A near-perfect score.
That was the result of a recent review conducted at Royal University Hospital, and it is great news for coders in Saskatoon Health Region.
"The Region participated in a national study led by the Canadian Institute of Health Information (CIHI)," explained Rhonda Murfitt, who was Manager of Health Records for Saskatoon Health Region when the review was conducted, now working in human resources as part of a cellular support for managers. "As part of the study, they sent an experienced coder into Royal University Hospital to study a set of charts – something they call re-abstraction – in order to measure the quality of coding and abstracting done by our staff."
Megan, Health Information Management Practitioner, Inpatient Coder at work.
What do coders do?
Coders review patient charts in their entirety, and then enter the codes for a patient's diagnosis and procedure into an electronic database. They then do an abstraction, which collects the times and other data elements from paper and electronic charts to enter into our software system. This provides the region and the province with information about how many people are being diagnosed with certain diseases, and how many have undergone procedures like joint replacements.
"A lot of decisions are made from the data we provide," Murfitt noted. "So it's important to do reviews, and it's comforting to know that our coders are doing such a good job, every day."
Re-abstraction studies like the one CIHI just did evaluate the overall quality of coding, determine the extent of coding variations, and identify the underlying causes of differences in coding.
There were only two areas where the review made recommendations for improvement. The first was in capturing information about obstetrical hemorrhages.
"For that area, we will be pulling charts to have a closer look at them and review with our staff how these cases are coded and whether improvements in clinical documentation are required," Murfitt explained.
As for the other area of improvement, the sample of charts taken was extremely small. Only two were coded wrong, but because of the small sample size, that made the score lower, percentage-wise.
"We did extremely well in every other indicator," Murfitt said. "We were at 100 per cent on coding obstetrical trauma and sepsis, which is well above the national average. We were also perfect when it came to coding low-risk deliveries. Our coders did absolutely amazing."
This is the first time a re-abstraction study has been completed using charts from the current year, Murfitt noted. "They used current data, so we could actually make changes before we sent our data to our SHIPS department and to the Ministry of Health, which is incredibly helpful, and ensures the data we send is absolutely accurate."
SHIPS (Strategic Health Information and Performance Support) is a Saskatoon Health Region department which supports a coordinated approach to utilizing health information for decision-making, planning, performance monitoring and management, evaluation and policy development.
"We are coding quickly – our turnaround time has dropped from six months to within 30 days – and we are coding accurately, as the re-abstraction shows. This means our data is provided to SHIPS and the Ministry in a timely fashion, so they can use it to make decisions," Murfitt said.
There are 12 coders at Saskatoon's three acute care sites who look after inpatient visits, as well as coders working specifically on day surgery and emergency visit records.
Coding is an exacting job.
"You have to know anatomy, pathophysiology, disease process, you name it," Murfitt said. "The schooling is intense, but you have to know a lot to do the job."