Coding in Ireland: time for recognition.
A coder's career is built on life-long learning through years of experience and continuing education. Recognition of coders' work within the Irish health system is long overdue. A project being undertaken in Ireland now is exploring ways to raise the coders' profile, promote a profession of clinical coders and in turn provide quality benchmarks for all stakeholders. The first part of this project is looking at accreditation of Irish coder training. (2)
The Health Research and Information Division (HRID) at the Economic and Social Research Institute (ESRI) is contracted by the Health Services Executive (HSE) to oversee all functions associated with the operation of the national Hospital InPatient Enquiry (HIPE) database, including the development and support of the data collection and reporting software, data quality reviews, audit, response to requests for data and the provision of annual reports on hospital activity. The HRID is also responsible for the education of the Irish clinical coder workforce and is the centre for clinical coding expertise in Ireland. There are currently 227 clinical coders with an additional 27 coding managers working in Ireland across 60 hospitals.
A key component of the health strategy Quality and Fairness: A Health System for You (Department of Health and Children 2001) is the importance of quality, and access to and the provision of health information. Health information is central to the efficient functioning of any healthcare system for policy, planning and research (Bramley & Reid 2005). With increased use of coded health data many countries now offer formal education to coders to ensure that they are competent and that coded data reflect the patient activities (McKenzie et al. 2004). Currently the Irish system uses the Australian modification of the World Health Organization's disease classification (ICD-10-AM) for diagnoses and the Australian Classification of Health Interventions (ACHI) to code procedures. (3) Australian Coding Standards provide guidance on the application of codes and the Irish Coding Standards, developed and published by the HRID further complement these. All personnel involved in coding HIPE data are trained by the HRID at the ESRI. Coding Notes, the quarterly newsletter published by HIPE at the ESRI, provides further information on coding guidelines. It also informs coders of any changes to the system, including upcoming courses, recent events, news and IT support. (4)
Basic, intermediate and advanced clinical coding courses are regularly organised by the ESRI. Specialised workshops on specific areas such as obstetrics, diabetes, cardiology and neoplasm coding are also run on a regular basis. These courses are based around the coding guidelines and instructions in the use of the classification. They also cover HIPE dataset standards and training on the use of HIPE data entry and reporting software (W-HIPE).
In the early days of HIPE, data were collected manually on paper and submitted to the national office for processing. It is now a computer-based health information system designed to collect clinical and administrative data on discharges from, and deaths in, acute hospitals in Ireland and is extensively used for research, planning and policy using software written, developed and supported by the HRID at the ESRI. Although technology has helped with coders' work, the pressures are much greater now with HIPE data being used by an ever increasing group of stakeholders. More data are being collected with additional variables being added periodically to the minimum dataset. Deadlines are shortening and data users' expectations are higher for high quality data at faster turnarounds. As coders require extensive training and experience to build coding skills, it is important that staff turnover is kept to a minimum.
I think a certificate would bring recognition and value for the specialised work we do. [It] would bring confidence and respect to each coder who obtains a certificate. (Irish Coder 2010)
The coding courses run by the ESRI are currently not accredited. In the absence of accredited coding courses in Ireland there is no way of measuring and demonstrating clinical coders' skill levels. HIPE/Casemix Coordinators (HCCs) (5) and coders see value in an accreditation process that determines skill levels and is linked to coder competencies, a career path and salary gradings (Bramley & Reid 2005). Lack of accreditation affects remuneration and promotion opportunities for coders and this in turn affects staff retention.
Since HIPE began in 1971, coding has been carried out by clerical staff. In Ireland clinical coders are generally drawn from administration staff and will often be assigned to HIPE coding rather than choosing the role. Some embrace this challenging role while others will not and will either choose to move on if they can or may have to remain in a job they do not like. Many coders in Ireland will be assigned to the department and commence training with the HRID as a result. Although this training is free to those within the system it is a considerable investment for individuals of their time and energies.
There is no standard grading structure within HIPE departments in hospitals and career mobility within coding is curtailed by the current system. In addition there is no formal recognition of training undertaken with the ESRI, thus coders have no official acknowledgment of their unique skills within the hospital system, although hospitals have used ESRI training records for their own organisational accreditation. This opens up the issue of the professionalisation of coding and the establishment of a career structure for the life-long coder. While these shortcomings may appear to mitigate against establishing a profession of experienced and educated coders there is a strong cohort of dedicated clinical coders in Ireland who continue within their role and will through experience and ongoing education advance their own position. People are motivated by being interested in their work, by challenges, and by increasing responsibility. For those who remain in coding by choice or by chance the establishment of a coding profession with clear career progression pathways would enhance coders' working conditions, retention, motivation, experience and education.
