Best practice in the management of clinical coding services: Insights from a project in the Republic of Ireland, Part 1

Abstract

Introduction: This article presents some of the results of a year-long project in the Republic of Ireland to review the quality of the hospital inpatient enquiry data for its use in activity-based funding (ABF). This is the first of two papers regarding best practice in the management of clinical coding services. Methods: Four methods were used to address this aspect of the project, namely a literature review, a workshop, an assessment of the coding services in 12 Irish hospitals by structured interviews of the clinical coding managers, and a medical record audit of the clinical codes in 10 hospitals. Results: The results included here are those relating to the quality of the medical records, coding work allocation and supervision processes, data quality control measures, communication with clinicians, and the visibility of clinical coders, their managers, and the coding service. Conclusion: The project found instances of best practice in the study hospitals but also found several areas needing improvement. These included improving the structure and content of the medical record, clinician engagement with the clinical coding teams and the ABF process, and the use of data quality control measures.

Best practice in the management of clinical coding services: Insights from a project in the Republic of Ireland, Part 2

“…As with Part 1 (Reid et al, 2017), there was good consistency in the findings obtained from the three methods (for Part 2) of the literature review, Best Practice Workshop and the CSA. It is unsurprising that the issues identified in the literature and workshop were confirmed by the coding managers interviewed.…”

“…As in Part 1 (Reid et al, 2017), the results are organised by the issues rather than giving the results of each of the methods used in turn. This is done in order to integrate the results from the various methods and avoid undue repetition.…”

“…As noted in Part 1 (Reid et al, 2017), the CSA interviewer scored the 12 hospitals out of a maximum score of 80. The scores ranged from 33 to 58.5 out of 80 (41.3–73.1%), and the average score for all hospitals was 58.6%.…”

“…As stated in Part 1 (Reid et al, 2017), the organisation of coding services in Irish hospitals differs from that which is usual in Australian hospitals. In Irish hospitals, the HIPE coding service is usually separate from the health information service.…”

Research in health information management: An expanding field of enquiry

“…In recent HIMJ issues, various aspects of data quality were investigated in numerous settings including primary care (Barnett et al, 2016), aged care (Davis et al, 2016), cancer registries (Fararouei et al, 2016), outpatient clinics (Munyisia et al, 2016), hospitals (Jylha et al, 2016; Monto et al, 2016), and a serology laboratory (Vecellio et al, 2015). The impact of data quality on activity-based funding is critical and a number of papers presented issues related to this (Munyisia et al, 2016; Reid et al, 2017).…”