Data Analytics in Action: Study on Clinical Coding in Nigeria ONUOGU PATIENCE NDIDI, RHIM, MBA DEPARTMENT OF HEALTH INFORMATION MANAGEMENT MAITAMA DISTRICT HOSPITAL ABUJA, NIGERIA
KNOWLEDGE AND PRACTICE OF CLINICAL CODING AMONG HEALTH INFORMATION MANAGEMENT PROFESSIONALS IN NIGERIA 2
Agenda Background Learning Objectives Definition of clinical coding Survey Results Submission Conclusion
LEARNING OBJECTIVES Recognize the knowledge and practice of clinical coding among Health Information Management Professionals in Nigeria. Identify the factors militating against the good practice of clinical Coding in Nigeria. Discuss possible solutions to the identifiable areas.
BACKGROUND The World Health Organization classified clinical coding as a major and exclusive responsibility of HIM professionals, specifying that clinical coders require knowledge of medical terminology, legal aspects of health information, health data standards, and computer or paper-based data management. Health Information Management (HIM) professionals play a critical role in maintaining, collecting and analyzing the data that health care providers rely on to deliver high quality health care. They are experts in managing patient health information and medical records, administering computer information systems, coding the diagnoses and procedures for health care services provided to patients. It is a discipline that has rapidly evolved toward roles of increasing complexity and demand in recent years. The coding profession has been one area at the centre of this growth. Even though the HIM profession is currently rethinking their coding and clinical processes due to widespread industry changes and initiatives. It has always been essential for coding professionals to have ongoing professional development to survive in this new environment. Enhancing clinical knowledge through education and resources is essential.
BACKGROUND continued In addition to W.H.O specification, Coding professional must have a solid base of Anatomy, pathophysiology and pharmacology. It s not enough to see a diagnosis, sign, or symptom documented in the medical records of patients. They must take time to search it out in the book or encoder and add it to the list of codes. Clinical knowledge is put to use continuously along with coding rules and guidelines to assign the proper code. Consider the following scenario : a 23-year-old female presents to the emergency room with the sudden onset of severe pelvic pain, vaginal bleeding, and light headache. She has a history of multiple abdominal surgeries, positive smoker, 1 pack per day. Serum β-hcg levels were elevated. The patient was diagnosed with an ectopic pregnancy and transferred to the operating room. Without knowing the pathophysiology and clinical picture of an ectopic pregnancy, an untrained person may code the pain, bleeding, light headache and abnormal lab values in addition to the ectopic pregnancy, where a trained coder knows all of these are signs and symptoms of the definitive diagnosis and are not to be assigned a code number.
Oral and written communication skills are essential, as well as the ability to effectively interact with all types of clinical staff including physicians, mid-level providers etc. Where many professionals are well versed in one or two specific areas, a coding professional must be knowledgeable in all body systems and know how to convey the information concisely and in several different styles: Face-to-face or written queries Coding education to providers and staff Appeal letters Day-to-day interaction Coding questions
The ability to formulate a query with clinical evidence from the medical record will garner the attention of the provider and decrease the likelihood of an unanswered question. The ability to speak with a provider in clinical terms about disease processes and formulate intelligent questions will gain the respect of the provider and increase the likelihood of successes in the future. Providers will also be more likely to listen to those who are clinically knowledgeable when being educated about coding issues, which is of utmost importance. The ability to speak to or query a provider or write an effective appeal letter with the clinical knowledge of a disease process further supports the importance of coding professional in the clinical validation process.
This is the time for coders to take the opportunity to expand their skills on the clinical side of coding and strengthen their position in the industry. Most coders are being given the chance to sharpen their clinical knowledge by their employers, they should all take that opportunity to grow their skills. It is a great time to increase their confidence in the very important position that they are in and capitalize on the opportunities that this Profession will bring. One way for coding professionals to demonstrate their advanced clinical knowledge is by attaining the Certified Documentation Improvement Practitioner (CDIP) credential. Professionals earning the CDIP credential will be distinguished as knowledgeable and competent in clinical documentation in patient health records and be positioned as leaders and role models in the HIM community.
The need for accurate, complete, efficient and timely clinical coding of diagnoses and procedure has become a critical issue In healthcare institutions. Its being utilized for statistical purposes, reimbursement, administration, epidemiology, health service research among others. As a result of this, it is highly imperative to consider effective management of knowledge in practice of clinical coding. In light of the above, AHIMA (2001) affirms that clinical coding should be performed by credentialed Health Management Professionals. This necessitates urgent need for Knowledge management for an efficacious outcome in health service delivery. Lack of specialized HIM Professionals in clinical coding and Certified Documentation Improvement Practitioner (CDIP) in Nigeria leaves room for errors that result in distortions of medical records quality, but extension of this specialities by AHIMA can alleviate this deficiencies.
DEFINITION OF CLINICAL CODING Clinical coding is the translation of medical terminology as written by clinicians to describe patient s complaints, problems, diagnosis, treatment or reasons for seeking medical attention in a coded format which is nationally and internationally recognized. It is one of the key components for coordination of all health system actions that are involved in providing or financing health services. It has a major impact on health care providers monitoring activities, assessment and estimate of the need for health services. ICD is the acronym for the International Classification of Diseases. The ICD is maintained by WHO to classify diseases and other related health problems recorded on many types of health and vital records. It is used to monitor the incidence and prevalence of diseases and other health problems. Presently ICD-10 edition and ICD-10-PCS are used for clinical coding in Nigeria.
