JournalTOCs

Health Information Management Journal
Journal Prestige (SJR): 0.268

Citation Impact (citeScore): 1
Number of Followers: 23

Hybrid journal * Containing 1 Open Access article(s) in this issue *
ISSN (Print) 1833-3583 - ISSN (Online) 1833-3575
Published by Sage Publications

[1086 journals]

Validation of ICD-10 codes shows intracranial venous thrombosis incidence
to be higher than previously reported
- Authors: Joel D Handley, Hedley CA Emsley
  Pages: 58 - 61
  Abstract: Health Information Management Journal, Volume 49, Issue 1, Page 58-61, January 2020.
  Background:Intracranial venous thrombosis (ICVT) accounts for around 0.5% of all stroke cases. There have been no previously published studies of the International Classification of Diseases, Tenth Edition (ICD-10) validation for the identification of ICVT admissions in adults.Objective:The aims of this study were to validate and quantify the performance of the ICD-10 coding system for identifying cases of ICVT in adults and to derive an estimate of incidence.Method:Administrative data were collected for all patients admitted to a regional neurosciences centre over a 5-year period. We searched for the following ICD-10 codes at any position: G08.X (intracranial and intraspinal phlebitis and thrombophlebitis), I67.6 (non-pyogenic thrombosis of intracranial venous system), I63.6 (cerebral infarction due to cerebral venous thrombosis, non-pyogenic), O22.5 (cerebral venous thrombosis in pregnancy) and O87.3 (cerebral venous thrombosis in the puerperium).Results:Sixty-five admissions were identified by at least one of the relevant ICD-10 codes. The overall positive predictive value (PPV) for confirmed ICVT from all of the admissions combined was 92.3% (60 out of 65) with the results for each code as follows: G08.X 91.5% (54 of 59), O22.5 100% (4 of 4), I67.6 100% (1 of 1), I63.6 100% (1 of 1) and O87.3 100% (1 of 1). There were 40 unique cases of ICVT over a 5-year period giving an annual incidence of ICVT of 5 per million.Conclusions:All codes gave a high PPV.Implications for practice:As demonstrated in previous studies, the incidence of ICVT may be higher than previously thought.
  Citation: Health Information Management Journal
  PubDate: 2020-01-01T08:00:00Z
  DOI: 10.1177/1833358318819105
  Issue No: Vol. 49, No. 1 (2020)
A review of the complexity adjustment in the Korean Diagnosis-Related
Group (KDRG)
- Authors: Sujeong Kim, Chaiyoung Jung, Junheum Yon, Hyeonseon Park, Hunsik Yang, Hyeon Kang, Dongjin Oh, Kukhwan Kwon, Sukil Kim
  Pages: 62 - 68
  Abstract: Health Information Management Journal, Volume 49, Issue 1, Page 62-68, January 2020.
  Background:The Korean Diagnosis-Related Groups (KDRG) was revised in 2003, modifying the complexity adjustment mechanism of the Australian Refined Diagnosis-Related Groups (AR-DRGs). In 2014, the Complication and Comorbidity Level (CCL) of the existing AR-DRG system was found to have very little correlation with cost.Objective:Based on the Australian experience, the CCL for KDRG version 3.4 was reviewed.Method:Inpatient claim data for 2011 were used in this study. About 5,731,551 episodes, which had one or no complication and comorbidity (CC) and met the inclusion criteria, were selected. The differences of average hospital charges by the CCL were analysed in each Adjacent Diagnosis-Related Group (ADRG) using analysis of variance followed by Duncan’s test. The patterns of differences were presented with R 2 in three patterns: The CCL reflected the complexity well (VALID); the average charge of CCL 2, 3, 4 was greater than CCL 0 (PARTIALLY VALID); the CCL did not reflect the complexity (NOT VALID).Results:A total of 114 (19.03%), 190 (31.72%) and 295 (49.25%) ADRGs were included in VALID, PARTIALLY VALID and NOT VALID, respectively. The average R 2 for hospital charge of CCL was 4.94%. The average R 2 in VALID, PARTIALLY VALID and NOT VALID was 4.54%, 5.21%, and 4.93%, respectively.Conclusion:The CCL, the first step of complexity adjustment using secondary diagnoses, exhibited low performance. If highly accurate coding data and cost data become available, the performance of secondary diagnosis as a variable to reflect the case complexity should be re-evaluated.Implications:Lack of reviewing the complexity adjustment mechanism of the KDRG since 2003 has resulted in outdated CC lists and levels that no longer reflect the current Korean healthcare system. Reliable cost data (vs. charge) and accurate coding are essential for accuracy of reimbursement.
