Clinic Coding New Concepts in Ingenuity

1
Clinic CodingNew Concepts in Ingenuity

• Prepared by Donna Thompson
• Supervisor Health Information Services
• Joseph Brant Memorial Hospital

2
The Mandate

• Nov. 8, 2001 letter from MOHLTC mandated the
  reporting of SDC, April 1, 2003, and stated they
  would examine feasibility of reporting certain
  high cost medical daycare procedures
• Reporting of dialysis, oncology and cardiac
  catheterization medical daycare and clinics
  deferred until October 1, 2003

3
The Process

• ACTRF meetings conducted
• Discussion and interpretation of data elements
• CIHI and Ministry available for assistance
• Discussion and support from peer hospitals

4
What Do We Need to Do?

• Code Oncology Clinic Activity
• Be creative in the use of existing resources to
  successfully meet the mandate

5
Our Data Structures Challenges

• Data Sources
• Opis
• Meditech Clinic Registrations
• Abstracting Software
• Winrecs
• Workload
• Volume 550 records per month

6
The Process

• Informal meeting with Peer Hospitals and CCO
• Discussion of process the real work flow
• Discussion of what codes to be used
• Discussion on CIHI coding queries
• Follow up questions raised

7
The Process

• Data captured and registered in Opis
• Patient demographics
• Initial working Diagnosis I10 I9
• Interventions completed
• Retrospective coding
• Customization of OPIS Reports
• Data Captured in Meditech
• By Functional Centre
• Location Code with diagnosis Procedure

8
The Customization Of Reports

• Create Customized report for Chemo and Clinic
  Visits
• Data already captured in OPIS prints on report
  used for coding
• Customized report created for visits in Meditech
• Data prints interventions performed

9
How We Achieve Our Results
10
Patients registered in OPIS or Meditech
Oncology Clinic Visits
Data Housed in respective system
Decision Making
Data Cycle
Funding
Customized Reports Printed
Data Submission Time lines
Adaptation of Software for submission
Submission To CIHI
Analysis Coding
11
Customization of Winrecs
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Customization Of Winrecs

• Create Profiles
• - Same information applied
  across many different patients eg Same Clinic
  type of visit different patients
• - Cloning of abstracts the
  same patient returning for many visits of the
  same nature. E.g. chemotherapy

13
Crunching of The Numbers

• 550 visits to be recorded
• Visits abstracted retrospectively
• 15 hours per week allocated to the process

14
Our Strategies For Success Customization

• Maximize the resources you have available
• Use staffing resources effectively
• -Optimize software to create efficiencies
• -Continually tweak the process