Www.ifhro.org 2nd SEAR Conference 13/10/09 IFHRO Promoting Health Records Standards Lorraine...

2nd SEAR Conference 13/10/09www.ifhro.orgwww.ifhro.org

IFHROIFHRO Promoting Health Promoting Health Records StandardsRecords Standards

Lorraine Nicholson President of IFHRO (International Federation

of Health Records Organisations)

2nd SE Asia Regional Conference, Perth, Australia13th October 2009


A Vision for IFHROA 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 Edinburgh1963 Chicago

In 1968 IFHRO was formed in Stockholm16 years, 5 international congresses and thousands of letters after the idea was initially discussed at the first international meeting in London in 1952


1968 Aims of the Federation1968 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


In 1976 - 8 years onIn 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”


Working with WHO 2004 - 2009 (1)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


Working with WHO 2004 - 2009 (2)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


Other IFHRO CollaborationOther 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


““The Relationship between Health Record The Relationship between Health Record Documentation and Clinical Coding”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.


Primary Purposes of Health Primary Purposes of Health Records (1)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


Primary Purposes of Health Primary Purposes of Health Records (2)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


Secondary Purposes of Health Secondary Purposes of Health RecordsRecords

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


Existing Standards for Health Records 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


Structure of the Health RecordStructure 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


Content and Completeness of Content and Completeness of

Documentation within the recordDocumentation within the record Content and completeness standards apply to the

format & definition of what is recorded in the agreed structure to ensure that:

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


Importance of Standards for Importance of Standards for Health RecordsHealth 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


NHS Standards (England)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


On-Going Use of the StandardsOn-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


Supporting the Use of the RCP Supporting the Use of the RCP Standards OperationallyStandards 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


Benefits of Standards for HIM’s & Benefits of Standards for HIM’s & CodersCoders

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


Standards & Coding QualityStandards & 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


Improving Coding Quality GloballyImproving 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


Improving Coding Quality GloballyImproving 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


Thank YouThank You

Lorraine Nicholson

President of IFHRO

[email protected]

+44 01706 355957

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