Health information management and clinical coding workforce issues.
Article Type: Report
Subject: Medical informatics (Management)
Health care industry (Information management)
Health care industry (Human resource management)
Medical care, Cost of (Management)
Labor market (Forecasts and trends)
Author: Shepheard, Jennie
Pub Date: 10/01/2010
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Oct, 2010 Source Volume: 39 Source Issue: 3
Topic: Event Code: 200 Management dynamics; 260 General services; 280 Personnel administration; 010 Forecasts, trends, outlooks Canadian Subject Form: Labour market Computer Subject: Health care industry; Company business management; Company systems management; Company personnel management; Market trend/market analysis
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 241781519
Full Text: In early 2008, it became apparent that many Victorian hospitals were having difficulty filling Health Information Manager (HIM) vacancies and that the service area most specifically affected was the clinical coding services. However, at that stage there was only anecdotal evidence to support the suggestion of a workforce shortage. There was no knowledge of the underlying issues and no understanding of the profile of the existing HIM workforce in Victoria. Nothing was known about attrition rates and, importantly, no definitive knowledge of vacancy rates. As this perceived shortage of clinical coders had the potential to adversely impact on the casemix funding model, the Victorian ICD Coding Committee (VICC) decided to undertake a survey and they enlisted the help of the Victorian Department of Health (DH) Workforce unit to do so. Two follow-up studies were subsequently undertaken by a small graduate group (2) within the DH. The findings of the initial survey and the two follow-up studies supported the contention that Victoria had a workforce problem.

Keywords (MeSH):

Government Financing; Healthcare Costs; Medical Record Administrators; Education; Australia.

Supplementary Terms:

Clinical Coders; Health Information Managers; Workforce

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In April 2009, the Commonwealth and states and territory governments (except for Western Australia) signed a Council of Australian Governments (COAG) agreement that will see the introduction of an Activity Based Funding (ABF) model to underpin the Commonwealth Government's contribution to the cost of delivering health services. The ABF model will apply to both admitted and non-admitted health services. This will have the effect of increasing the demand for Health Information Managers (HIMs) and clinical coders.

For Victoria, where a casemix funding model has been in place for 17 years for acute admitted services, the transition will be easier but there may be an interstate demand for Victorian expertise that will place Victoria's workforce under greater pressure.

At the time of writing this report, a working party has been established by the Victorian Department of Health (DH) to develop strategies for acting upon some of the recommendations made by the graduate projects and to look at the overall health information workforce, including the clinical costing workforce. The lessons learnt from Victoria's work could be relevant for other states and territories as ABF is rolled out nationally.

Introduction

Victoria has been in the fortunate position for some time of having an undergraduate course in health information management to provide a steady supply of HIMs to work in our hospitals, the DH, and in other related organisations. This has resulted in HIMs being the primary source of skilled personnel to undertake clinical coding services in Victorian hospitals. With the introduction of a casemix funding model in 1993, HIMs were well placed in hospitals to develop a high level understanding of the (then) Australian National Diagnosis Related Groups (AN-DRG), to participate in the education of management and clinical personnel regarding the new funding model, and to develop the in-house auditing programs for clinical coding and clinical documentation, which are a key feature of most public hospitals in Victoria today.

From around 2006-2007, the VICC was becoming increasingly aware of the fact that many hospitals were struggling to attract applicants for their coding position vacancies. Pre-audit surveys also showed that some hospitals were having difficulty attracting and retaining health information management staff to get their coding done. While it was difficult to understand the extent of the problem, there was no doubt that it was frustrating to many HIMs, and, importantly, from the DH's perspective, there was no doubt that many health services were struggling to report their coded data within the timelines set by the Department. Basically, it was obvious that Victoria's clinical coding workforce was in crisis.

The 2008 workforce survey

As there was no available evidence to support the suggestion that a decreasing number of graduates was the underlying cause of the problem, the VICC decided to undertake a survey of the existing HIM workforce in Victoria, to learn more about the workforce situation and to find out what could be done to overcome the workforce shortage.

Survey participants

Information was sought as to where all the current HIMs and clinical coders in Victoria were working; if they were working at all; how many hours they worked; how long they planned to stay in the workforce; and if they were currently unemployed, whether or not they planned on returning to the workforce. This survey was developed in 2008 with the help of the Service and Workforce Planning Branch of the (then) Department of Human Services (3) and was sent electronically to all HIMs for whom contact details were available. These HIMs were asked to forward the survey on to any other HIMs who may not have received it, or who were no longer working. There were 506 respondents and, although the total number of HIMs in Victoria is not known, it is suspected that this represented close to 100% of the workforce.

