Health information management : journal of the Health Information Management Association of Australia最新文献

Background: While the smart aged care service platform in China significantly enhances aged care services in China by integrating resources, it struggles with "data silo" issues due to the absence of data standards, leading to poor data integration, limited data-sharing and fragmented system functions. Objective: The study aimed to develop a minimum dataset (MDS) for smart aged care service platforms that constitutes core data to support real-time demand analysis and cross-regional cooperation, as well as to provide a foundation for the construction of a smart aged care data resource framework. Method: The study was developed in three phases: (1) bidding documents, policies, standards and literature were collected; (2) by analysing the content of the documents, the study constructed the structure of the MDS and extracted data elements afterward; and (3) a two-round Delphi process with 26 specialists was subsequently performed to revise the draft, and 24 institution staff invited to review and determine the MDS prototype. Results: Smart aged care service platforms included three types of users: older adults and their families; aged care organisations and regulatory authorities. The final MDS contained 122 items (26 optional items) with 6 first-level categories and 17 second-level categories. The most recognised sub-categories were nursing diagnosis, demographics and medical history. The data of government regulatory agencies was also important. Conclusion: The developed MDS provides a standardised framework for data integration and sharing in smart aged-care service platforms. Implications for health information management: The MDS can enhance data quality, facilitate personalised care, support evidence-based decision-making and promote research and innovation in aged care.

Background: Research underpins and informs a profession's growth. Research and practice have a fundamental relationship involving knowledge production and its applications to a profession's work.

Objectives: To investigate health information management professionals': interest in investigator involvement in research; exposure to, or opportunity for, research investigator involvement; areas of research interest; barriers to research investigator involvement.

Method: A cross-sectional study design was utilised. An online survey elicited data on respondents': demographics, employment, roles; access to research information; interest and experience in research engagement; experience of barriers to research investigator involvement.

Results: Of 112 respondents: 64.3% reported no research involvement; 35.7% had research team experience; 83.9% retrieved research information from the web; 73.9% had no role-based research component; 51.3% had been approached by other (workplace-based) researchers to access and analyse data. Barriers to investigator involvement were personal, organisational and logistical, with lack of time the greatest impediment (62.5%) followed by cost (33.9%), lack of confidence (33%) and not knowing who to approach, or how (31.3%). Research skill development was important for 14.1%. Clinical Coding and Classification Systems (13.3%) and eHealth (12.6%) were considered likely to benefit most from health information management-related research.

Conclusion: Health information management practitioners generally have interest in research engagement; barriers include time, money and confidence.

Implications for practice: Provision of research skills and the anomaly of requests for facilitation of data access and analyses alongside absence of a research component in their formal roles require attention. The professional association should actively encourage collaborative academic-practitioner research and showcase new evidence for practice.

Background: The World Health Organization (WHO) announced the release of the 11th edition of the International Classification of Diseases (ICD) in May 2019. Although Statistics Korea has been involved in the ongoing research on ICD-11 since 2017, we have been unable to achieve agreement on the gold standards for case scenario clinical coding in previous studies due to high levels of variance in the coding results of participants. Objective: The purpose of this study was to enhance clinical coding accuracy and consistency in ICD-11 by identifying and clarifying the reasons for these inconsistencies through the use of clear clinical coding rules. Method: A pre-experimental design was applied. Two clinical coding field trials (FTs) were conducted in 'ICD-11 for Mortality and Morbidity Statistics (2022 Mar)' targeting diagnostic terms and case scenarios. In the first FT, clinical coding rules were derived by analysing the results, while the second FT was performed under the clinical coding rules set by the first FT. Results: Across the two FTs, accuracy rates for diagnostic terms (75.8% and 71.8%, respectively) were higher than for case scenarios (62.5% and 71.9%). The main reason for the low accuracy levels was post-coordination. Conclusion: For case scenario clinical coding, low accuracy could be explained by variance in clustering methods between participants. This suggests that the accuracy of ICD-11 clinical coding could be increased if the variance between clustering methods can be reduced through the use of a clear coding guide. A guide for various ambiguous cases in each institution and the provision of a proper post-coordination list in the stem code could also be effective.

