Preparing Clinicians to Use and Understand Emerging Clinical Terminologies the Challenges

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Preparing Clinicians to Use (and Understand)
Emerging Clinical Terminologies the Challenges

• Jeannette Murphy
• Senior Lecturer in Health Informatics
• CHIME
• j.murphy_at_chime.ucl.ac.uk

Kalmar, Sept 2005
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Need for Common Language

• Ninety years ago an English-speaking nurse
  attended a meeting of the (then) recently
  established International Council of Nurses
• She observed
• While attending a special meeting of the ICN in
  Paris, I was naturally at once struck by the fact
  that the methods and the ways of regarding
  nursing problems were ... as foreign to the
  various delegations as were the actual languages,
  and the thought occurred to me that ... sooner or
  later we must put ourselves upon a common basis
  and work out what may be termed a "nursing
  esperanto" which would in the course of time give
  us a universal nursing language (Hampton Robb,
  1909).

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Overview of this Talk

• Health Informatics Education Training
• Recommendations
• Clinical Coding and Classification
• The Evidence whats being taught
• Who is Responsible?
• The Needs of Adult Learners
• The Way Forward

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Health Informatics Education Training

• Trends
• Health (medical) informatics now a recognised
  academic discipline
• Consensus that some components of HI should be
  integrated into the clinical curriculum
• Has not been easy to achieve this goal
• Some topics have caught the imagination of
  teachers and students
• Other topics less popular

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Components of Health Informatics
Clinical Systems
Data Quality And Management
EHRs
Knowledge Management
Secondary Uses Clinical Data
Security/
Telemed / Telecare
Basic IT Skills
Confidentiality
Coding Classification
Coding Classification
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Coding and Classification -Language of Health

• As move towards Information Age Healthcare,
  essential to get clinicians to buy-in to the need
  to understand the principles of coding and
  classification
• Coding - just one element of Health Informatics
• Topic has been seen as boring, technical,
  irrelevant province of coders, administrators,
  managers, statisticians

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Key Message

• Text, images, sounds, and many other sources of
  data can be stored and retrieved by computers,
  but for computers to "understand" the data it
  must be put into a code. Until the onset of the
  information age coding and classification of data
  in any format was not considered an urgent task
  during consultations.
• Mitchell Wyatt, 2005

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The Grand Challenges for HI Educators

• Move away from preoccupation with IT skills
• Define competencies and levels
• Achieve consensus who needs to know what, do
  what at what stage
• Ensuring educators have skills, knowledge and
  motivation
• Dealing with older staff
• Finding a way to engage learners

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Recommendations

• What elements of HI should be part of the
  clinical curriculum?
• A variety of recommendations, national and
  international
• Produced by professional bodies, government
  agencies, health service providers and HI experts

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IMIA Recommendations

• International Medical Informatics Association
  (IMIA) has produced guidelines
• Recommendations specify learning outcomes for
  professionals in healthcare
• For IT users
• For health informatics specialists

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Other Standards

• In UK, the NHS has elaborated various gold
  standards, learning outcomes
• Learning to Manage Health Information
• IMT Competencies
• Royal Colleges
• Royal College of Physicians (London) Health
  Informatics Unit has produced a draft curriculum
  for HI

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Whats Proposed for Clinical Coding
Classification?

• IMIA specifies 2 Learning Outcomes for Users of
  IT systems
• Appropriate documentation and health data
  management principles, including ability to use
  health and medical coding systems
• Intermediate level
• Construction of health and medical coding systems
  and their representation principles
• Intermediate level

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Learning to Manage Health Information (LtMHI) - UK

• Key Points for Good Practice
• Health professionals need to appreciate
  relevance, application and limitations of
  clinical coding so that individual practitioners
  and the wider health service can make best use of
  electronic clinical data / information.

