Clinical Coder Training Tool Project

This project is open to those interested to join the discussion and development.  If you are interested, would like to know more, be involved or to discuss the tooling and resources contact:   CCTT@gehco.org

Specification

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Comment Document   Please send us your comments.

Submit Specification comments to heather.grain@gehco.org

All contributions, and actions taken based upon comments will acknowledged.

Project Summary

The Problem

There is a shortage of appropriately trained clinical coders.  Employers want coders who are work ready and to up-skill existing coders.  Training organisations find it difficult to find suitable staff to teach and develop clinical coding courses and the workload in maintaining those courses is so extensive that few courses can justify the costs involved and therefore do not offer courses.  Training organisations also find it difficult to provide students with material that mimics the medical records, and the workplace situation  that they will encounter when employed.  Students are not motivated to take courses as jobs are not advertised widely or openly and students are often found inadequately or inconsistently trained and so not given employment.

The Solution

The Clinical Coder Training Tool (working project name) provides a solution to these problems.  It  is a tool delivered through a cloud based, secure, online platform.  This software includes:

  • A repository of health records for Clinical Coding training for morbidity reporting using ICD, or other clinical classifications.  Each case is classified to indicate:
    • classification system used (e.g. ICD-10-AM 10th edition or any classification system used in healthcare). This function supports the management of changes of edition etc
    • body system (broad topic)
    • specific clinical topic
    • level of difficulty
    • standard being tested
    • Status - new record submission (not yet processed but record put forward for inclusion or discussion), in progress (being considered for inclusion in record pool), active (in record pool - this record has all required metadata and answers)
    • Record type - query/discussion, sample record for coding.
  • A student management system - to manage the student progression through the learning process, including number of tries at record group (identified in the governance system)
  • answers - simple and complex as well as feedback.
  • A governance system where users can determine (for example)
    • the type of records (classification system, body system, clinical topic, level of difficulty, standard etc) to be included in the student experience,
    • the number of cases
    • whether exercises or tests
    • for a student cohort.

This tool is referred to throughout this document as the CCTT.

The Tool will

  • support the clinical coding community (coders, hospitals, government, and the profession) and the education community
  • improve the consistency of education
  • reduce the effort to maintain educational materials
  • include student progress monitoring mechanisms giving all students a similar experience and guaranteeing all students have coded the required number and type of cases for their skill level, while offering alternative records to vary the actual cases seen (i.e. students will not all see exactly the same cases).
  • engage the coding community to support quality processes and content

through provision of

  • Healthcare information systems (PMI, ATD, Post Discharge Processing, Clinical Code Data Entry) - simulated for the purpose of training - similar to common products but not a specific vendor product.
  • Medical records of episodes of care of fictitious patients
  • Coding answers (initially - ICD-10-AM-10th edition), feedback and references confirmed by a group of experienced coding auditors and members of the governance community.

The Tool is designed to support quality coder training, and to assist educators in maintaining their coding courses at the high quality essential for coder development.  The Tool will be  made available to educational and healthcare organisations on a not for profit, cost sharing model.

The development and ongoing viability of the tool is dependent upon support from potential beneficiaries including:

  • Governments seeking to expand the number of clinical coders in their jurisdictions
  • Clinical Coding educational organisations
  • Clinical Coding and Health Information Management professional bodies seeking to ensure the quality and provide training in clinical coding
  • Healthcare organisations
  • Individual experienced clinical coders and health information managers

This project will develop over 3 stages:

Development Stage 1 (in progress)

This stage establishes the coding record resources, the core information system, and the impartial experienced governance structures necessary to ensure quality and utility of the Tool and the content maintained in the Tool.  The stage is limited to the functionality required for proof of concept.  Testing and initial roll-out and will be in later stages.  This process has support from the Victorian Department of Education and Training and the Victorian Department of Health.

  • Establish Clinical Coding Training Tool Project Governance Committee and Escrow arrangement.
  • Confirm detailed requirements using and open-standards-based approach (including open disposition of comments received).
  • Collect health records for clinical coding, assigning codes to those records (in different code system versions, and with links to relevant simulated hospital systems to support the coding process. Contributions will be welcomed (the project as proposed by GeHCO will leverage existing records used for coding by its members).
  • Provide a standards based structure (not limited to a single vendor product or environment)

Deliverables

  • Cloud based ICD Tool and repository and training system (including student management)
  • A process for governance of the content (records, answers and feedback) will be managed by GeHCO through community engagement and dedicated coding staff.
  • Web site upon which open publication of coding jobs can be made (to encourage students to enrol in courses and to assist employers to find clinical coding staff)
Development Stage 2

Stage 2 establishes interfaces between coding software products (that have chosen to join the Tool project), reporting and error management systems.  The interfaces would also support clinical coding audit simulation.

  • Offer standard interfaces to coding software products such as:
    • DRG grouper/s
    • Encoders
    • Data warehousing
    • Other
  • Send data to Government required reporting data collection (such as VAED) in a test environment to support student report management and learning
  • Send data to cancer registration processes - should a simulated environment be made available
  • Retrieve records for coding based upon defined criteria (audit simulation)
Development Stage 3

Stage 3 is still being defined and represents potential additional functionality such as:

  • Linkage to other Global eHealth Collaborative projects, including EHR simulation and HealthCare Information System/s
  • Linkage to tools for screen development such as Clinical Knowledge Manager and OceanInformatics (ISO 13606). This is the information model of the Electronic Health Record being accepted internationally and used in Australian eHealth initiatives as the basis for screen development and record content storage.
  • Linkage to other standards based initiatives such as OpenEHR training environment, HL7, SNOMED CT.
  • Linkage to maps, such as those to and from ICD-10 to train Mapping Specialists.