Results

Results of the survey showed that 93% of respondents were female, compared with 91% of nurses being female, and a higher than normal percentage were born in Australia (86%). The workforce was young relative to other workforces, with 51% less than 40 years old and only 10% aged over 55 years.

Of respondents who were working, 52% were full time, 31% were part time and 3% were casual; the rest were not currently working. Eleven percent (58 respondents) were not working in HIM jobs in Victoria, half of whom were in unrelated work and the remainder were either working interstate or not working at all. Only one third of these 58 respondents were planning to return to HIM work. Of the 506 respondents, 182 were working more than 40 hours per week, with 133 of those working the 40-plus hours at one location, 40 working across two locations, and 9 working across three locations.

Only 16% of the respondents had a Health Information Management Association of Australia (HIMAA) coding certificate, reflecting the fact that most of the clinical coding in Victoria is done by HIMs. Two hundred and sixteen (43%) of the respondents were working in clinical coding positions, including coding educator and coding coordinator positions, and a further 96 had a second job in clinical coding, meaning that at least 61% of the respondents worked at least some of their time in a clinical coding position. One hundred and nine of the 506 worked in a second job and 17 of these worked in a third job. These second and third jobs were all clinical coding positions.

The average weekly hours worked was relatively high for all age groups, including the hours worked by HIMs aged over 50 years, when work hours typically taper off.

Graduate group project one

Survey participants

In 2009, a graduate group at the DH was given the task of conducting a second survey to examine qualifications, experience, working hours, retention rates, records coded per hour, and other issues affecting coding rates, to gain a different perspective on the coding workforce. This group surveyed public hospitals. They distributed the survey to 94 health services, of which 42 responded. (4)

Results

Results of the second survey (graduate group project one) demonstrated that for the 42 health service organisations that responded to the survey, 63.55% of the available clinical coding positions had not been filled. These results also identified the various means that respondent organisations had employed to meet the workforce shortfall, including paid and unpaid overtime, outsourcing of the clinical coding function, and employment of contract coders. Moreover, this survey found that 25% of clinical coders spent time on duties other than clinical coding and that these graduates considered this an inefficient use of a scarce resource.

Results of the graduate group project one survey were compared with those of the Australian Clinical Coder Workforce survey, conducted in 2002 by the National Centre for Classification in Health (NCCH), which had identified 38 coder positions vacant across Australia and plans to create a further 26 coder positions across Australia. This was equated to a shortfall of 64 full-time equivalent coders across Australia, with NSW and Victoria being the most in need. Using the NCCH report data for comparison purposes, it appeared that there was in fact an increase in vacancy rates for the clinical coder workforce, at least in Victoria.

Graduate group project two

Survey participants

In late 2009, a second group of graduates undertook a project to look at the available training courses for clinical coders. This group interviewed representatives from La Trobe University, HIMAA, rural and metropolitan health services, and some new coders.

Results

Survey participants reported difficulty in attracting new students to the training courses, with most students hearing about the health information management or clinical coding professions via word of mouth, or previous exposure to the profession at their current or former workplaces. They also concluded that both health information management and clinical coding are 'hidden' professions, with a low profile in the health service industry in spite of their importance to the appropriate funding of hospitals.

The casemix funding environment

In a casemix funding environment, no health service can afford to have poor quality clinical coding. Therefore, inexperienced coders need to be supported with substantial on-the-job training before they are considered competent. This was confirmed by the second graduate group project, which reported that most health services accepted that they had no choice but to put resources towards this on-the-job training. Of course, this takes time from an experienced coder, further exacerbating the shortfall of coding time in the particular hospital or health service.

Findings from these various surveys and projects, which focused on the clinical coder workforce within the health services, has shown that a broad range of knowledge, well beyond the knowledge of coding classification alone, is what defines a good clinical coder in a casemix environment. Specific knowledge includes medical terminology, anatomy and physiology, casemix systems, AR-DRG classification, specific funding models (Victoria has a Weighted Inlier Equivalent (WIES) payment model), as well as knowledge of local admission policies.