  Citation: Health Information Management Journal
  PubDate: 2020-01-01T08:00:00Z
  DOI: 10.1177/1833358318795804
  Issue No: Vol. 49, No. 1 (2020)
2019 Reviewers List
- Pages: 80 - 80
  Abstract: Health Information Management Journal, Volume 49, Issue 1, Page 80-80, January 2020.
  
  Citation: Health Information Management Journal
  PubDate: 2020-01-01T08:00:00Z
  DOI: 10.1177/1833358319895334
  Issue No: Vol. 49, No. 1 (2020)
Under-coding of dementia and other conditions indicates scope for improved
patient management: A longitudinal retrospective study of dementia
patients in Australia
- Authors: Kara Cappetta, Luise Lago, Jan Potter, Lyn Phillipson
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:Under-coding of dementia during hospitalisation results in an inability to identify all patients with dementia using hospital administrative data. Clinical coding can be viewed as a proxy for management; therefore, under-coding indicates dementia was not considered in the patient’s management. While under-coding of dementia is well established, there is sparse evidence on whether dementia is coded in subsequent hospitalisations among patients with a known diagnosis.Objective:(a) To describe patterns of dementia coding over 5 years after a first-coded (i.e. index) admission for dementia; (b) to identify factors associated with clinical coding of dementia; and (c) to identify patient subgroups at risk of not being coded to inform future interventions to improve hospital identification and management of dementia.Method:Retrospective study of longitudinal hospital data from 1 July 2006 to 30 June 2015 for 7919 patients hospitalised during the 5 years’ post-index admission for dementia in a regional local health district of New South Wales, Australia.Results:Dementia was coded in 63.9% of admissions in the 12 months following index admission for dementia; this decreased to 53.7% after 5 years. Patients were 20% more likely to have dementia actively managed when it co-occurred with delirium. Under-coding varied across conditions, with dementia more likely to be coded in admissions for falls and pneumonitis, and less likely for heart failure, pneumonia and urinary tract infection (UTI).Conclusion:The frequency with which dementia was not coded highlights opportunities to improve identification and management of dementia through dementia-specific care, enhanced clinical protocols, and interventions focused around heart failure, pneumonia and UTI admissions.
  Citation: Health Information Management Journal
  PubDate: 2020-01-23T10:53:24Z
  DOI: 10.1177/1833358319897928
Personal electronic healthcare records: What influences consumers to
engage with their clinical data online' A literature review
- Authors: Kellie-Anne Crameri, Lynne Maher, Pieter Van Dam, Sarah Prior
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:Online electronic records such as patient portals and personally controlled electronic health records (PEHRs) have been widely viewed as a key component to modernising the delivery of healthcare but the uptake of such systems has been slow.Objective:The purpose of this literature review was to determine what influences consumers to engage and interact with their clinical data online.Method:A scoping literature review following PRISMA guidelines was completed. Electronic patient record research published between January 2009 and December 2018 was included. Following screening and full-text reviews, a total of 64 records were included in this review.Results:Three key areas of influence on consumer engagement with their clinical data online emerged: demographic factors affecting consumer interaction with PEHRs; consumers’ perceived benefits and detriments of PEHR use; and the influence of PEHR use on consumer empowerment and responsibility.Discussion:Consumer motivation and readiness for engaging with their clinical data online and their long-term ongoing use of these systems requires further exploration.Conclusion:As worldwide rates of consumer interactions with individual online clinical data remain low, what influences consumer engagement with a PEHR remains unknown. Further research into the consumer perspective of, and interaction with, a PEHR, needs to be undertaken to determine if factors such as frequent usage of the system by consumers leads to improved clinical outcomes.