The Irish Coder Accreditation Project
I think it is of vital importance for a proper coding education scheme to be in place ... Coders in Ireland are not recognised as being educated by clinicians and many are unwilling to co-operate with their coders. (Irish Coder 2010)
This project has developed from a long held belief that clinical coders in Ireland need to be recognised for their skills and for the ongoing education they undertake which is necessary to carry out this important role within the hospital. I recently carried out a survey of HIPE coders and HIPE/Casemix Coordinators (HCCs) in Ireland, exploring areas including their attitudes to their role, their position in the hospital, their functions and their understanding of the purpose of the data they collect. The main aim of the questionnaire was to explore coders' view on their current education and openness to new educational opportunities were they to be made available. There are 227 coders on the active mailing list, both full and part time, and 27 coder managers. Eighty five coders responded, giving a response rate of 37%. Fourteen managers replied, giving a response rate of 52%. Full time coders made up 72% of respondents (n = 61) with the remaining 28% (n = 24) working part-time. Most respondents were enthusiastic about coder accreditation though those who responded may be more likely to be those keen to progress. (6)
Upon reviewing the questionnaires it is clear that the situation for coders in Ireland seems to have changed little in the 30 or so years since I started working as a coder. Even with increased use of HIPE data, higher profile of the data, the reliance of managers and clinicians on these data for performance measurement and policy making, the position of coders within the hospital is still perceived by some coders as disconnected and separate. There is no consistency in the department where HIPE is located within the hospital. In both coder and HCC questionnaires there are a wide range of departments reported with fourteen different departments cited from 99 respondents, for example the finance department, IT and administration. Coders also reported multiple duties along with their coding work, from pulling charts to general secretarial work to running reports on the HIPE data. Coding needs to be recognised as a dedicated skilled profession and identified within the health service as such. The accreditation and certification of training will lead to a clearer recognition of the role and position of coders within the healthcare system. With a recognised role and accredited training coders can establish themselves within the system and this in turn will provide stability and a cohort of well trained and dedicated professionals
Making coders visible
Hospital Staff are completely ignorant of what HIPE does and why we need (the) medical records and therefore are completely uncooperative. (Irish Coder 2010)
This project evaluates the current situation for clinical coders in Ireland with regard to their education programs and the options for the advancement of the training programs to a recognised qualification. This would afford both the coder and the users of HIPE with a proven data quality benchmark in the provision and use of these important hospital activity data. A review of clinical coder training programs, data quality and audit procedures within the Hospital In-Patient Enquiry Unit at the ESRI carried out in 2004 recommended that the training should be linked to accredited training bodies and that the ESRI should seek recognition as an accredited training body:
Recognition as an accredited training body so that certificates or statements of attainment relating to the competency-based assessments are recognised in the workplace as an entry-requirement. The National Qualifications Authority of Ireland may be the body through which this can be achieved. (Bramley & Reid 2005)
This project is currently pursuing the best options with the awarding bodies in Ireland. The initial consultation process with the coders and HCCs will further inform decision making to advance coder education in Ireland.
Learning from the past, informing our future
I'd love to expand my knowledge and get formal recognition for what is a difficult but rewarding profession. (Irish Coder 2010)
HIPE data are being used by an increasing number of groups to inform, monitor and research hospital health services. With such important work being based on the work of this skilled group it is important that this work is to the highest standards. The ESRI provides the training and data quality support for the system, coder accreditation would provide further assurance on the quality of these data and would provide a benchmark for users. HIPE is being used increasingly by the HSE; for example, for Healthstat, the monthly published measurement of hospitals' performance (8) attention is once again on the coders' work, as happened previously in 1989 when Casemix was first introduced as a funding mechanism in Ireland. Clinicians are now questioning the ability of administration staff to collect this information. This is a debate that has been going on for many years, particularly in Europe where coding has traditionally been done by doctors. Some European countries are moving to a clinical coder profession. As a coder myself I am in no doubt that trained and experienced dedicated clinical coders are the best people to carry out this work.