The introduction of a casemix funding model in Victoria in 1993 took HIMs, particularly those working in clinical coding, 'from the basement to the penthouse'! Their knowledge and expertise was in demand as never before. Those working in clinical coding positions were expected to have answers to many questions being asked at the time. Importantly, their work was scrutinised by hospital managers and finance officers, who questioned the assignment of certain codes in an effort to optimise DRG outcomes. Clinical coders were required to attend clinical meetings, conduct quality activities, and participate in education activities, both for themselves and for other staff in the hospital. They were also required to slow down, make routine use of the index to the classification rather than rely on memory to assign codes and take time to read the coding standards, refer to dictionaries and other resources for anything they did not understand, and to stay current with the latest advice issued by the NCCH and by the VICC. Clinical coders became regular attendees at clinical meetings where they communicated the nuances of the funding model and the classification to medical staff. They also were at the forefront of developing internal auditing programs that checked code assignment and worked to improve clinical documentation in the medical records. The resultant positions that were created in many hospitals were filled primarily by HIMs.

It is unlikely that this impact was foreshadowed with any understanding of the increased numbers of HIMs and clinical coders that would be needed to manage the demand. With the COAG agreement being signed for an activity-based funding model to be used in most states and territories to obtain Commonwealth funding, this demand will be reflected across the country. This demand will be for both clinical coders and HIMs to complete the coding and to take on the higher level roles of coding educator, coding coordinator and coding auditor in the country's hospitals. There will also be a need for experienced HIMs to work in the development of the classifications, both the ICD-10-AM/ACHI and the AR-DRG, and possibly also to work in clinical costing systems.

From Victoria's workforce perspective, a national ABF funding model will have a different effect. Victorians already know how to work in an activity-based funding environment and Victoria has ready access to the health information management graduates from La Trobe University. However, there is still a struggle to maintain adequate numbers in the workforce and the graduates are now even more attractive than they have previously been for interstate positions. Thus, Victoria needs to do something to withstand an increased demand from outside their borders for coders and HIMs with casemix experience.

Demand for HIMs in non casemix areas

The 2008 survey and the two subsequent graduate projects made it abundantly clear that HIMs are increasingly in demand in Victoria in areas outside of clinical coding and outside the hospital environment. The rollout of the HealthSMART (5) project in Victoria has taken several HIMs into IT related work, both in hospitals and with the HealthSMART project groups. At the time of writing this report, the Victorian DH employs approximately 30 HIMs and is actively seeking to employ more HIMs in various areas of the Department. Similarly, HIMs are being sought to work in research institutions, in health funds and private organisations, such as the Transport Accident Commission and Work Safe Victoria. Victorian health information management graduates are also in demand interstate, where there are no health information management courses. This leaves fewer HIMs available to work in clinical coding and casemix-related jobs in Victoria.

National health reform

A national partnership agreement on hospital and health workforce reform was announced in November 2008 by COAG. Under the terms of this agreement, a National Health Workforce Agency will be established and funding will be made available to train additional health workers. However, the emphasis here is on the provision of clinical training with a view to increasing the numbers of medical, nursing and allied health workers. There is no mention of the health information management or clinical coder workforce. This agreement includes the use of activity-based funding as a means of reforming hospitals and explicitly states that nationally consistent classifications and data collections and nationally consistent costing models will be required. But, again, there is no mention of the health information management and clinical coder workforce, which is fundamental to 'consistent classifications' and to 'data collections'.

Nationally, the National Health Information Standards and Statistics Committee (NHISSC) convened a workshop in June 2009, specifically to discuss the issue of shortages in the health information management and clinical coder workforce, as well as the shortage of costing specialists. This Committee commissioned a national survey to be undertaken to ascertain the current numbers of people working as clinical coders (either health information management or clinical coding trained) to gain an understanding of the current vacancy rates. This survey was conducted by the Australian Institute of Health and Welfare (AIHW) during the early part of 2010 and results are expected to be available during the second half of 2010.

Recommendations

Recommendations from the two graduate projects undertaken in Victoria include the following suggestions: health services should promote the health information management profession; host student placements; engage with training institutions; sponsor students in the existing courses; and provide bursaries to school leavers and others interested in undertaking the existing courses. Further, the DH should subsidise courses (existing and new); promote the profession; provide support person(s) for health services to train new staff; fund additional staff; and provide an award for clinical coders. These things, if they can be done, will assist in solving the workforce shortage.

