Use of mixed methods to investigate case definitions to improve the identification of serious injury cases from hospital episode data.

INTRODUCTION: It has been commonplace internationally, when using hospital data, to use the principal diagnosis to identify injury cases and the first external cause of injury code (E-code) to identify the main cause. Our purpose was to investigate alternative operational definitions of serious non-fatal injury to identify cases of interest for injury surveillance, both overall and for four common causes of injury. METHODS: Serious non-fatal injury cases were identified from New Zealand (NZ) hospital discharge data using an alternative definition: that is, case selection using principal and additional diagnoses. Separately, identification of cause used all E-codes on the discharge record. Numbers of cases identified were contrasted with those captured using the usual definition. Views of NZ government stakeholders were sought regarding the acceptability of the additional cases found using these alternative definitions. Views of international experts were also canvassed. RESULTS: When using all diagnoses there was a 7% increase in 'all injury' cases identified, a 17% increase in self-harm cases and 8% increase in falls cases. Use of all E-codes resulted in a 4% increase in self-harm cases, 2% increase in assault cases and 1% increase in both falls and motor vehicle traffic crash cases. DISCUSSION: A case definition based solely on principal diagnosis fails to count a material number of serious non-fatal injury cases that are of interest to the injury prevention community. There is a need, therefore, to use an alternative case definition that includes additional diagnoses. Use of multiple E-codes to classify cause of injury should be considered.

[The REVELA13 observatory to study new cases of bladder tumor among women living in Bouches-du-Rhône county]. / Rôle de l'observatoire REVELA13 dans l'épidémiologie des tumeurs de vessie des femmes dans les Bouches-du-Rhône.

INTRODUCTION: The REVELA13 observatory is a unique epidemiological tool listing the new cases of kidney tumors, bladder tumors and acute leukaemias in the Bouches-du-Rhône county (France). Aim was to exploit for the first time data from this observatory regarding new cases of bladder tumors≥T1 in women from 2012 to 2014. MATERIALS: This epidemiological study was observational and descriptive. Fifteen non-nominative variables from the REVELA13 database were analyzed in order to describe the clinical and pathological characteristics of the incident cases as well as their spatial and temporal distribution. The incidence rates expressed in new cases per year per 100000 inhabitants were standardized on the world age, calculated with 95 % confidence intervals and compared to national estimates for the same period. RESULTS: Incident bladder tumor cases were recorded in 291 women, corresponding to a standardized incidence on the world age of 3.85 [3.32-4.37] new cases per year per 100,000 population, 54 % higher than the national estimates of 2012 and 2015. Median age of diagnostic was 75.9 years. Sex ratio was 19.41 % (W/M). Tumors were predominantly non-muscle-invasive (52 %), high grade (69 %) and without associated carcinoma in situ (Cis) (49 %). The two most affected territories were Marseille and Aubagne-La Ciotat. CONCLUSION: The REVELA13 observatory has improved our epidemiological knowledge on female bladder tumors in Bouches-du-Rhône county and highlighted a local over incidence. LEVEL OF EVIDENCE: 3.

Quantifying severe urinary complications after radical prostatectomy: the development and validation of a surgical performance indicator using hospital administrative data.

OBJECTIVES: To develop and validate a surgical performance indicator based on severe urinary complications that require an intervention within 2 years of radical prostatectomy (RP), identified in hospital administrative data. PATIENTS AND METHODS: Men who underwent RP between 2008 and 2012 in England were identified using hospital administrative data. A transparent coding framework based on procedure codes was developed to identify severe urinary complications which were grouped into 'stricture', 'incontinence' and 'other'. Their validity as a performance indicator was assessed by evaluating the consistency with diagnosis codes and association with patient and surgical characteristics. Kaplan-Meier methods were used to assess time to first occurrence and multivariable logistic regression was used to estimate adjusted odds ratios (ORs) for patient and surgical characteristics. RESULTS: A total of 17 299 men were included, of whom 2695 (15.6%) experienced at least one severe urinary complication within 2 years. High proportions of men with a complication had relevant diagnosis codes: 86% for strictures and 93% for incontinence. Urinary complications were more common in men from poorer socio-economic backgrounds (OR comparing lowest with highest quintile: 1.45; 95% confidence interval [CI] 1.26-1.67) and in those with prolonged length of hospital stay (OR 1.54, 95% CI 1.40-1.69), and were less common in men who underwent robot-assisted surgery (OR 0.65, 95% CI 0.58-0.74). CONCLUSION: These results show that severe urinary complications identified in administrative data provide a medium-term performance indicator after RP. They can be used for research assessing outcomes of treatment methods and for service evaluation comparing performance of prostate cancer surgery providers.