This project has far-reaching implications across much of the hospital system. Clinical staff and hospital management need to recognise the skills of clinical coders and the information they provide. The importance of good medical records to support this work needs to be highlighted to both managers and clinicians. Support for HIPE departments is important to ensure that data are collected in a timely accurate way. This includes supporting training and data quality initiatives, ensuring job specifications are clear and work conditions are appropriate. Unsuitable and noisy work environments were mentioned as having a major impact on coders' work in the questionnaire. The inconsistency in the location of HIPE within a hospital and the variety of non coding duties assigned to coders are issues that will need to be addressed.
Human resources (HR) at national (HSE) and hospital level need to identify coder competencies and ensure appropriate recruitment and training processes are in place. Often staff will be put into coding when a job becomes vacant or may be moved out of the HIPE department to fill other vacancies as deemed necessary.
Issues around industrial relations (IR) follow on from the points raised above with HR. In the past when proposals were made to create a 'coder grade' there was opposition from the unions. With an accreditation to support this proposal the grading could be grounded in evidence to implement a proper coder career structure. This would offer the Irish coding profession a stabilised trained and experienced workforce and enhance the retention of skilled, educated and experienced coders within the system. It would also enable coder mobility within the system, allowing recruitment from a regulated workforce.
This climate of economic downturn, staff shortages, recruitment moratoriums and industrial action could mitigate against the introduction of a change for coders in the form of increased training and expectations. Staff in hospitals are under pressure and it could prove difficult to convince coders to undertake certification of coder training with no obvious remuneration. This is only the first phase of a major project to introduce accredited coder training and will inevitably lead to a review of coding services within the Irish system. Focus groups with coders and HCCs will be held to further inform this ongoing project. I am confident that with this initial work on establishing the project and highlighting the issues is an important development for clinical coders and the HIPE system in Ireland to advance clinical coding to a recognised healthcare profession.
It is important to progress this project to ensure coders are recognised for their unique skills and dedication to their field. Further initial steps will involve engaging with clinicians in Irish hospitals to raise awareness of the work of clinical coders and seek cooperation in the education program. Engagement with hospital managers and the HSE will also ensure support for the clinical coder's role and recognition for accredited training undertaken by coders. The HCCs and coding managers can be the champions for the cause by developing their role and also the role of coders to ensure optimisation for all of HIPE. Good management of coding services will enhance the whole system.
Accredited coder education would provide an appropriate, substantial and recognised training program for clinical coders in Ireland to enhance the position and recognition of coding as a skilled profession within the healthcare system, and also to ensure those data coded meet the highest national and international data quality standards. With accredited coder education in place the profession of Irish clinical coders will finally be recognised.
Bramley, M. and Reid, B. (2005). Clinical coder training initiatives in Ireland. Health Information Management Journal 34(2): 40-46.
Department of Health and Children. (2001). Quality and Fairness: A Health System for You. Available at: http://www.dohc. ie/publications/quality_and_fairness.html (accessed 10 August 2010).
McKenzie, K., Walker, S., Dixon-Lee, C., Dear, G. and Moran-Fuke, J. (2004). Clinical coding internationally: a comparison of the coding workforce in Australia, America, Canada and England. Paper presented at the International Federation of Health Records Congress (IFHRO) Congress & AHIMA Convention Washington.
Deirdre Murphy BA, MA
Health Research and Information Division
Economic and Social Research Institute (ESRI)
Member, International Advisory Panel
Health Information Management Journal
(1) Quotations from Irish coders are taken from responses to a questionnaire conducted in early 2010. This is discussed later in this article.
(2) Undertaken by the Author as part fulfilment of an MSc in Health Services Management at Trinity College Dublin. The final thesis is due for completion in October 2010.
(3) Ireland has coded using Australian modification of the WHO International Classification of Diseases, 10th Revision (ICD-10-AM) and the Australian Classification of Health Interventions (ACHI), 4th Edition for procedures for all discharges since 1.1.2005. Ireland updated to 6th Edition in January 2010.
(4) Coding Notes is available free on line at www.esri.ie and individuals may also sign up to receive new editions.
(5) HCCs act as coding managers.
(6) A recent Work to Rule in place for union members in some hospitals for the first 6 months of 2010 during the time of the survey may have affected responses to the survey. This Work to Rule was a protest against cost cutting measures imposed related to the current economic downturn in Ireland. Submitting data to the ESRI was prohibited by this Work to Rule and had affected the monthly exports from the hospitals since January 2010.
(8) See http://www.hse.ie/eng/ staff/Healthstat/about/ for further information.
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|Publication:||Health Information Management Journal|
|Date:||Oct 1, 2010|
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