  Citation: Health Information Management Journal
  PubDate: 2020-01-10T09:53:55Z
  DOI: 10.1177/1833358319895369
Knowledge and documentation of patient health information among
traditional health practitioners in urban and peri-urban areas of
eThekwini Municipality, KwaZulu-Natal Province, South Africa
- Authors: Tracy Zhandire, Nceba Gqaleni, Mlungisi Ngcobo, Exnevia Gomo
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:Documentation of patient health information (PHI) is a regulatory requirement and hence a standard procedure in allopathic healthcare practice. The opposite is true for African traditional medicine (ATM) in most African countries, including South Africa, despite legal and policy frameworks that recognise and mandate the institutionalisation of ATM. Developing good practice standards for PHI documentation is an essential step in the institutionalisation of ATM.Objective:This study examined the knowledge and practices of documentation of PHI by traditional health practitioners (THPs) in Durban, eThekwini Municipality, KwaZulu-Natal Province, South Africa.Methods:In this quantitative cross-sectional study, snowball sampling was used to identify and recruit THPs. An interviewer-administered questionnaire was used to gather data. Chi-square tests and logistic regression were used to assess associations of knowledge and practice of documentation of PHI with potential predictors; age, gender, education, type of practitioner, experience, number of patients seen per day and location of the practice.Results:Of the 248 THPs who participated, 71.8% were female. Mean (SD) age was 47.4 (14.2), ranging 18–81 years. The majority (65.7%) were Izangoma (diviners). Overall, 42.9% of the THPs reported knowledge of patient medical records (PMRs). In logistic regression, only number of patients seen per day remained a significant predictor of knowledge about PMR. THPs who reported seeing 6–10 patients were five times more likely (Odds Ratio (OR): 5.164, 95% Confidence Interval (CI): 1.270–20.996; p = 0.022) to report knowledge of PMR than those seeing
  Citation: Health Information Management Journal
  PubDate: 2019-12-31T08:04:15Z
  DOI: 10.1177/1833358319890475
Integration of the UNHCR Refugee Health Information System into the
National Health Information Management System for Uganda
- Authors: Caroline Kyozira, Catherine Kabahuma, Jamiru Mpiima
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:The Uganda Government, together with development partners, has provided continuing support services (including protection, food, nutrition, healthcare, water and sanitation) to refugee-hosting Districts to successfully manage refugees from different neighbouring countries in established settlements. This service has increased the need for timely and accurate information to facilitate planning, resource allocation and decision-making. Complexity in providing effective public health interventions in refugee settings coupled with increased funding requirements has created demands for better data and improved accountability. Health data management in refugee settings is faced with several information gaps that require harmonisation of the Ugandan National Health Management Information System (UHMIS) and United Nations High Commission for Refugees (UNHCR) Refugee Health Information System (RHIS). This article discusses the rationale for harmonisation of the UNHCR RHIS, which currently captures refugee data, with the UHMIS. It also provides insights into how refugee health data management can be harmonised within a country’s national health management information system.Method:A consultative meeting with various stakeholders, including the Ugandan Ministry of Health, district health teams, representatives from UNHCR, the United Nations Children Education Fund (UNICEF), United States Government and civil society organisations, was held with an aim to review the UHMIS and UNHCR RHIS health data management systems and identify ways to harmonise the two to achieve an integrated system for monitoring health service delivery in Uganda.Results:Several challenges facing refugee-hosting district health teams with regard to health data management were identified, including data collection, analysis and reporting. There was unanimous agreement to prioritise an integrated data management system and harmonisation of national refugee stakeholder data requirements, guided by key recommendations developed at the meeting.Conclusion:This article outlines a proposed model that can be used to harmonise the UNHCR RHIS with the UHMIS. The national refugee stakeholder data requirements have been harmonised, and Uganda looks forward to achieving better health data quality through a more comprehensive national UHMIS to inform policy planning and evidence-based decision-making.
  Citation: Health Information Management Journal
  PubDate: 2019-12-06T09:55:35Z
  DOI: 10.1177/1833358319887817
Data quality in healthcare: A report of practical experience with the
Canadian Primary Care Sentinel Surveillance Network data
- Authors: Behrouz Ehsani-Moghaddam, Ken Martin, John A Queenan
  Abstract: Health Information Management Journal, Ahead of Print.
