How many clinicians does it take to build a health information management system?

On Wednesday, 22 March, NSW Health held an eHealth NSW Chief Clinical Information Officer's Clinical Engagement Forum entitled 'How do we put nurses and midwives in the driver’s seat for future changes to the eMR?'

Not a single health information management (HIM) professional was on the session’s panel of experts, even though HIMs are widely recognised within NSW Local Health Districts as the real drivers of EMR implementation.

The 2008 Garling Report in NSW is one of a spate of similar responses to adverse medical outcomes around the country in the early 2000s that identified the need for greater involvement of clinicians in senior decision making roles within the hospital system.

The resulting emphasis on clinician engagement by NSW Health since has been a welcome redress to the dominance of bureaucratic managerialism in hospital systems that dominated the country from the 1980s through to the turn of the century.

In the late 2000s the National E-Health Transition Authority (NEHTA) was slow to identify the need to engage with clinicians. Its clinical engagement unit was almost an afterthought, and had to work overtime to secure clinician engagement in the development of a user-friendly personally controlled electronic health record (PCEHR). And in the end, NEHTA lost many of its key clinical leads prematurely.

It has been heartening to see a key differentiating feature of the Australian Digital Health Agency (ADHA) in its formation is that clinician as well as consumer engagement has been placed front and centre. However, in eHealth, more than in any other area of healthcare quality improvement, the danger of throwing the HIM “baby out with the bathwater” in the rush to engage doctors and now, it seems, nurses and midwives, is high risk for eHealth success.

Like doctors, nurses and midwives are expert in their professional roles, but they are not members of the HIM profession. Their degrees are in medicine and nursing, not HIM, and their specialisations are clinical, rarely in HIM. If clinicians specialise in any health information area, it is usually in health informatics.

So why encourage the role substitution of an existing area of expertise which has a professional contribution of over 70 years to the Australian healthcare system in the tertiary sector? When will we start to see state, territory and (bless them) federal governments focus on placing HIM professionals in the EMR driving seat – especially given they are already there?

The Health Information Management Association of Australia (HIMAA)’s submission to the ADHA’s recent quest for stakeholder “co-production” of a National Digital Health Strategy, based on policy engagement with association members, makes two major recommendations:

  • The need for the effective management of identifiable digital health information systems (HIS) by qualified HIM professionals such as health information managers (HIMs) and clinical coders
  • HIM workforce supply based in a national health information workforce (HIW) capability framework led by the HIW peak bodies.

The submission also calls for attention to clinical classification interoperability as well as software interoperability.

A systems approach

HIMs and clinical coders have come a long way from the uniformed medical records librarians who used to dog doctors around the hospital for some greater intelligence on the hieroglyphics hastily scrawled on a medical record as a result of a patient encounter.

For a start, development of the international classification of disease has since the 1940s reached a level of sophistication to enable the role of the clinical coder to merit occupational status separate to that of the HIM.

HIMAA pioneered national distance education in clinical coding at the pre-university level of vocational education and training (VET) from 1990, and is now the largest provider of a Certificate IV in Clinical Classification in Australia.

The association has also accredited HIM degree courses against competency standards developed by the profession to meet industry needs for profession entry by graduates since 1992. The systemic contribution of health information to local, regional and population health planning has demanded increasing expertise in pan-organisational management of health information systems rather than the mere librarianship of medical records.

The advent of activity-based funding (ABF) has drawn hospital finance departments into the need for highly accurate coded health information that is of quality and integrity in order to secure funding allocations.

The pull of finance has led to the division of the health information service (HIS) team, with coders increasingly reporting to chief financial officers instead of HIMs.

Yet the success of an integrated eHealth system now possible through the digitisation of health information depends on the integrated relationship between HIMs and coders that is central to an effective HIS.

Information governance throughout the health system will become of key concern as the digitisation of health information increasingly makes its vital contribution to the integration of healthcare across tertiary and primary sectors. This will lead to the quality improvement as well as cost containment advantages so sought by government and HIMs are the natural professional source for this expertise.

The effective management of identifiable digital health information systems by a team of qualified HIM professionals such as HIMs and clinical coders must be a key strategy in a national digital health strategy.

Health information workforce

In 2010 the Australian Institute of Health and Welfare (AIHW) published a definitive study of health information management workforce in Australia which achieved an 86 per cent response rate in the public hospital system.

The report identified the increasing proportion of clinical cCoders in the health workforce who did not have HIM degrees. It also identified a need for a minimum increase of 1757 FTE clinical coders in the ensuing five-year period to meet industry demand.