However, an obstacle still exists: the absence of a clear and comprehensive understanding of the existing workforce. Surveys provide a snapshot at any given point in time but do not provide ongoing dynamic information about workforce movements. Information about where health information management graduates may be at any specific time is not available. Thus, it is not possible to contact HIMs to encourage them back into the workforce, for example, or to help hospitals find people to work for them. A registration process for HIMs and clinical coders would help with this issue. State or Commonwealth awards for clinical coders are also required to establish clinical coding as a recognised profession. Currently, Queensland is the only state to have such an award in place.

Before real progress can be made on this workforce issue, some important conversations need to take place. Specifically, it is essential to clearly articulate the difference between a HIM and a clinical coder. Currently, this may only be an issue for Victoria but it may become relevant for other states and territories in an activity-based funding environment. The outcomes of such a conversation would enable courses to be tailored to meet current workforce demands. It is possible that a new qualification is needed, in addition to the health information management degrees and the clinical coding certificate courses.

Secondly, it is necessary to understand who is responsible for the provision of an adequate workforce in an activity-based funding environment. Without such an understanding, there will be no clear way forward to address the workforce issues. Is it the responsibility of government, the training institutions, or the health services themselves, or are HIMs, as individuals, responsible to some extent? The author contends that all HIMs have some responsibility here, and that each of the above (governments, educational institutions, health services and HIMs) has a role to play:

* Departments of Health may have to make resources available, possibly both financial and human, to support new courses or the expansion of existing courses.

* Universities and other training institutions may need to develop and run new courses and expand existing courses. There is a financial risk but one that may be well worth taking.

* Hospitals and other industry organisations need to support students by providing industry placements, on the job training, bursaries and other practical support.

* Individuals have to be ready to work to support these interventions including stepping up to be involved in teaching, which may mean more work for all HIMs.

Conclusions

There are some unknowns in this conversation about the health information management and clinical coder workforce. First, the introduction of an electronic health record (EHR) has the potential to change the role of the clinical coder and may in fact decrease the demand for clinical coders. SNOMED will be at the forefront of this change and it is possible that mapping tables will produce the ICD-10-AM and ACHI codes and very little else will need to be done. However, there is no certainty as to when Australia will have an EHR and neither has the impact of an EHR been fully articulated. Given that the current coding standards require a human decision to be made, it is unclear to what extent clinical coding can be automated with a true electronic health record. It would seem foolish to rely on the EHR to solve clinical coding workforce issues.

It is also necessary to understand that the activity-based funding model signed off by COAG is not limited to admitted patient activity but also requires that patient level information be collected and reported for non-admitted patient activity. Non-admitted activity includes emergency department and outpatient clinics and if it is necessary to provide clinical codes for all these patients then the demand on the clinical coding workforce will increase exponentially.

It is very difficult to get this issue onto the agenda of workforce professionals, who are also dealing with a shortage of medical, nursing and allied health personnel, and it is to shortages in these professions that money and political energy are being directed. There is enough evidence to make it clear that there are not enough people dedicated to coding currently in Victoria and that this may well be the case in the rest of the country very soon. The challenge is: what can HIMs do about it?

Postscript

Since this paper was presented at the Clinical Documentation, Coding and Analysis Conference a working party has been established by the Victorian Department of Health to investigate ways in which the various recommendations from the graduate projects can be executed and to develop a strategic plan to protect and expand Victoria's health information workforce (HIMs, clinical coders and costing specialists).

(1) This report is based on a paper presented at the Clinical Documentation, Coding and Analysis Conference, Melbourne, March 2010.

(2) Graduate groups consist of graduates from any discipline, who had recently been employed in a Government Department and who had chosen to participate in the 'graduate program', which consisted of a 12-month rotation program through four different Government Departments.

(3) The Victorian Department of Human Services was restructured in 2009 and became two Departments: the Department of Human Services and the Department of Health.

(4) The results of this survey have not been officially released or published. However, the Department of Health has given permission for the findings to be discussed in various forums including as part of the conference presentation.

(5) HealthSMART is Victoria's whole-of-health information and communication technology (ICT) strategy.

Jennie Shepheard RMRL, GDipHthAdmin, CertHthEco, MPH

Senior Health Information Manager

Advisor

Health Data Acquisition

Funding and Information Policy

Hospital and Health Service Performance

Department of Health

50 Lonsdale Street

Melbourne VIC 3000

AUSTRALIA

Tel: +61 3 9096 0484

email: Jennie.Shepheard@health.vic.gov.au
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