  Data quality (DQ) is the degree to which a given dataset meets a user’s requirements. In the primary healthcare setting, poor quality data can lead to poor patient care, negatively affect the validity and reproducibility of research results and limit the value that such data may have for public health surveillance. To extract reliable and useful information from a large quantity of data and to make more effective and informed decisions, data should be as clean and free of errors as possible. Moreover, because DQ is defined within the context of different user requirements that often change, DQ should be considered to be an emergent construct. As such, we cannot expect that a sufficient level of DQ will last forever. Therefore, the quality of clinical data should be constantly assessed and reassessed in an iterative fashion to ensure that appropriate levels of quality are sustained in an acceptable and transparent manner. This document is based on our hands-on experiences dealing with DQ improvement for the Canadian Primary Care Sentinel Surveillance Network database. The DQ dimensions that are discussed here are accuracy and precision, completeness and comprehensiveness, consistency, timeliness, uniqueness, data cleaning and coherence.
  Citation: Health Information Management Journal
  PubDate: 2019-12-06T01:24:45Z
  DOI: 10.1177/1833358319887743
Stakeholder’s perceived value of surgical audit data provided by the
Victorian Audit of Surgical Mortality
- Authors: Thomas Cloney, Jessele Vinluan, Andrew Chen, Claudia Retegan, Philip McCahy
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:Clinical audits can vary in their effectiveness depending on how the information is provided and the relationship between those giving and receiving feedback. In the Australian state of Victoria, the Victorian Audit of Surgical Mortality (VASM) is a state-wide mortality audit that, prior to this study, did not have a bidirectional feedback mechanism in place to gauge perception of the audit held by its stakeholders.Objective:We aimed to investigate the perceived quality of the audit’s information and the effectiveness of the audit’s communication strategies from the stakeholder population.Methods:We used a mixed methods approach to provide open-ended explorations into stakeholders’ views while also providing structured tools for conducting annual reviews. The qualitative data were analysed using an inductive content analysis.Results:Between 2015 and 2017, 240 VASM stakeholders were contacted, of whom 82 (34.2%) agreed to be interviewed. The VASM’s data were perceived to be of high quality and used in a variety of ways. The audit’s communication strategies were seen to be adequate but could be more targeted to the stakeholder. There is a perception that the audit might not be relevant to hospital stakeholders that are not themselves clinicians, despite direct involvement with the audit.Conclusion:This study helps to explain the role the audit plays among its stakeholders and offers three overarching recommendations for improvement strategies: produce data sharing strategies that are relevant to rural or highly specialised surgical centres, improve communication to be targeted at stakeholders and explore methods to provide feedback to hospital management with more individualised feedback.
  Citation: Health Information Management Journal
  PubDate: 2019-11-29T10:55:37Z
  DOI: 10.1177/1833358319885223
Protection of digital health information: Examining guidance from the
physician regulatory colleges in Canada
- Authors: Neil G Barr, Glen E Randall
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:The use of information and communication technology (ICT) has tremendous potential to enhance communication among physicians, leading to improvements in service delivery. However, the protection of health information in digital/electronic format is an ongoing concern.Objective:The purpose of this study was to examine guidance for the protection of health information when using ICT from all 10 of Canada’s provincial regulatory colleges for physicians and to discuss the potential policy and service delivery implications.Method:A search of the regulatory college websites was conducted, followed by a document analysis (content and thematic).Results:The college website search identified 522 documents; 12 of these documents (from 8 of the 10 colleges) met the study criteria. These documents were notable for the considerable variation in the scope and detail of guidance provided across the colleges.Conclusion:While the federal–provincial division of powers in Canada enables different jurisdictional approaches to health service delivery and, thus, opportunities for policy learning, this governing structure may also contribute to a lack of incentive for collaboration, leading to an absence of standardised guidance for health information protection when using ICT. This, in turn, may result in unequal and inequitable protection of health information across the provinces. Therefore, a macro-level approach to policy development in this area may hold the greatest promise for enhancing the protection of health information and doing so in a more standardised manner in countries with federal systems of governance.