SURVEY This study was conducted at the National continuing education program organized by Health Records Officers Registration Board of Nigeria (HRORBN) at National Hospital in Abuja 2015 and in some selected Secondary Hospitals in Abuja. The workshop constitute representatives of Health Information Management professionals of the Thirty six states and the federal Capital Territory Abuja Nigeria. Selected secondary hospitals in Abuja were Gwarinpa general hospital, Maitama district hospital, Wuse district hospital and Asokoro district hospital. A semi-structured questionnaire was used to elicit information from the respondents. A total of two hundred and fifty questionnaires were used to elicit information from the respondents, two hundred and twenty were duly filled and returned back. ( one hundred and fifty HIM professionals among those that attended the workshop gave their consent for participation, while seventy participants were from the selected secondary hospitals in Abuja). Tables and simple percentage statistical analysis were used to analyze the data.
RESULTS Fig 1. QUALIFICATIONS OF THE RESPONDENTS 250 200 150 100 50 0 Masters Bsc Hnd Technicians Total Frequency 46 56 86 32 220 Percentage 21 25 39 15 100 It was seen from fig 1 that 46 (21%) of the respondents have masters, 56 (25%) have BSC, 86 (39%) have Higher National Diploma (HND), while 32 (15%) have Technician in Health Information Management. This simply shows that respondents with HND qualification have the highest response with 39%.
250 Fig 2. YEARS OF EXPERIENCE 200 150 100 50 0 0--5 6--10 11--15 16 &ABOVE TOTAL FREQUENCY 36 60 94 30 220 PERCENTAGE 16 27 43 14 100 Fig 2. revealed that 36 (16%) of the respondents have 0-5 years experience, 60 (27%) have 6-10 years of experience, 94 (43%) have 11-15 years of experience while 30 (14%) have 16 and above years of experience. This means that respondents with 11-15 years of experience have the highest response with 43%.
Fig 3. Clinical Coding is a core practice of Health Information Management? 250 200 150 100 50 0 Yes No No idea Total Frequency 220 0 0 220 Percentage 100 0 0 100 A total respondents of 220 (100%) agreed that Clinical coding is a core practice of Health Information Management. This means that all the respondents were of the opinion that Clinical coding is a core practice of the profession.
Fig 4. DO you have the knowledge of clinical coding? 250 200 150 100 50 0 yes no Total frequency 190 30 220 percentage 86 14 100 Respondents of 190 (86%) have the knowledge of clinical coding, while 30 (14%) of the respondents said that they don t have the knowledge of clinical coding.
Fig.5 Do you practice clinical coding in your organization?. 250 200 150 100 50 0 Yes No Total Frequency 160 60 220 Percentage 73 27 100 Fig 5. shows that 160 (73%) of the respondents practice clinical coding in their organizations while 60 (27%) don t practice clinical coding in their organizations.
250 Fig.6 Do you encounter any challenges while coding? 200 150 100 50 0 Yes No I don t code Total Frequency 160 0 60 220 Percentage 73 0 27 100 Fig 6 Shows that 160 (73%) of the respondents encounter challenges while coding, 60 (27%) said they don t practice clinical coding.
Fig 7. Will you support the knowledge and practice of clinical coding among Health Information Management Professionals in Nigeria?. 250 200 150 100 50 0 Yes No Total Frequency 220 0 220 Percentage 100 0 100 An overwhelming 220 (100%) of the respondents agreed to support the knowledge and practice of clinical coding among Health Information Management Professionals in Nigeria.
SUBMISSION This study has described the Knowledge and practice of Clinical coding among Health information Management professionals in Nigeria. All respondents were of the opinion that Clinical coding is a core practice of the profession. (86%) have the knowledge of clinical coding. (73%) of the respondents practice clinical coding in their organizations. (73%) of the respondents encounter challenges while coding. (100%) of the respondents agreed to support the knowledge and practice of clinical coding among Health Information Management Professionals in Nigeria. Challenges to clinical coding practices in Nigeria are enormous ranging from problems of manual coding, medical errors, illegible handwriting, non-completion of discharge summary, inexperienced clinical coders, inadequate and unmotivated workforce.
The two major challenges border on clinical documentation and health data quality as it affects clinical coding. Documentation issues have been of primary concern for coding quality and it has been suboptimal in developing nations such as Nigeria. AHIMA (2001),affirms that clinical coding should be performed by credentialed Health Management Professionals. This necessitates urgent need for Knowledge management for an efficacious outcome in health service delivery. In the light of this, we are employing AHIMA to extend the credentialed health Information Management examinations such as CDIP, CCA, CCS, RHIT, RHIA, etc. to Nigeria. Approval of PEARSON International test centre in Nigeria is paramount at this time in order to enhance the career and make us role model in health information management profession.
CONCLUSION This study suggests advocacy and coding education with a view to modifying the orientation of all stakeholders and to sensitize relevant authorities on the benefits of clinical coding practices in order to maximize its outcome and in effect, improve public health in the country.
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