Nuance Healthcare Solution Report Clinical Coders Clinical coders - the challenges, opportunities and the role technology can play in their future Having carried out an online survey of clinical coding professionals, Nuance Communications convened a roundtable to discuss the challenges the profession faces, the way it is likely to change and the part that technology could play in their future. Nuance Healthcare Solution Report 2 Clinical Coders About this report This report was written following the roundtable event held in London and chaired by Michael Jones, Associate Director of Education (Clinical Coding) Institute of Health Records & Information Management. Nuance would like to thank the following for their contribution to the roundtable and the report: Gareth Jones ACC, Clinical Coding Improvement Manager, Manchester University NHS Trust Gillian Cartledge ACC, Head of Coded Data & Standards Assurance, Northern Care Alliance NHS Group Carolyn Cooper ACC, Head of Clinical Coding, Guy’s and St Thomas’ NHS Foundation Trust Adam Theobald, Head of Clinical Coding and PbR Assurance, King’s College Hospital NHS FT Gregory Stephenson, Head of Coding Services, University College Hospitals London NHS FT Gary Bagley, Head of Clinical Coding Solutions & Assurance, Mersey Internal Audit Agency Richard Burdon ACC, Classifications & Terminology Standards Manager, NHS Wales Informatics Service Yvette Lloyd, Clinical Coding Service Improvement Lead, Swansea Bay University Health Board Denise Blackman ACC, Head of Clinical Coding, East Kent Hospital University NHS FT Michael Thick, Director and CMO, Aqcuity Ltd Michael Jones ACC, Associate Director of Education (Clinical Coding), IHRIM Nuance Healthcare Solution Report 1 Clinical Coders Contents 1.0 Executive summary 2.0 Introduction 3.0 What are the challenges faced by clinical coders? 4.0 SNOMED – an opportunity for joined up healthcare 5.0 Clinical coding in Wales 6.0 What impact does technology and AI have on clinical coding? 7.0 What are the solutions to these challenges? 8.0 Recommendations Nuance Healthcare Solution Report 2 Clinical Coders 1.0 Executive summary The role of clinical coders is pivotal to the NHS. They use health records to translate clinical terms into a sequence of codes which describe the diagnoses and procedures. For the NHS in England this Documenting relevant co- This report makes a series of activity ensures accurate payment morbidities is also an area of recommendations which should for providers of care through the concern. In order to claim correct help to improve the day-to-day National Tariff Payments System payments for care and treatment, lives of clinical coders and ensure (NTPS). In England, the data clinical coders must include all that what is sometimes seen as derived from the codes is used in relevant comorbidities. Clinicians backroom function is given the Hospital Episode Statistics (HES) may not amend or include them daylight it deserves. and Secondary Usage Services if they have been previously (SUS). This means it becomes documented. As coders can only We are advocating more detailed the basis for performance code episodically, they may fail to guidance and support from NHS measurement and benchmarking, include relevant conditions. Digital around standards and but also for planning future health policies, and a mandate to enforce services and improvements in These challenges could be better coding standards is needed patient care. overcome by encouraging better in order to reduce variation in the communication between clinical way information is collated, so that However, clinical coders face many coders and clinicians, yet a further it is not up to the coder to wade challenges. The move towards a challenge for many coders in through notes and interpret these. digital NHS which is supposed the NHS is that they are often in A clear vision for SNOMED CT to support better use of data has different locations and away from implementation and use is needed, inherent challenges for coders. front line care. too, so this can be consistent There is significant variation in the across the country. EPRs should implementation of record keeping Coders often feel the main enable coders to begin working in standards and record keeping emphasis on their job is one of real time, which will in turn enable systems. Electronic patient financial accuracy rather than data timely validation of information records (EPRs) create a further analysis and service improvement with cases fresh in the minds of challenge as they are cumulative and the NTPS doesn’t help in the clinician. Improving coders’ and designed to allow clinicians this respect. The NTPS can knowledge of medical conditions a longitudinal view of care - create perverse incentives and and increasing communication particularly relevant for patients consistency of data quality can be with clinicians will lead to a greater who have many comorbidities or affected by this. understanding of the patient chronic illnesses. However, from a diagnosis and treatment and clinical coding perspective, codes Despite these challenges, there therefore better data and insights. are based on episodes of care and are opportunities for clinical the standards need to change to coders, and it is likely that new We also recommend a nationally reflect the new way of working with technology will have a direct standardised job specification EPRs. impact on their role. Rather than and pay band for coders to raise build walls and defend what they their profile and value perception The role itself is often see as the typical coding role, amongst other clinical staff. Trust misunderstood. There needs to coders are being encouraged to boards must work to increase their be a culture shift which helps to embrace what the future could understanding of the importance elevate what clinical coders do, hold and evolve so the role of good quality data and the value highlighting the benefit of accurate becomes more about developing this brings to service planning coding to clinical colleagues which insights from the data. SNOMED rather than focusing on the number in turn will encourage them not to CT is one example of an NHS- of records processed. Finally, as think about ‘wrong codes’, but how wide change, which although not clinical coders will play a vital they can play a part in improving universally acknowledged, could role in the data-driven NHS of the coding. Clinical coders need to be a catalyst for elevating the role future, they should be given more have a greater understanding of the coder. training and support so they can of how the data is used, so they be maximally effective and can can reinforce the importance of help drive improvements. accurate and consistent recording. Nuance Healthcare Solution Report 3 Clinical Coders 2.0 Introduction The World Health Organisation It is therefore easy to see why Yet, despite the apparent advan- (WHO) has declared 2020 as clinical coding is fundamental to tages, there is reticence amongst the International Year of the the NHS and why it will be increas- coders who have concerns that Nurse and Midwife in honour of the ingly useful. However, the methods AI is after their jobs. However, bicentenary of the birth of Florence used for collecting this data have AI should be perceived as an Nightingale. Nightingale is not significantly changed in the opportunity rather than a threat. popularly remembered as the past 25 years. The coding process The future requirements of the founder of modern nursing, but is a manual task that requires a workforce will change and the her pioneering contributions to the specialist trained member of staff, profession must be forward field of statistics are less widely the clinical coder, to transact thinking and focus on identifying acknowledged. episodes of care in hospital the knowledge that will be needed administration systems. liaising with clinicians using new Nightingale recognised the impor- technologies, such as SNOMED tance of collecting and arranging Clinical coders work from the CT, and upgrading skills in line with data and their power to inform and health records of patients, whether changing roles. transform; the observations she paper, electronic or both, analysing recorded in Istanbul hospitals dur- the text written by clinicians and In turn, this will create a framework ing the Crimean War are testament translating their clinical terms into for the upcoming generation to that¹. In 1860 she wrote a paper a sequence of alphanumeric codes of informatics professionals that advocated for the systematic which describe the diagnoses and which aligns with the objectives collection of hospital data using a procedures. of Health Education England’s uniform classification of diseases Building a Digital Ready Workforce and operations. This went on There is nationally mandated programme6. to form the basis International training for clinical coders that Classification of Disease (ICD)². effectively instructs on the It is clear that the clinical coding common toolbox of methods profession is well served by its So, it is not unreasonable to argue which all coders rely on, but much passion and expertise. that ‘The Mother of Nursing’ also of what makes a good coder is has a claim to the title ‘Mother experiential. Therefore, results – Michael Jones ACC of Clinical Coding’. Much has can vary due to differences in Associate Director of Education happened since her time but the judgement when analysing and (Clinical Coding) principles for the routine collection abstracting