HIMAA was far the largest supplier of VET level clinical coding graduates in Australia during those five years, but they succeeded in graduating just 726 coders – not even half the minimum forecast. And this is during a period in which the introduction of ABF has increased demand for coders.

The problem in forecasting the health information workforce (HIW) needs of a rapidly expanding and transformational eHealth sector is the availability of accurate data. Even estimates of health informatician need was based on extrapolations of the AIHW research in health information management.

Other HIW occupations postulated by the Health Workforce Australia (HWA) Health Information Workforce Report of 2013, data analysts and costing specialists, are difficult to find workforce definitions, let alone workforce data.

Recourse to Australian Bureau of Statistics (ABS) data to analyse the HIM workforce demonstrates how fraught HIW data supply is:

ABS Census Data200120062011Census 2001, 2006, 20112009 FTE AIHW
Clinical Coders18052183106941%1186
Health Information Managers8651255147370%630
Total Profession2670343825425%1816

When the HIM estimate based on population self-report in 2006 and 2011 is compared to the more substantive AIHW estimate in 2009, the dissonance is doubled in both cases.

Two key recommendations from two successive national HIW summits in 2015 and 2016 have been:

  • The need for a census of the health information workforce and regular collection of data; to inform
  • Development of a national capability framework for HIW configuration.

A response to the first of these recommendations has been forthcoming from a collaboration between the University of Tasmania and University of Melbourne, led by Dr Kerryn Butler-Henderson and Associate Professor Kathleen Gray respectively.

Development of an HIW data-set is already underway in preparation for a national census of HIW that can be replicated periodically to inform HIW configuration. This initiative has the active support from, amongst others, the three peak bodies presenting the 2015 national HIW Summit: HIMAA, HISA and the Australasian College of Health Informatics (ACHI).

It has been suggested at both HIW summits that a platform already exists for the development of a national HIW capability framework: the international Skills Framework for an Information Age (SFIA). For a capability framework with the agility to meet the rapidly emerging HIW, however, active engagement between education providers, industry (employers), governments and the peak HIW bodies responsible for the professional competencies that underpin the HIW professions is essential.

The IT-driven, organisational change focus of SFIA is too narrow and localised to achieve what is required by eHealth in Australia right now.

ADHA is well-placed to provide leadership and funding for the development of a dynamic and responsive HIW capability framework. HIM workforce supply based in a national HIW capability framework led by the HIW peak bodies has a central place in a National Digital Health Strategy.

Classification as well as software

The need for health information software interoperability has been widely canvassed in National Digital Health Strategy discourse, and is obvious. Electronic collisions between competing computer programming and languages in the transfer and storage of digital and scanned health information will lead to loss or corruption of units of meaning, so that information in is lost in information out.

But the need for interoperability of clinical classification, which has far deeper structural implications for the management of knowledge in health information systems, is not even on the table.

The digital language planned for the My Health Record, SNOMED CT, is not a system of clinical classification. It is terminology-based and operates as a transformational grammar, generating meaning rather than capturing it.

By contrast, the International Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM, used in the Australian hospital system, is a sophisticated reporting tool designed to generate the meaningful capture of the content of patient care which, through the allocation of classification codes, is searchable, transferable, storable and reportable such that information in is information out.

It generates a statistical capability for analysis such that health information can inform health planning and, these days, financing, as well as act as a live resource for healthcare professionals to inform the patient’s journey at any point of care.

To give some idea of the value of a classification system, HIMAA publishes the authoritative text on abbreviations, acronyms and symbols used by clinicians in recording their engagement with patients. Now in its 6th edition, there are over 10,000 variations in meaning an HIS needs to manage from the hands of clinicians.

By contrast, ICD-10-AM offers clinical coders 16,953 codes to accurately reflect the full depth and complexity of clinical consultation, with an additional 9049 codes for interventions and morphology of neoplasms. The difference in terms of knowledge management between the health data generated by frontline health professionals from point of care and health data produced by classification is palpable.

General practice also has a system of clinical classification: the International Classification of Primary Care (ICPC). But there isn’t a GP in the country who uses it to manage their medical records.

If general practice is to continue to depend on the terminology-based SNOMED-CT to supplement its absence of any system of clinical classification of health information, interoperability between SNOMED-CT and ICD-10-AM is essential for the accuracy, quality, integrity and usability of health data as information by tertiary and primary sectors.

The capability of digitised health information to achieve the national integration of primary and tertiary care is literally crippled without the interoperability of clinical classification.

Interoperability of clinical classification should play a vital role in a National Digital Health Strategy and the HIM profession represents the expertise fulcrum for the development of such interoperability.

Richard Lawrance is CEO of HIMAA.

Posted in Australian eHealth


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