  Citation: Health Information Management Journal
  PubDate: 2019-09-12T03:47:57Z
  DOI: 10.1177/1833358319873968
The necessity to develop a national classification system for Iranian
traditional medicine
- Authors: Reza Safdari, Hossein Rezaeizadeh, Goli Arji, Alireza Abbassian, Mehrshad Mokhtaran, Reza Dehghan, Sara Shekalyou
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:Classification of disease and interventions in traditional medicine (TM) is necessary for standardised coding of information. Currently, in Iran, there is no standard electronic classification system for disease and interventions in TM.Objective:The current study aimed to develop a national framework for the classification of disease and intervention in Persian medicine based on expert opinion.Method:A descriptive cross-sectional study was carried out in 2018. The existing systems for the classification of disease and interventions in TM were reviewed in detail, and some of the structural and content characteristics were extracted for the development of the classification of Iranian traditional medicine. Based on these features, a self-administered questionnaire was developed. Study participants (25) were experts in the field of Persian medicine and health information management in Tehran medical universities.Results:Main axes for the classification of disease and interventions were determined. The most important applications of the classification system were related to clinical coding, policymaking, reporting of mortality and morbidity data, cost analysis and determining the quality indicators. Half of the participants (50%) stated that the classification system should be designed by maintaining the main axis of the World Health Organization classification system and changing the subgroups if necessary. A computer-assisted coding system for TM was proposed for the current study.Conclusion:Development of this classification system will provide nationally comparable data that can be widely used by governments, national organisations and academic researchers.
  Citation: Health Information Management Journal
  PubDate: 2019-09-10T03:08:05Z
  DOI: 10.1177/1833358319872820
Health information technology foresight for Iran: A Delphi study of
experts’ views to inform future policymaking
- Authors: Morteza Hemmat, Haleh Ayatollahi, Mohammadreza Maleki, Fatemeh Saghafi
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:Policymakers require a systematic approach when planning for information technology needs in healthcare.Objective:The aim of this study was to obtain experts’ predictions of future health information technology (HIT) needs until 2025 for Iran in relation to the relative importance of key technologies, expected timeframe of realisation, areas that may be impacted upon and obstacles to achieving these goals.Method:This article presents results from the third phase (a Delphi study) of a larger mixed-method study. Policymakers from the Iranian Ministry of Health and faculty members from different medical universities across the country who were expert in the field of HIT were invited to participate (n = 61).Results:Participants (39) completed the first-round questionnaire and 24 completed the second. The development of personal health records (n = 32, 82.0%), the development of clinical decision-making systems (n = 30, 76.9%) and the use of business intelligence for collecting and analysing clinical and financial data (n = 32, 82.0%) were predicted to occur after 2025. The healthcare areas predicted to experience the greatest impact from most HITs were facilitating patient–provider communication and improving healthcare quality. Key barriers to achieving HITs were related to weaknesses in planning and limited financial resources for most technologies.Conclusion:By identifying the areas of impact and the barriers to achieving the HIT goals, more accurate planning is possible and resources can be allocated according to priorities.
  Citation: Health Information Management Journal
  PubDate: 2019-08-16T02:43:10Z
  DOI: 10.1177/1833358319868445
Assessing the information quality and usability of My Health Record within
a health literacy framework: What’s changed since 2016'
- Authors: Louisa Walsh, Bronwyn Hemsley, Meredith Allan, Maria R Dahm, Susan Balandin, Andrew Georgiou, Isabel Higgins, Shaun McCarthy, Sophie Hill
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:This study examined the health literacy demands of My Health Record (MyHR) in the context of preparing for a government-announced opt-out system by repeating two studies of health information and usability conducted in 2016.Objective:To examine whether Australia’s MyHR meets the information and usability needs of people at risk of low health literacy and changes since 2016.Method: Content analysis: Informed by the 2016 methods and findings, measures of information quality, themes and target audiences were recorded and reported for each online consumer-facing health information resource. Heuristic evaluation: An evaluation of the MyHR and supporting information website was conducted using a predetermined checklist of usability criteria. A list of usability violations for both websites was identified.Results:Total number of resources grew from 80 in 2016 to 233 in 2018. There was little change since 2016 to average readability levels, target audiences, presentation style, links between resources and usability of MyHR. Compared to 2016, this study demonstrated increases in resources from non-government organisations; video resources; translated resources; and resources with themes of privacy, security and post-registration use.Conclusion:This study identified some improvements in information quality since 2016, but gaps remain in information quality and usability which may negatively impact the ability for people with low health literacy to access and use MyHR.Implications:This study provides a framework for ongoing monitoring and evaluation of the suitability of MyHR for people at risk of low health literacy.