Aim: To conduct and report on psychometric tests for a valid and reliable measurement tool for evaluating digital hospitals by healthcare professionals. Method: This psychometric study took place in a public digital hospital in Turkey. It was carried out with the participation of 355 healthcare professionals. Data were collected between September and October 2023 using an online survey and non-probability convenience sampling method. Statistical Package for Social Science Version (SPSS) 26.0 and analysis of moment structures version 24.0 were used to analyse the data. It was used for the psychometric properties and analyses of the scale (item analysis, explanatory factor analysis, confirmatory factor analysis (CFA), convergent and divergent validity statistics, Cronbach Alpha internal consistency coefficient, dependent sample t-test, and intraclass correlation). Results: The content validity index of the scale is 0.92. As a result of exploratory factor analysis (EFA) and CFA in separate samples, a total of 30 items and four sub-factors were obtained. Cronbach Alpha value of the scale is over 0.90 for both samples. In the four-factor structure, 82.64% of the total variance was explained. The 30-item and four-factor structure obtained in EFA was confirmed in CFA, and convergent and divergent validity statistics were provided. Test-retest results showed that the scale has high reliability. Conclusion: The digital hospital evaluation scale is valid and reliable for healthcare professionals to evaluate digital hospitals.

Background: Effective documentation and coding in health care are crucial for patient care, safety, workflow improvement and accurate billing. Objectives: This quality improvement study aimed to enhance History and Physical (H&P) note documentation and charge capture processes to integrate coding and billing aspects, capture authentic work, preserve the H&P's integrity and align H&P-related revenue with actual performance. Method: A multidisciplinary team, including divisional leadership and specialists in documentation improvement, electronic health records, lean/six sigma methodology, a nocturnist and a senior-level physician coding auditor, initiated a quality improvement project. Educational efforts targeted approximately 50 hospitalists at a Departmental meeting in January 2023 (Department of Medicine, University of North Carolina School of Medicine), followed by the development and iterative testing of a standardised H&P note template in March 2023, officially disseminated to the entire Department in June 2023. Results: Despite limited impact from education alone, the implementation of an updated H&P template in May 2023 and department-wide distribution in June led to an immediate increase in average work relative value units (wRVU) per encounter, driven by enhanced capture of prolonged time codes and key medical decision-making phrases. The sustained correlation between template usage and increased wRVUs demonstrated a consistent, elevated plateau compared to the education phase. Conclusion: Collaboratively designed and user-informed note templates, balancing usability, efficiency and revenue-generating elements, proved more effective than education alone in integrating complex changes into clinical practice and enhancing coding and billing accuracy. Implications: Results of this study underscore the benefits of standardised documentation tools in enhancing both clinical and financial outcomes, suggesting that healthcare institutions could improve revenue capture, and documentation accuracy by adopting similar approaches.

Background: Accurate coded diagnostic data are important for epidemiological research of stroke.

Objective: To develop, implement and evaluate an online education program for improving clinical coding of stroke.

Method: The Australia and New Zealand Stroke Coding Working Group co-developed an education program comprising eight modules: rationale for coding of stroke; understanding stroke; management of stroke; national coding standards; coding trees; good clinical documentation; coding practices; and scenarios. Clinical coders and health information managers participated in the 90-minute education program. Pre- and post-education surveys were administered to assess knowledge of stroke and coding, and to obtain feedback. Descriptive analyses were used for quantitative data, inductive thematic analysis for open-text responses, with all results triangulated.

Results: Of 615 participants, 404 (66%) completed both pre- and post-education assessments. Respondents had improved knowledge for 9/12 questions (p < 0.05), including knowledge of applicable coding standards, coding of intracerebral haemorrhage and the actions to take when coding stroke (all p < 0.001). Majority of respondents agreed that information was pitched at an appropriate level; education materials were well organised; presenters had adequate knowledge; and that they would recommend the session to colleagues. In qualitative evaluations, the education program was beneficial for newly trained clinical coders, or as a knowledge refresher, and respondents valued clinical information from a stroke neurologist.

Conclusion: Our education program was associated with increased knowledge for clinical coding of stroke. To continue to address the quality of coded stroke data through improved stroke documentation, the next stage will be to adapt the educational program for clinicians.

