening and cancer-related information.

Mature use of casemix - are we there yet?

In this paper we consider the progress made in using casemix in Australia. We argue that while the casemix infrastructure has been highly developed and the casemix-based funding systems of some states are mature, there is still more development needed to use the data for clinical questions such as quality improvement activities. Further research is needed to establish what is needed to describe the impact of casemix on clinicians and hospitals in a context of increasing accountability and transparency and where questions of efficiency cannot be ignored.

Evaluation standards for clinical coder training.

This paper reports on an evaluation of clinical coder training programs, recently carried out in Ireland. In building an evaluation framework, the literature was reviewed to identify best practice standards, current practice, and professional opinion against which a sound judgment could be made. The literature was variable but nevertheless useful for the identification of evaluation standards. These standards are reproduced here in order to add to the literature. We also discuss the areas that would benefit from further research, thus contributing to the discourse on best practice in evaluating clinical coder training programs.

A comparison of two sources of data on fungaemia in two hospitals.

Fungal bloodstream infection (BSI) is of increasing concern in the hospital environment. This study compared routine hospital discharge data at two inner Sydney hospitals with a pathology database over a 6-year period. A high level of underreporting was found, with only 42% of the pathology database cases assigned an appropriate code in the hospital discharge data despite evidence of the infection being found in 97% of the medical records identified from the pathology database. The location of the evidence in the medical record had an impact on whether or not the infection was assigned a code. There was a greater likelihood that a code would be assigned if the infection was documented on the front sheet of the medical record. Improvements can be made to the reporting of fungal BSI if clinicians record it on the front sheet and if coders review the whole medical record before coding.

Investigation of leukaemia and lymphoma AR-DRGs at a Sydney teaching hospital.

Using non-blinded methodology, this study checked the coding of acute leukaemia, non-acute leukaemia and lymphoma episodes assigned to the AR-DRGs R60 A, B, C and R61 A, B during the fiscal year 2000-2001 at a Sydney teaching hospital. The purpose was to investigate whether the assignment of fewer episodes of these diseases to the highest complexity AR-DRGs during that year compared to 1999-2000 was due to miscoding, or due to a true decrease in episodes. A check of all 242 episodes revealed a degree of miscoding (mainly under-coding) of complications and comorbidities that had caused a 15% DRG error rate; nevertheless, there was a true decrease in the highest complexity episodes. The error in DRG assignment may have caused some financial disadvantage to the hospital.

Clinical coder training initiatives in Ireland.

The Hospital In-Patient Enquiry and National Perinatal Reporting System (HIPE & NPRS) Unit of the Economic and Social Research Institute in Ireland requested a review of its coder training programs and data quality initiatives, primarily because of the decision to implement a major change in Ireland's morbidity classification in January 2005. In August 2004, a formative evaluation using qualitative methods was conducted to assess the Unit's programs and initiatives. A number of opportunities for building on the solid frameworks the Unit has implemented were identified. In this paper, we focus on the Unit's coder training programs. The Unit's data quality initiatives will be discussed in a subsequent paper (Bramley & Reid 2005).

Morbidity data quality initiatives in Ireland.

In 2004, the Hospital In-Patient Enquiry and National Perinatal Reporting System (HIPE & NPRS) Unit of the Economic and Social Research Institute in Ireland requested a review of its coder training programs and data quality initiatives, primarily because of the decision to implement a major change in the morbidity classification in January 2005. In August 2004, the authors conducted a formative evaluation using qualitative methods to assess the Unit's programs. A number of opportunities for building on the solid framework the Unit has implemented were identified. The preceding paper focused on the Unit's coder training programs (Bramley & Reid 2005). In this paper, the Unit's data quality initiatives are examined.

Reaction-controlled diffusion: Monte Carlo simulations.

We study the coupled two-species nonequilibrium reaction-controlled diffusion model introduced by Trimper et al. [Phys. Rev. E 62, 6071 (2000)] by means of detailed Monte Carlo simulations in one and two dimensions. Particles of type A may independently hop to an adjacent lattice site, provided it is occupied by at least one B particle. The B particle species undergoes diffusion-limited reactions. In an active state with nonzero, essentially homogeneous B particle saturation density, the A species displays normal diffusion. In an inactive, absorbing phase with exponentially decaying B density, the A particles become localized. In situations with algebraic decay rho(B)(t) approximately t(-alpha(B)), as occurring either at a nonequilibrium continuous phase transition separating active and absorbing states, or in a power-law inactive phase, the A particles propagate subdiffusively with mean-square displacement (t)(2)(A)> approximately t(1-alpha(A)). We find that within the accuracy of our simulation data, alpha(A) approximately alpha(B) as predicted by a simple mean-field approach. This remains true even in the presence of strong spatiotemporal fluctuations of the B density. However, in contrast with the mean-field results, our data yield a distinctly non-Gaussian A particle displacement distribution n(A)(x-->,t) that obeys dynamic scaling and looks remarkably similar for the different processes investigated here. Fluctuations of effective diffusion rates cause a marked enhancement of n(A)(x-->,t) at low displacements /x-->/, indicating a considerable fraction of practically localized A particles, as well as at large traversed distances.

A preliminary analysis of differences in coded data from Australia and Maryland.

Hospital discharge data from Maryland in the United States have many more diagnosis and procedure codes compared with coded data from Australia. In order to investigate the source of these additional codes, we analysed 4000 records from each country. There were few differences in the two samples for age, sex or number of deaths. For procedures, an important source of difference was that Maryland coders used many more diagnostic and non-surgical codes compared with Australian coders. Despite significant differences for many of the disease categories, it was not possible to learn many lessons from the Maryland data because nearly half of these codes were not related to the categories we selected for the study. For diagnoses, further work is needed to understand the differences in the number of codes used in the two countries.

Cost and quality: The challenge for physiotherapists in a casemix funded environment.

Inpatient health care in Australia is currently undergoing major change, moving from historically derived budgets to systems requiring much greater accountability to revenue providers. It is crucial for clinical staff, as well as administrators, to understand these changes as clinicians will be required to provide accurate and appropriate information regarding costs incurred and health benefits achieved to justify the services they provide. This article reviews three major initiatives in health care; casemix classification, outcomes evaluation and benchmarking, and analyses the role these processes play in achieving better and more efficient health care. The impact of these processes and the opportunities they provide for the physiotherapy profession are discussed.