  Citation: Health Information Management Journal
  PubDate: 2019-08-02T01:51:29Z
  DOI: 10.1177/1833358319864734
Low back pain websites do not meet the needs of consumers: A study of
online resources at three time points
- Authors: Nathalia Costa, Mandy Nielsen, Gwendolen Jull, Andrew P Claus, Paul W Hodges
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:The popularity of the Internet as a source of health-related information for low back pain (LBP) is growing. Although research has evaluated information quality in health-related websites, few studies have considered whether content and presentation match consumer preferences.Objective:The aim of this study was to evaluate whether LBP website content and presentation matched preferences of consumers with LBP, whether matching preference of consumers changed over 8 years as recognition of people-centred healthcare has developed and whether this differs between countries of Internet searching.Method:The most prominent and top 20 LBP websites were identified using common search engines in 2010, 2015 and 2018. Websites identified in the top 20 in 2010 were followed up if not identified in 2015 and 2018. Two reviewers independently evaluated websites with a 16-item checklist developed from research of consumer preferences. In 2015, websites were identified using searches conducted using IP addresses from Australia, the United States of America (USA), the United Kingdom and Canada. After removal of duplicates, 55 websites were evaluated in 2010. In 2015 and 2018, 33 and 28 new sites, respectively, were identified, and 37 previous websites were re-evaluated.Results:In 2010 and 2015, websites predominantly originated from USA and were sponsored by “for-profit” organisations. In 2018, most websites originated from Australian “not-for-profit” organisations. None of the websites provided information on all content areas. At least 55% of websites were rated as poor or fair. No site rated as excellent overall. There was some worsening over time. Country of search did not affect results.Conclusion:Websites retrieved using typical searches did not meet information and presentation preferences of people with LBP.
  Citation: Health Information Management Journal
  PubDate: 2019-07-03T02:57:50Z
  DOI: 10.1177/1833358319857354
Wearable devices in healthcare: Privacy and information security issues
- Authors: Liezel Cilliers
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-05-31T04:00:18Z
  DOI: 10.1177/1833358319851684
Utilisation of hospital information systems for medical research in Saudi
Arabia: A mixed-method exploration of the views of healthcare and IT
professionals involved in hospital database management systems
- Authors: Halima Samra, Alice Li, Ben Soh, Mohammed Al Zain
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-05-03T02:18:23Z
  DOI: 10.1177/1833358319847120
Development of an evidence-based e-health readiness assessment framework
for Uganda
- Authors: Vincent M Kiberu, Maurice Mars, Richard E Scott
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-04-23T03:10:25Z
  DOI: 10.1177/1833358319839253
Workforce survey of Australian graduate health information managers:
- Authors: Merilyn Riley, Kerin Robinson, Natasha Prasad, Barbara Gleeson, Emma Barker, Dennis Wollersheim, Julie Price
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-04-22T04:05:23Z
  DOI: 10.1177/1833358319839296
Understanding health information management practices in public hospitals
in Kuwait
- Authors: Dari Alhuwail
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-03-21T04:47:23Z
  DOI: 10.1177/1833358319837247
The disconnection between the Brazilian health information system and the
cases of mercury exposure in Amazon
Open Access Article
- Authors: Nathália Santos Serrão de Castro, Marcelo de Oliveira Lima
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-03-12T03:21:11Z
  DOI: 10.1177/1833358319833063
Research data management in practice: Results from a cross-sectional
survey of health and medical researchers from an academic institution in
Australia
- Authors: Michelle A Krahe, Julie Toohey, Malcolm Wolski, Paul A Scuffham, Sheena Reilly
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-03-12T03:20:50Z
  DOI: 10.1177/1833358319831318
Clinical coding and the quality and integrity of health data
- Authors: Jennie Shepheard
  First page: 3
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-09-12T03:48:16Z
  DOI: 10.1177/1833358319874008
Computer-assisted clinical coding: A narrative review of the literature on
its benefits, limitations, implementation and impact on clinical coding
professionals
- Authors: Sharon Campbell, Katrina Giadresco
  First page: 5
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-06-04T03:11:54Z
  DOI: 10.1177/1833358319851305
A qualitative evaluation of clinically coded data quality from health
information manager perspectives
- Authors: Chelsea Doktorchik, Mingshan Lu, Hude Quan, Cathy Ringham, Cathy Eastwood
  First page: 19
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:It is essential that clinical documentation and clinical coding be of high quality for the production of healthcare data.Objective:This study assessed qualitatively the strengths and barriers regarding clinical coding quality from the perspective of health information managers.Method:Ten health information managers and clinical coding quality coordinators who oversee clinical coders (CCs) were identified and recruited from nine provinces across Canada. Semi-structured interviews were conducted, which included questions on data quality, costs of clinical coding, education for health information management, suggestions for quality improvement and barriers to quality improvement. Interviews were recorded, transcribed and analysed using directed content analysis and informed by institutional ethnography.Results:Common barriers to clinical coding quality included incomplete and unorganised chart documentation, and lack of communication with physicians for clarification. Further, clinical coding quality suffered as a result of limited resources (e.g. staffing and budget) being available to health information management departments. Managers unanimously reported that clinical coding quality improvements can be made by (i) offering interactive training programmes to CCs and (ii) streamlining sources of information from charts.Conclusion:Although clinical coding quality is generally regarded as high across Canada, clinical coding managers perceived quality to be limited by incomplete and inconsistent chart documentation, and increasing expectations for data collection without equal resources allocated to clinical coding professionals.Implications:This study presents novel evidence for clinical coding quality improvement across Canada.