Objective: To map clinical registries within the Central Adelaide Local Health Network (CALHN); and to identify how these registries were currently used for addressing unwarranted clinical variation in care.

Method: An online survey was sent to all Heads of Units (HoUs) within CALHN. The survey addressed participation, type of data, reporting processes and use of the clinical registries for research, quality assurance (QA), quality improvement (QI) and clinical variation in health care.

Results: Twenty-six HoUs responded (26%); 25 contributed to a clinical registry (96%); all provided data to more than one registry, but only 34.6% had an existing financial and governance arrangement with the network. Health outcomes were the most common datapoints; 77% of all data were collected manually; and 38.5% of data analysis was risk adjusted. Access to aggregated data varied across the registries; and 65.4% of reports included benchmarks and outliers. Clinical registries were used for research in 65.4%, and QA and QI in 73.1 and 69.2%, respectively. Most used external comparators and measured clinical variation, but there was marked inconsistency in the exploring clinical variation, improving care and reporting activities.

Conclusion: Based on this sample, clinical registries within CALHN did not currently appear to be a reliable resource to consistently address unwarranted clinical variation but were shown to be valuable resources for research and quality initiatives at a high level. Further research is required to facilitate effective integration of clinical registries with administrative and quality systems.

Background: Health data sharing is important for monitoring diseases, policy and practice, and planning health services. If health data are used for secondary purposes, information needs to be provided to assist in reuse.

Objectives: To review government health information asset websites to ascertain the extent of readily available, explanatory documentation for researcher sharing and reuse of these data.

Method: Documentary analysis was undertaken on selected Victorian Government health information assets' websites in Australia. Data were obtained on nine information-categories: data custodian; data context; data dictionary; quality controls; data quality; limitations; access process; privacy/confidentiality/security and research requests/outputs. Information-categories were compared by dataset type (administrative or population-health) and by curating organisation (government or other agency). Descriptive statistics were used.

Results: The majority of the 25 websites examined provided information on data custodian (96%) and data context (92%). Two-thirds reported access process (68%) and privacy/confidentiality/security information (64%). Compared with population-health websites, administrative dataset websites were more likely to provide access to a data dictionary (67% vs 50%) and information on quality controls (56% vs 44%), but less likely to provide information on the access process (56% vs 75%) and on research requests/outputs (0% vs 56%, p = 0.024). Compared with government-curated websites, other agency websites were more likely to provide information on research requests/outputs (80% vs 7%, p < 0.001).

Conclusion: There is inconsistent explanatory documentation available for researchers for reuse of Victorian Government health datasets. Importantly, there is insufficient information on data quality or dataset limitations. Research-curated dataset websites are significantly more transparent in displaying research requests or outputs.

Background: Electronic medical records (EMRs) have the potential to improve and streamline the quality and safety of patient care. Harnessing the full benefits of EMR implementation depends on the utilisation of advanced features, defined as "mature usage." At present, little is known about the maturity of EMR usage by allied health professionals (AHPs).

Objective: To examine current maturity of EMR use by AHPs and explore perceived barriers to mature EMR utilisation and optimisation.

Method: AHPs were recruited from three health services. Participants completed a 27-question electronic questionnaire based on the EMR Adoption Framework, which measures clinician EMR utilisation (0 = paper chart, 5 = theoretical maximum) across 10 EMR feature categories. Interviews were conducted with both clinicians and managers to explore the nature of current EMR utilisation and perceived facilitators and barriers to mature usage.

Results: Questionnaire responses were obtained from 193 participants AHPs. The majority of questions (74%) showed a mean score of <3, indicating a lack of mature EMR use. Pockets of mature usage were identified in the categories of health information, referrals and administration processes. Interviews with 21 clinicians and managers revealed barriers to optimisation across three themes: (1) limited understanding of EMR opportunities; (2) complexity of the EMR change process and (3) end-user and environmental factors.

Conclusion: Mature usage across EMR feature categories of the EMR Adoption Framework was low. However, questionnaire and qualitative interview data suggested pockets of mature utilisation.

Implications: Achieving mature allied health EMR use will require strategies implemented at the clinician, EMR support, and service levels.