Health classification--a complex world.
Article Type: Editorial
Subject: Information management (Methods)
Diseases (Australia)
Diseases (Identification and classification)
Medical protocols (Evaluation)
Practice guidelines (Medicine) (Evaluation)
Author: Shepheard, Jennie
Pub Date: 02/01/2009
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Feb, 2009 Source Volume: 38 Source Issue: 1
Topic: Computer Subject: Information accessibility
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 216488657
Full Text: We classify many things in our lives in order to make sense of them and to make them useful to us. In fact without this instinct to categorise the things with which we deal on a daily basis, we would find life very difficult. Supermarket shopping and searching for books on the library shelf, for example, would be difficult tasks indeed. In the work place, Health Information Managers (HIMs) and Clinical Coders make daily use of very specific classifications: the Australian modification of the International Classification of Diseases, ICD-10-AM, and the Australian Classification of Health Interventions (ACHI). These classifications are used by HIMs and Clinical Coders to assign codes for diseases and procedures respectively to the medical records of admitted patients. They in turn are used to derive AR-DRGs, another classification with which we are required to be very familiar. There are several other classifications that are used in the hospitals and health services that are less well known but with which those who work in specialist areas have become familiar, and yet other less formal classifications that have become essential knowledge for HIMs and Clinical Coders working in certain areas.

In many ways HIMs and clinical coders are themselves an extension of these classifications; they are the means by which classifications, or more specifically the information they represent, are made available to the other users of these classifications: the researchers, health service planners, and various funding bodies. We consider these classifications to be 'ours' but in fact we are merely one of many professional bodies with a significant interest in ICD-10-AM, ACHI and other health classifications.

This issue of the Health Information Management Journal (HIMJ) focuses on classification, and the articles it contains combine to provide an insight into the ways in which disease classifications are used and the variety of people who make use of them. It also gives a glimpse of the different career paths that are available to those with expert knowledge of the classifications as well as the variety of careers that need at least a working knowledge of these classifications. The coder profiles represent a fascinating mix of career paths (as well as being something of a travelogue!), and highlight the options we all have to move between the public and private sectors, the industry based and academic workplaces, and to be involved in professional development and committee work that 'gives back' to the profession that serves us so very well.

The databases of 'administrative' information that have so comprehensively replaced the card indices and paper files of a previous paper-based era are easily accessed and interrogated, making them very attractive resources to researchers. As noted by Jude Michel and Terri Jackson in their paper, they allow timely analysis of data to identify trends and issues as soon as they arise, and they enable the conduct of large scale research that would be prohibitively expensive if a review of medical records was required (Michel & Jackson 2009). Desktop research can be performed on the reasons for admission to hospital, the adverse events that occur in hospital, and the demographics of various groups of patients (maternity, cancer etc.) to mention just some examples. This can all be done by searching through the strings of codes using powerful computers; there is no need to travel to a hospital or even open a medical record! This research in turn is important in the development of many aspects of public health policy including the development of the classifications themselves. The lure of these inexpensively collected data attracts researchers in all fields and highlights the need for classification experts to work beside researchers to provide information about changes in the classifications over time such as those provided in the ICD-10-AM/ACHI/ACS chronicle (NCCH 2008); to assist with interpretation of the coded data; and importantly to help ensure that this type of research is good research. Two of the research papers published in this issue have been based on this type of research, interrogating and examining subsets of our national databases. They provide valuable information about classifications: Hong, Walker and McKenzie (2009) examine the quality of morbidity (specifically, injury) data derived from coded hospital sources in Vietnam, while research reported by McKenzie, Cheng and Walker (2009) is concerned with the classification of external causes of injury in mortality databases in Australia. They also highlight other issues that are relevant to the successful use of classifications, such as the quality of the documentation, and illustrate the importance of accurate interpretation of the data.

The other two research papers emphasise the importance of clinical coding audits as a quality assurance tool in the maintenance of high quality data and the risks to those data that are associated with poor documentation. Soo et al. (2009) are also concerned with injury documentation and the use of activity codes which were introduced in the ICD-10-AM, Third Edition. Cheng et al. (2009) review the consequences of inaccurate coding, and report on a Victorian hospital clinical coding audit which demonstrates one of these consequences: the possibility of under funding through casemix due to incomplete or inaccurate coding.

The reports in this issue of HIMJ aim to profile the complexity of the 'classification' world and various issues that impact on the functioning of that world. Much important activity takes place behind the scenes and is not particularly glamorous; we never see the Medical Record Department or Health Information Service on the front page of the newspaper in spite of the fundamental importance of the work that is done in these areas. Similarly, changes in clinical practice and in admission practices impact on the workloads of Health Information Managers and Clinical Coders, but this aspect of the changes is rarely quantified or even acknowledged.

In their report, Postle, Koeldnik and Miocevich (2009) list various factors that impact on the workplaces of coders, and suggest a need for us to be proactive about addressing them, and Doyle and Dimitropoulos (2009) outline the cycle of classification development and provides some insight into the complexity of this process. We are all familiar with the Clinical Coders Creed and the complexity of decision making that is required to perform the task of code assignment; Prudames (2009), however, reminds us that the private sector has an even more complex environment in which to work, one in which funding considerations are not just important but often threaten the coder's integrity and the usefulness of the classification itself. Health Information Managers and Clinical Coders are often unaware of the extent to which coded data are used by researchers to reach all sorts of conclusions about our health services, and Michel and Jackson (2009) comprehensively dispel any notion that our coding falls into a 'big black hole' never to be seen again. Their interesting contribution takes us on a fascinating journey with our coded data. Meanwhile, Bidie (2009) has been able to transfer her Australian acquired skills internationally, as she shows in her discussion about clinical coding in another country. I do not think our coding auditors will adopt the title of 'reabstractors' but it is interesting to note that not only clinical coding but also auditing of that coding provides career opportunities worldwide.

