IFHRO Promoting Health Records Standards

1. IFHROPromoting Health Records Standards Lorraine Nicholson President of IFHRO (International Federation of Health Records Organisations) 2nd SE Asia Regional Conference, Perth, Australia 13th October 2009 2nd SEAR Conference 13/10/09

2. A 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 Edinburgh 1963 Chicago In 1968 IFHRO was formed in Stockholm 16 years, 5 international congresses and thousands of letters after the idea was initially discussed at the first international meeting in London in 1952 2nd SEAR Conference 13/10/09

3. 1968 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 2nd SEAR Conference 13/10/09

4. In 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” 2nd SEAR Conference 13/10/09

5. 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 2nd SEAR Conference 13/10/09

6. 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 2nd SEAR Conference 13/10/09

7. Other 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 2nd SEAR Conference 13/10/09

8. “The Relationship between Health Record 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. 2nd SEAR Conference 13/10/09

9. Primary Purposes of Health 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 2nd SEAR Conference 13/10/09

10. Primary Purposes of Health 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 2nd SEAR Conference 13/10/09

11. Secondary Purposes of Health Records 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 2nd SEAR Conference 13/10/09

12. Existing Standards for Health Records There are two types of existing standards for Health Records • Structure of the Health Record • Content and completeness of the documentation within the record 2nd SEAR Conference 13/10/09

13. Structure 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 2nd SEAR Conference 13/10/09

14. Content and Completeness of Documentation 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 2nd SEAR Conference 13/10/09

15. Importance of Standards for Health Records Both types of standards for records are vitally important for clinical coding purposes • STRUCTURE - so that relevant information to determine complete & accurate codes can be easily located • CONTENT - because the completeness and accuracy of the coding relies on content 2nd SEAR Conference 13/10/09

16. 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 2nd SEAR Conference 13/10/09

17. On-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 2nd SEAR Conference 13/10/09

18. Supporting the Use of the RCP Standards 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 2nd SEAR Conference 13/10/09

19. Benefits of Standards for HIM’s & Coders 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 2nd SEAR Conference 13/10/09

20. Standards & 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 2nd SEAR Conference 13/10/09

21. Improving 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 2nd SEAR Conference 13/10/09

22. Improving 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 2nd SEAR Conference 13/10/09

23. Thank You Lorraine Nicholson President of IFHRO l.nicholson@zen.co.uk +44 01706 355957 2nd SEAR Conference 13/10/09