Job characteristic perception and intrinsic motivation in medical record department staff.

INTRODUCTION: Human resources are key factors in service organizations like hospitals. Therefore, motivating human recourses to achieve the objectives of an organization is important. Job enrichment is a strategy used to increase job motivation in staffs. The goal of the current study is to determine the relationship between job characteristics and intrinsic motivation in medical record staff in hospitals related to Medical Science University in Isfahan in 2011-2012 academic year. METHOD: The type of the study is descriptive and corelational of multi variables. The population of the study includes all the medical record staffs of medical record department working in Medical Science hospitals of Isfahan. One hundred twentyseven subjects were selected by conducting a census. In the present study, data collected by using two questionnaires of job characteristics devised by Hackman and Oldeham, and of intrinsic motivation. Content validity was confirmed by experts and its reliability was calculated through coefficient of Cronbach's alpha (r1 = 0.84- r2 = 0.94). The questionnaires completed were entered into SPSS(18) software; furthermore, statistical analysis done descriptively (frequency percent, mean, standard deviation, Pierson correlation coefficient,...) and inferentially (multiple regression, MANOVA, LSD). FINDINGS: A significant relationship between job characteristics as well as its elements (skill variety, task identity, task significance, autonomy and feedback) and intrinsic motivation was noticed. (p < or = 0.05). Also the results of multivariable regression showed that the relationship between job characteristic and intrinsic motivation was significant and job feedback had the most impact upon the intrinsic motivation. No significant difference was noticed among the mean amounts of job characteristic perception according to age, gender, level of education, and the kind of educational degree in hospitals. However, there was a significant difference among the mean amounts of job characteristic perception according to the unit of service and the years of servicein hospitals. CONCLUSION: The findings show that all job characteristics had positive effect upon intrinsic motivations and job feedback had the most effect on intrinsic motivation. Hence, it is necessary to take into account that job characteristics have a great role in changing the level of intrinsic motivation in the staffs.

Validating self-reported strokes in a longitudinal UK cohort study (Whitehall II): Extracting information from hospital medical records versus the Hospital Episode Statistics database.

BACKGROUND: Valuable information on the determinants of non-fatal stroke can be obtained from longitudinal observational cohort studies. Such studies often rely on self-reported stroke events, which are best validated with external medical evidence. The aim of this paper is to compare the information on incident non-fatal stroke events arising from different sources. METHODS: We carried out a validation of self-reported stoke events among participants in the Whitehall II Study, a large UK based cohort study (baseline sample size 10,308 men and women). RESULTS: 106 stroke events were self-reported in three self-administered questionnaires between 2002 and 2009. Eight (7.5%) of these events were discarded as false positives after medical review, 66 were validated by information from the NHS Hospital Episode Statistics (HES) database in England, 16 by manual searches of hospital records alone, and 12 by letters from general practitioners alone. HES provided information on an additional (i.e. not self-reported) 47 events coded as stroke during the period 2002 to 2009 in hospitals in England among the original baseline participants. Of these, 43 participants were no longer active in the study and 4 had completed questionnaires but not reported a stroke event. CONCLUSIONS: Validating self-reported strokes in cohort studies with information from the NHS HES database was efficient and provided information on probable non-fatal stroke events among cohort members no longer in active follow-up. Manual extraction from hospital notes can provide supplementary information beyond that available in the HES discharge summary and was used to sub-type some strokes. However, the process was labour intensive. Multiple sources are needed to capture maximum information on stroke events but increasingly with hospitalisation in the acute phase of stroke, HES has an important role. Further development of HES is required to assure validity and coverage.

Impact of data source and time reference of functional status on hospital mortality prediction.