Career opportunities exist for HIMs in the conduct of audits, in the development of good documentation standards, form design, and the development of electronic health records, all of which have an impact on the success of our classifications. In Australia we are lucky to have a classification workforce that is highly skilled relative to international standards, where some countries have only 50% of their classification workforce holding formal qualifications (Walker 2006). The profiles featured in this issue serve to demonstrate the enormous diversity of skills and professional adaptability of clinical coders in Australia. Sims (2009) stumbled into the profession seemingly by accident, but hers is a story of pride and satisfaction in her career. Sims' career path has been 'non-traditional', taking her ultimately to a position in the Australian Institute of Health and Welfare, as well as leading to close involvement with HIMAA. Stanfield's (2009) overview of the progress of clinical coding from the days of paper-based files to electronic health records which she has experienced is fascinating, and illustrates the rapidity of change that is occurring in the profession.

These two examples show just how challenging and rewarding a career in health information management can be. However, workforce shortages and declining enrolments in health information management courses in this country are concerning many people who recognise the expanding, and increasingly unmet, need for qualified personnel in this, and many other aspects of health information management. We must not become complacent about the skills we have, our good fortune in having training courses available (certificate, degree and masters), and the need to promote our professions and our classifications.

We are also fortunate in Australia that we can participate in the development of our classifications with relative ease. While political concerns often drive these developments, Australian Health Information Managers and Clinical Coders are represented on, or have input into, those committees that make decisions about classification changes and this is an aspect of our work and our responsibilities that we must continue to embrace. Regular participation in and attendance at international conferences, such as the IFHRO South East Asian Conference reported by Emily Price in this issue, will enhance both the national and international standing of Australian HIMs.

We are currently world leaders in the classification area and the future is exciting; we can look forward to the promise of SNOMED, another classification that could become 'ours', and the electronic health record. But that future hinges to some extent on our ability to use our classifications effectively, to ensure that others use them effectively and to grow our profession so that there will always be enough of us.

In closing I would like to emphasise our collective professional responsibility to use these classifications:

* accurately--with respect to the conventions and standards inherent in the classification and being mindful of the consequences when important decisions are made on the basis of inaccurate information.

* independently--of the source of the information, so that we are not unduly influenced by the clinicians or our own expanding clinical knowledge; of political issues, so that we are not unduly influenced by funding and other imperatives; and of future users, so that we provide information that is as true as possible leaving the interpretation of what that truth is in various contexts to those whose task it is to do that.

It is my hope that you all find something in this issue of HIMJ to inspire you and perhaps to encourage you to expand your career options.


Bidie, A. (2009). Aspects of coding in Canada: through the eyes of an Australian HIM. Health Information Management Journal 38(1): 62-63.

Cheng, P., Gilchrist, A., Robinson, K.M. and Paul, L. (2009). The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding. Health Information Management Journal 38(1): 35-46.

Doyle, K. and Dimitropoulos, V. (2009). Keeping your classification up to date. Health Information Management Journal 38(1): 50-51.

Hong, T.T., Walker, S.M. and McKenzie, K. (2009). The quality of injury data from hospital records in Vietnam. Health Information Management Journal 38(1): 15-21.

ICD-10-AM/ACHI/ACS Chronicle of Changes from First to Sixth Edition, National Centre for Classification in Health --Australia, June 2008.

Kearsey, I. (2008). When did we start doing that? Documenting the evolution of health information in Australia. Health Information Management Journal 37(2): 5-8.

McKenzie, K., Cheng, L. and Walker, S.M. (2009). Correlates of undefined cause of injury coded mortality data in Australia. Health Information Management Journal 38(1): 8-14.

Michel, J. and Jackson, T. (2009). Australian routine data: not just for funding. Health Information Management Journal 38(1): 53-58.

Postle, B., Koeldnik, N. and Miocevich, T. (2009). The coding conundrum: a workplace perspective. Health Information Management Journal 38(1): 47-49.

Prudames, F. (2009). Sailing the seven Cs with the clinical coders' creed--the eighth 'C' for private sector coding. Health Information Management Journal 38(1): 59-61.

Sims, N. (2009). Professional profile: Australian Institute of Health and Welfare. Health Information Management Journal 38(1): 67-68.

Soo, I.H-Y., Lam, M.K., Rust, J. and Madden, R. (2009). Do we have enough information? How ICD-10-AM Activity codes measure up. Health Information Management Journal 38(1): 22-34.

Stanfield, W. (2009). Professional profile: Warringal Private Hospital, Melbourne. Health Information Management Journal 38(1): 69-71.

Walker, S. (2006). Capturing health information: A perspectives paper. Health Information Management Journal 35(3): 13-22.

Jennie Shepheard RMRL, GDipHthAdmin, CertHthEco

Senior Health Information Manager


Health Data Acquisition, Health Information Funding and

Health Information Policy

Metropolitan Health and Aged Care Services

Department of Human Services, Victoria

50 Lonsdale Street

Melbourne VIC 3000


Tel: +61 3 9096 0484

Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.