Driving Clinical Documentation and Data Integrity (CDI) continues to be a key function of Health Information Managers, Clinical Coders and Clinical Documentation Specialists alike.

As health information professionals we are aware that documentation practices may vary according to:

• the nature and use of the document
• who is interacting with the record and unit or specialty the type of record, and
• who has responsibility for documenting care and episode information.

Overarching documentation requirements are detailed in Actions 1.16, 1.17, 1.18 and Action 6.11 and of the National Safety & Quality Healthcare Standards (NSQHS). In this webinar, we will consider the clinical documentation practices and requirements outlined in NSQHS as well as the Good Medical Practice Guideline and Professional Practice Guidelines for Nurses and Allied Health Staff.

In addition to considering these guidelines, the webinar focuses on supporting engagement and quality documentation across the record and within units through specific standards alignment and appreciation of professional practice guidelines that underpin clinician documentation practices. This information will be discussed in the context of specific documents or forms, and illustrate how we can use awareness of standards and guidelines to support ongoing engagement with CDI programs and embed improvement in clinical practice.

Do not miss out on this webinar on 13 October 2021 that covers the core competence in data, records management, standards and governance as they relate to information management.

Electronic Health Records (EHRs) are the key digital health technology in the increasingly diversifying modes of health care delivery.  Accurate, accessible, consistent and contemporaneous health record information is central to the success of telehealth, Zoom consults in primary and tertiary health care. Furthermore, consistent modes of data collection in EHRs has the potential to inform the interoperability with new technologies such as wearables and post discharge care applications.

Health Information professionals have a strong and enduring interaction with health care records and large body of knowledge that can be brought to bear on the ongoing transformation of EHRs and evolving technologies.

Heather Grain notes that EHRs, like their paper based and digitally based forebears need structure.  She shares that the discoveries from the UK and Europe show that where that structure is built upon a consistent understanding of the data in the record the record itself gains power.

Heather brings her expert knowledge to this important area of Health Information Management and provides insights into the tool “openEHR” which is used internationally to:

• define the content of health records
• reduce software development time
• information exchange errors and expenses.

This webinar will also consider the Clinical Knowledge Manager which is an open source tool used by many countries (including Australia) as the underpinning approach innovations such as MyHealthRecord.   Heather will reflect on how this approach has resulted in data that is consistent and comparable but still flexible and displayed in ways which fit the needs of each individual use case; ultimately this enables EHRs which can use data like lego to build what is needed.

Join Heather Grain and HIMAA on 15 September 2021 and learn the future of EHR and health data design, and how to access and use these standards and tools.

Policy work is part of the role of many health information managers. This free webinar will discuss good practices in developing and reviewing policies, procedures, and guidelines. How can we consult stakeholders efficiently to understand the best balance between standards, compliance, and operational practicalities? How can we draft texts so they’re concise, unambiguous, and easy to read? What’s the best mechanism to monitor the implementation of new requirements and monitor the effectiveness of policy texts? The webinar will help HIMAA understand its members’ policy skills needs, to inform the planning of a professional development workshop later this year.

The webinar will be led by Dr. Kai Jensen of PolicyTrain, a consultant, editor and trainer, and editor who specialises in policy improvement. Kai has worked extensively with higher education institutions and other organisations, such as health profession peak bodies, to make organisational policies more effective.

Health Information Managers and Clinical Coders have unique skill sets that are fundamental to accurate funding of health care. Documentation improvement is a core skill we apply to identify data and documentation improvement opportunities. We achieve enhanced documentation integrity through audit, education, coding queries, and clinician engagement.

Our expertise in data management, data quality, and clinical information abstraction contributes to the future of sustainable, efficient health care funding and the viability of the Activity Based Funding (ABF) model. The importance of clinical documentation to funding and safe care has resulted in the emergence of the Clinical Documentation Specialist (CDS) as a key HIS team member.

To enhance our understanding of how to leverage our expertise in documentation improvement programs the HIMAA CDI Webinar Series will run over the next 12 months. We will consider how we can adapt our existing clinician relationships, apply our knowledge of the health care system, data collections, and funding models to respond to the need for sustainable CDI programs.

The first in its CDI Series, Operational CDI will look at the HIM/Coder value proposition, the CDI points of intersection with the wider health system, and aspects of HIS oversight in CDI programs. It will explore how and where CDI is placed and can be leveraged across your workplace.

We hope to see you on 23 July 2021 and find out what else you would like to see in this Series!