BACKGROUND: The study objective was to compare physical function documented in the medical records with interview data, and also to evaluate hospital mortality predictions using pre-admission and on-admission functional status derived from these two data sources. METHODS: A prospective cohort study of 1402 subjects aged 65 years and older to the general medicine department of an acute care hospital was conducted. Patient-reported pre-admission and on-admission functional status for impairment in any of the five activities of daily living (ADLs) items (feeding, dressing, grooming, toileting and bathing), transferring and walking, were compared with those extracted from the medical records. For the purpose of mortality prediction, pre-admission and on-admission impairment in transferring from the two data sources were included in separate multivariable logistic regression models. We used a variable selection method that combines bootstrap resampling with stepwise backward elimination. RESULTS: For all ADL categories, the agreement between the data sources was good for pre-admission functional status (k: 0.53-0.75) but poor for on-admission status (k: 0.18-0.31). On-admission impairment was higher in the medical records than at interview for all basic ADLs. Using interview data as the gold standard, although sensitivity for pre- and on-admission ADLs was high (59-93%), specificity for on-admission status was poor (30-37%). The pre-admission models using interview data predicted mortality better than the model using medical records (c-statistic: 0.83 versus 0.82). Similar results were found for models incorporating on-admission functional status (c-statistic: 0.84 versus 0.81). However, the differences between the four models were not statistically significant. CONCLUSION: Medical records can be a good source for pre-admission functional status but on-admission functional impairment was over-reported in the medical records. The discriminatory power of the hospital mortality prediction model was significantly improved with the incorporation of functional status information but it was not significantly affected by their time reference or source of data.

Clear road ahead: no dead-end jobs in this coding department.

A coding department reorganizes its career paths from the bottom up, creating a culture of professional development.

How accurate is ICD coding for epilepsy?

PURPOSE: Assess the validity of ICD-9-CM and ICD-10 epilepsy coding from an emergency visit (ER) and a hospital discharge abstract database (DAD). METHODS: Two separate sources of patient records were reviewed and validated. (1) Charts of patients admitted to our seizure monitoring unit over 2 years (n = 127, ICD-10 coded records) were reviewed. Sensitivity (Sn), specificity (Sp), and positive and negative predictive values (PPV and NPV) were calculated. (2) Random sample of charts for patients seen in the ER or admitted to hospital under any services, and whose charts were coded with epilepsy or an epilepsy-like condition, were reviewed. Two time-periods were selected to allow validation of both ICD-9-CM (n = 486) and ICD-10 coded (n = 454) records. Only PPV and NPV were calculated for these records. All charts were reviewed by two physicians to confirm the presence/absence of epilepsy and compare to administrative coding. RESULTS: Sample 1: Sn, Sp, PPV, and NPV of ICD-10 epilepsy coding from the seizure monitoring unit (SMU) chart review were 99%, 70%, 85%, and 97% respectively. Sample 2: The PPV and NPV for ICD-9-CM coding from the ER database were, respectively, 99% and 97% and from the DAD were 98% and 99%. The PPV and NPV for ICD-10 coding from the ER database were, respectively, 100% and 90% and from the DAD were 98% and 99%. The epilepsy subtypes grand mal status and partial epilepsy with complex partial seizures both had PPVs >75% (ICD-9-CM and ICD-10 data). DISCUSSION: Administrative emergency and hospital discharge data have high epilepsy coding validity overall in our health region.

Quality control methods at a hospital.

PURPOSE: Healthcare providers need the information contained in patient records to provide high-quality services. To be effective, patient record assembly must be completed in a timely manner. This study aims to analyse the medical records assembly process for a hospital in Southeastern United States having difficulty meeting standard completion times established by the Joint Commission on the Accreditation of Healthcare Organization. DESIGN/METHODOLOGY/APPROACH: Several quality improvement tools were used to evaluate and improve the assembly process. FINDINGS: As a result of the study, a new procedure was implemented. Consequently, the hospital reduced the time required to assemble medical records, thereby improving efficiency and effectiveness. There are hopes to further improve the process. RESEARCH LIMITATIONS/IMPLICATIONS: The study provides guidance on how statistical process control techniques can be applied to improve hospital services. The techniques employed can be used to analyze and improve any process. However, results are limited to improving medical record assembly processes at one particular hospital. ORIGINALITY/VALUE: Past studies considered the application of various statistical process control techniques for improving healthcare quality. The study extends research by employing process improvement efforts to understand and develop medical record assembly in a regional hospital via process flow diagramming and control charts.

