Defining Best Practice across countries: International Health Information Management Literature Review

Stephen Badham ^a, Manal Nasser Al Khalifah ^b, Sharon Roumanos ^a

Introduction
An international literature review was performed to identify best practice across key areas within the health information domain. This was performed on behalf of the National Casemix Centre of Excellence (NCCoE) as part of the Development of Clinical Coding and Clinical Coding Related Governance Project. The review findings have informed the definition of the future state for national health infromation management (HIM) governance in the Kingdom of Saudi Arabia (KSA) and provide valuable insights for other countries.

Methods
The methodology involved an extensive review of published literature, with 276 articles reviewed across all continents, with KSA, Australia, USA, Canada, UK, and Ireland featuring predominately.

The focus was to determine the current situation across countries and to identify best practice in relation to the following areas:

1. Health information and health data governance and HIM frameworks;


2. Clinical coding quality and auditing;
   
   
3. Clinical documentation improvement programs;
   
   
4. Health information and coder education and training;
   
   
5. HIM workforce structure and career development:
   
   
   • Structure of HIM services;
   
   
   • Core functions and competency standards for HIM professionals;
   
   
   • Mechanisms to identify HIM workforce requirements;
   
   
   • Rewards for professional recognition.

Results
The paper will present on review's key findings and emerging themes of relevance for HIM internationally, including the importance of:

• Governance and Standards:
  
  
  
  
  
  • Strong information and data governance frameworks;
  
  
  • International and national data standards;
  
  
  • Classification systems;
  
  
  • Standardised data dictionaries;
  
  
  • Key Performance Indicators (KPIs);
  
  
  • Key resources from national HIM bodies.
  
  


• Technology:
  
  
  
  
  
  • Use of technology in coding;
  
  


• Processes:
  
  
  
  
  
  • Best practices in coding, audit and clinical documentation improvement (CDI);
  
  
  • Auditing and data quality assurance processes;
  
  
  • Importance of coded data and it use.
  
  


• People:
  
  
  
  
  
  • Structure and main roles of the HIM and clinical coder workforce;
  
  
  • Competency frameworks;
  
  
  • Career pathways and barriers to career development;
  
  
  • Coding training and education programs;
  
  
  • Rewards systems.
  
  

The paper will also present key areas impacting on HIM practices, and reflect on what these mean for the profession, including:

• Legislation, standards and regulations, including national safety and quality standards;


• Funding models for hospitals;


• Digital Health (EMRs) and emerging technologies for automation and efficiency, including coding software solutions;


• HIM and coding workforce challenges.

Conclusions
To be successful and meet the ongoing changes occurring in healthcare, HIM professionals must acquire new skills, continue their education and obtain new credentials. HIM professionals will increasingly be needed in specialist leadership, teaching, information governance and informatics roles. Roles and skills must align with industry needs which support high quality coded data, health information governance, EMR, CDI, funding, and research. It is important that HIMs build on their strong foundation of skills and knowledge and transform the workforce to ensure it can meet the future needs of healthcare. This will require new career pathways and academic curricula o meet future workforce needs, including informatics, big data, analytics, and information governance.


^a Beamtree, Australia
^b National Casemix Center of Excellence, Saudi Arabia

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