  Citation: Health Information Management Journal
  PubDate: 2019-07-09T03:15:32Z
  DOI: 10.1177/1833358319855031
Health records as the basis of clinical coding: Is the quality
adequate' A qualitative study of medical coders’ perceptions
- Authors: Vera Alonso, João Vasco Santos, Marta Pinto, Joana Ferreira, Isabel Lema, Fernando Lopes, Alberto Freitas
  First page: 28
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-02-12T03:53:02Z
  DOI: 10.1177/1833358319826351
Suicidal and self-harm presentations to Emergency Departments: The
challenges of identification through diagnostic codes and presenting
complaints
- Authors: Jerneja Sveticic, Nicholas CJ Stapelberg, Kathryn Turner
  First page: 38
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:The accuracy of data on suicide-related presentations to Emergency Departments (EDs) has implications for the provision of care and policy development, yet research on its validity is scarce.Objective:To test the reliability of allocation of ICD-10 codes assigned to suicide and self-related presentations to EDs in Queensland, Australia.Method:All presentations due to suicide attempts, non-suicidal self-injury (NSSI) and suicidal ideation between 1 July 2017 and 31 December 2017 were reviewed. The number of presentations identified through relevant ICD-10-AM codes and presenting complaints in the Emergency Department Information System were compared to those identified through an application of an evolutionary algorithm and medical record review (gold standard).Results:A total of 2540 relevant presentations were identified through the gold standard methodology. Great heterogeneity of ICD-10-AM codes and presenting complaints was observed for suicide attempts (40 diagnostic codes and 27 presenting complaints), NSSI (27 and 16, respectively) and suicidal ideation (38 and 34, respectively). Relevant ICD codes applied as primary or secondary diagnosis had very low sensitivity in detecting cases of suicide attempts (18.7%), NSSI (38.5%) and suicidal ideation (42.3%). A combination of ICD-10-AM code and a relevant presenting complaint increased specificity, however substantially reduced specificity and positive predictive values for all types of presentations. ED data showed bias in detecting higher percentages of suicide attempts by Indigenous persons (10.1% vs. 6.9%) or by cutting (28.1% vs. 10.3%), and NSSI by female presenters (76.4% vs. 67.4%).Conclusion:Suicidal and self-harm presentations are grossly under-enumerated in ED datasets and should be used with caution until a more standardised approach to their formulation and recording is implemented.
  Citation: Health Information Management Journal
  PubDate: 2019-07-05T06:52:30Z
  DOI: 10.1177/1833358319857188
Importance of coding co-morbidities for APR-DRG assignment: Focus on
cardiovascular and respiratory diseases
- Authors: Julio Souza, João Vasco Santos, Veronica Bolon Canedo, Amparo Betanzos, Domingos Alves, Alberto Freitas
  First page: 47
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-05-02T03:05:55Z
  DOI: 10.1177/1833358319840575
The importance of clinical documentation improvement for Australian
hospitals
- Authors: Patricia Hay, Kathy Wilton, Jennifer Barker, Julie Mortley, Megan Cumerlato
  First page: 69
  Abstract: Health Information Management Journal, Ahead of Print.
  Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in “real time” so that it is fit for reporting, analysis and reimbursement. Every country has differing healthcare systems and this article has focused on validating the relevancy of CDI for the Australian healthcare environment.