PREPARING FOR VANESSA'S LAW: COLLABORATION BETWEEN THE MEDICAL RECORDS AND PHARMACY DEPARTMENTS AT A CANADIAN HOSPITAL CENTER.

BACKGROUND AND OBJECTIVE: In the context of Vanessa's Law, the medical records department and the pharmacy team of a mother-child hospital collaborated to create a system for coding adverse drug reactions (ADRs). This study was conducted to validate the coding of ADRs by the medical records team. MATERIAL AND METHODS: This retrospective descriptive study covered 12 months of coding of hospitalization data by the medical records team (November 1, 2017, to October 31, 2018). The pharmacy team performed twice-monthly analysis to validate the ADR data, based on coded information for drugs and associated clinical manifestations. RESULTS: Over the 12-month study period, a total of 755 ADRs were coded by the medical records department (i.e., 2.1 ADRs per day, corresponding to 7.1% of admissions). For 34 (4.5%) of these ADRs, the pharmacy team made a change to the code originally assigned by the medical records department. Eighty-five (11.5%) of the coded ADRs were deemed serious, as defined by Health Canada, but only 13 (15%) of these serious ADRs were reported to the regulatory authority. The new process allowed clinical manifestation codes to be associated with individual drugs in the pharmacy's Med-Echo-Plus® software, which facilitated interpretation of the data. Following this study, coding practices were reviewed, a coding algorithm was developed, and the codes for 18 drugs were clarified. CONCLUSION: This study highlights the feasibility of establishing a link between the medical records and pharmacy departments to validate the coding of ADRs. At the study hospital, this linkage has identified serious ADRs, for which reporting will soon be required by Health Canada.

Risk factors for albicans and non-albicans candidemia in the intensive care unit.

OBJECTIVE: To determine risk factors for bloodstream infections (BSI) with Candida non-albicans (C-NA) species and Candida albicans (CA) among critically ill patients. DESIGN: Case-control study. SETTING: Adult medical and surgical intensive care units (ICUs) at two university hospitals. PATIENTS: Consecutive patients with C-NA and CA BSIs from 1995-2005 formed the two case groups. Controls were patients without candidemia who were randomly selected in a ratio of 5:1 and matched by study hospital, ICU type (medical vs. surgical) and by ICU admission date within a 3-month period. INTERVENTIONS: Data collected included demographics, comorbidities, exposure to antibiotics and antifungals, and ICU factors such as total parenteral nutrition (TPN), blood product transfusions, invasive procedures, central venous catheters, hemodialysis, and mechanical ventilation. We built multivariable logistic regression models, which identified risk factors for C-NA or CA BSIs compared with controls. Variables were adjusted for time-at-risk. MEASUREMENTS AND MAIN RESULTS: There were 67 patients with C-NA BSIs, 79 patients with CA BSIs, and 780 controls. In multivariable models, factors associated with an increased risk of C-NA compared with controls included major pre-ICU operations [odds ratio; (95% confidence interval)] [2.12; (1.14-3.97)], gastrointestinal procedures [2.24; (1.49-3.38)], enteric bacteremia [3.43; (1.39-8.48)], number of hemodialysis days [6.20; (2.67-14.4)], TPN duration [2.87; (1.40-5.90)], and mean number of red blood cell transfusions [2.72; (1.33-5.58)]. Factors associated with an increased risk of CA BSIs compared to controls were very similar and included major ICU operations [1.26; (1.14-3.97)], enteric bacteremia [3.45; (1.38-8.63)], number of hemodialysis days [3.84; (1.75-8.40)], TPN duration [11.0; (5.52-21.7)] and mean number of red blood cell transfusions [1.97; (0.98-3.99)]. CONCLUSIONS: We found multiple common risk factors for both non-C. albicans and C. albicans BSIs, however we could not differentiate between these two groups based on clinical characteristics alone.

What they fill in today, may not be useful tomorrow: lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran.

BACKGROUND: The medical record is used to document patient's medical history, illnesses and treatment procedures. The information inside is useful when all needed information is documented properly. Medical care providers in Iran have complained of low quality of Medical Records. This study was designed to evaluate the quality of the Medical Records at the university hospital in Tabriz, Iran. METHODS: In order to get a background of the quality of documentation, 300 Medical Records were randomly selected among all hospitalized patient during September 23, 2003 and September 22, 2004. Documentation of all records was evaluated using checklists. Then, in order to combine objective data with subjective, 10 physicians and 10 nurses who were involved in documentation of Medical Records were randomly selected and interviewed using two semi structured guidelines. RESULTS: Almost all 300 Medical Records had problems in terms of quality of documentation. There was no record in which all information was documented correctly and compatible with the official format in Medical Records provided by Ministry of Health and Medical Education. Interviewees believed that poor handwriting, missing of sheets and imperfect documentation are major problems of the Paper-based Medical Records, and the main reason was believed to be high workload of both physicians and nurses. CONCLUSION: The Medical Records are expected to be complete and accurate. Our study has unveiled that the Medical Records are not documented properly in the university hospital where the Medical Records are also used for educational purposes. Such incomplete Medical Records are not reliable resources for medical care too. Some influencing factors external to the structure of the Medical Records (i.e. human factors and work conditions) are involved.

Gastroenterology in Italian clinical practice. The RING Study: six years' data from gastroenterology departments.

AIM: Computer systems in hospitals provide information on the work of each single operative unit and the complexity of its caselist. However, in Italy, there is no official data-base for Gastroenterology Departments, to summarize their work. METHODS: The RING (Ricerca-INformatizzata-in-Gastroenterologia) study has collected, through a software made on purpose, 113 237 hospital discharge files (HDF) from 55 Italian hospital Gastroenterology Units, since 2001. This caselist provides a picture of the patients and is useful for clinical/management evaluation. RESULTS: Between January 2001 and December 2006, 55 Gastroenterology Units gathered 88240 HDF referring to ''ordinary admissions''. The male:female rate was 1:1, mean age was 61.3+/-18.5 years. Mean hospital stay was around eight days. Over the years there was a significant drop in DRG183 (miscellaneous digestive disorders-without complications) from 11.5% to 7.4% (P<0.0001), with no similar increase in DRG182 (with complications) which rose from 3.1% to 4.0%. Principal discharge diagnoses are post-hepatic and alcohol-related cirrhosis, hepatocarcinoma, acute pancreatitis, duodenal/gastric ulcer. CONCLUSIONS: The RING data show that the gastroenterologist has been working increasingly with patients whose pathologies would have been ''inappropriately'' treated surgically (DRGs 204 and 174). Inappropriate gastroenterological treatment seems to have decreased as well as the DRG183 with no apparent ''opportunistic'' compensatory increase in DRGs with complications, such as 182.

HIM jobs of tomorrow.

Tomorrow's HIM jobs are arriving today, as technology transforms how we capture, manage, and use information. Following are 11 jobs that represent evolving roles and emerging opportunities. Some are familiar roles with a new twist. Others are new roles, and some are possibilities. All are opportunities for HIM professionals to use their core competencies in new ways and move into positions that have not been thought of as career tracks for HIM.

Record limbo. Hybrid systems add burden and risk to data reporting.

Maintaining dual paper and electronic systems is often a necessity in the transition to digital record systems. The challenge in reporting data is keeping track of what data reside where.

Minimizing hybrid records. Tips for reducing paper documentation as new systems come online.

It can be tempting for providers to reach for paper, especially when things get hectic. Planning and support help keep the hybrid record from getting more hybrid than it has to be.

Getting up to code. While some wait for vendors to save them from ICD-10, savvy CIOs are taking the reins early.

For mandates, a passing grade is good enough--don't over-do. Alert the CEO early, but wait for a plan before going to the Board. Partner with end-user departments. Don't rely on your vendor to prepare for government mandates. Utilize information from CHIME, AHIMA and peers.

Release of information: are hospitals taking a hit?

Outsourcing release-of-information requests helps hospitals alleviate administrative and compliance burdens and expense. Recently, state lawmakers have begun to draft legislation reducing the maximum fee that may be charged for copies of electronically stored records. The reduced fees may not cover expenses. If such legislation makes it difficult for outsourcing companies to make a profit from this service, hospitals ultimately could bear the expense and risk.