  Citation: Health Information Management Journal
  PubDate: 2019-07-15T03:15:35Z
  DOI: 10.1177/1833358319854185
Malnutrition definitions in clinical practice: To be E43 or not to be'
- Authors: Wendy Phillips, Jennifer Doley, Kelli Boi
  First page: 74
  Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  PubDate: 2019-05-27T03:16:44Z
  DOI: 10.1177/1833358319852304
Use of electronic medical record templates improves quality of care for
patients with infantile spasms
- Authors: Jonathan D Santoro, Amanda Sandoval, Maura Ruzhnikov, Elise Brimble, Whitney Chadwick, Courtney J Wusthoff
  Abstract: Health Information Management Journal, Ahead of Print.
  Background:Infantile spasms (IS) is a neurologic disorder of childhood where time to treatment may affect long-term outcomes. Due to the clinical complexity of IS, care can be delayed.Objective:To determine if the use of electronic medical record templates (EMRTs) improved care quality in patients treated for IS.Method:Records of patients newly diagnosed with IS were retrospectively reviewed both before and after creation of an EMRT for the workup and treatment of IS. Quality of care measures reviewed included delays in treatment plan, medication administration, obtaining neurodiagnostic studies and discharge. The need for repeat neurodiagnostic studies was also assessed. Resident physicians were surveyed regarding template ease of use and functionality.Results:Of 17 patients with IS, 7 received template-based care and 10 did not. Patients in the non-template group had more delays in treatment (p = 0.010), delay in medication administration (p = 0.10), delay in diagnostic studies (p = 0.01) and delay in discharge (p = 0.39). Neurodiagnostic studies needed to be repeated in 5 out of 10 patients in the non-template group and none of the 7 patients in the template group (p = 0.04). Surveyed resident physicians reported improved coordination in care, avoidance of delays in discharge and improved ability to predict side effects of treatment with template use.Conclusion:In a single centre, the use of protocolised EMRTs decreased treatment delays and the need for repeated invasive procedures in patients with newly diagnosed IS and was reported as easy to use by resident physicians.Implications:The use of protocolised EMRTs may improve the quality of patient care in IS and other rare diseases.
  Citation: Health Information Management Journal
  DOI: 10.1177/1833358318794501
Systemic analysis of medication administration omission errors in a
tertiary-care hospital in Quebec
- Authors: Thomas G Poder, Serge Maltais
  Abstract: Health Information Management Journal, Ahead of Print.
  Objective:Medication administration omission errors (MAOEs) occur frequently in hospitals and can significantly affect patient health. An interdisciplinary committee was formed in summer 2012 to analyse incident/accident reports (AH-223-1 forms) of MAOEs for the 2011–2012 fiscal year in order to identify contributing factors and to propose preventive solutions. Special attention was paid to events with consequences for patients.Method:An aggregate data analysis involving four major steps was conducted: sampling, categorisation, identification of contributing factors, and seeking preventive solutions. One hundred omissions were randomly selected from the 889 reported for this period. All omissions categorised as having had consequences for patients were then added, making a final total of 145 omissions. The omissions were categorised using an Ishikawa diagram developed from an exploratory literature review and process mapping. Subsequent to failure modes, effects and criticality analysis, cause-and-effect diagrams were constructed with the main prioritised categories to differentiate the proximal causes from the root causes. Brainstorming was used to develop solutions, which were then prioritised with an impact/effort matrix.Results:This study identified 27 categories of MAOEs, of which the 7 most frequent and the most critical accounted for 79.3% of the reports. The event categories, in decreasing order of importance, were related to intravenous (IV) therapy (29.0%), failure in using the medication administration record (MAR; 23.4%), failure in creating/updating the MAR (10.3%), medications on the patient’s bedside (7.6%), and three types of MAOEs related to transcribing prescriptions (9.0%).Conclusion:The interdisciplinary committee formulated 10 main recommendations related to these 7 categories, including 3 for IV therapy and 4 for failure in using or creating/updating the MAR.
  Citation: Health Information Management Journal
  DOI: 10.1177/1833358318781099
Corrigendum
- Abstract: Health Information Management Journal, Ahead of Print.
  
  Citation: Health Information Management Journal
  DOI: 10.1177/1833358316654595