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LtMHI 5 Expectations for Learning

• Use terms appropriately in the preparation of
  records to convey content and context
• Demonstrate the importance of shared meaning for
  inter-professional communication
• Identify the benefits of using a standard (coded)
  terminology within computerised clinical records

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LtMHI Expectations for Learning

• Differentiate between coding of clinical data for
  direct patient care (e.g. using Clinical Terms
  Version 3) and classification codes for
  statistical purposes using national and
  international classifications (e.g. HRGs and
  ICD10)
• Identify the advantages and disadvantages of
  standard clinical vocabularies in practice

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Learning Outcomes - LtMHI

• Appropriate use of clinical terms in preparing
  and updating records
• Understanding the basis and applications of
  different clinical coding systems and related
  vocabularies
• Ability to explore and understand the nature and
  importance of shared meanings for
  interprofessional communication

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Assessment of LOs - LtMHI

• To test knowledge and understanding
• Draft a short paper describing and commenting on
  the use of and problems associated with different
  clinical coding systems
• Describe and comment on the current problems of
  intrerprofessional communication in clinical
  language both within the health service and with
  professional groups in other health, social care
  and related organisations

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Assessment of LOs - LtMHI

• To demonstrate skills
• Demonstrate to a clinical supervisor or medical
  records expert an understanding of the clinical
  terms used in at least three realistic patient
  records and be able to discuss if these records
  are adequate or could be improved

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Health Informatics Unit of RCP, UK

• Produced a draft HI curriculum which includes two
  items relating to coding and classification
• Demonstrate awareness of different coding systems
  e.g. Clinical Terms / Read Codes, ICD, OPCS,
  SNOMED, finance and product codes
• Differentiate between coding for direct patient
  care (e.g. using Clinical Terms V3) and
  classification codes for statistical purposes
  (e.g. ICD-10, HRGs)

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RCP Draft Curriculum

• Appreciate benefits of using a standard
  terminology within computerised clinical records
• Use terms appropriately in the preparation of
  records to convey content and context

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Surveys into HI Education Training

• GEHR educational deliverable - 1994
• London-Scotland Survey 1998
• Welsh study - 2001
• RHIED study - 2003
• To determine what elements of HI are included in
  medical, nursing curricula
• Not concerned with quality of programmes, success
  rates, or perspective of learners

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London-Scotland Survey, 1998

• Interviewed curriculum leaders, clinical tutors,
  basic medical scientists, medical librarians,
  clinical skills tutors, health informatics
  advisors and pre-registration house officers
• all the medical schools in London and Scotland
  (n11)
• Aim of study - determine what elements of HI
  were included in the medical curriculum

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London-Scotland Study

• Work sponsored by Council of Heads of Medical
  Schools in the UK
• Sample
• 4 medical schools in Scotland
• 7 medical schools in London
• Conducted face-to-face interviews using open
  ended questionnaire
• Interviews conducted by two teams

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London-Scotland Study - topics

• Themes were derived from content analysis of
  documents issued by General Medical Council
• Identified four main topics to explore with
  respondents
• ? Health Records
• ? Professional Communication
• ? Ethical and Legal Imperatives
• ? Education and Research

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Teaching about Coding Classification

• General Medical Council Guidance on Record
  Keeping
• In providing care you must keep clear,
  accurate contemporaneous patient records which
  report the relevant clinical findings, the
  decisions made, the information given to patients
  and any drugs or other treatment prescribed.

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Proforma on Record Keeping

• How, when and where do students learn about
• the purpose, role and structure of personal
  patient records in medical practice
• the need for accuracy and data quality
• making sure that notes are legible
• understanding the terms used in records
• the importance of definitions for communication
• the advantages and disadvantages of unstructured,
  semi-structured and fully structured records

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Proforma on Record Keeping

• How, when and where do students learn about
• their own record keeping (do they receive regular
  feedback on their notes)
• where patient records are stored and how to
  retrieve records
• systems for coding and classification and their
  local use

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Findings London-Scotland Study

• Little direct teaching, structured on health
  records
• Exposure happens during clinical attachments
• Very much dependent on what clinical tutors see
  as important
• Very little attention paid to the language of
  health

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Coding and Classification - Low Priority

• Very little explicit, formal teaching on
• The terms used to describe patients condition,
  treatment, prognosis
• Coding and classification systems
• How records are structured
• The importance of definitions for communication
• Some questioned whether these topics belong in
  undergraduate curriculum

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Opportunities to Learn about Coding and
Classification

• General Practice
• Epidemiology courses
• During research projects e.g. audit
• Observed considerable variation between schools

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Welsh Study, 2001

• Study of Doctors, Nurses, PAMs and others
  commissioned by Welsh Assembly
• 1,467 respondents asked about their current HI
  skills and their access to technology

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HI Topics in Welsh Study

• Topics included
• Reading and writing health records
• Clinical Language
• Teamworking
• Knowledge Management
• Confidentiality and Security
• Secondary Use of Clinical Data
• Clinical and Service Audit
• Working Clinical Systems
• Telemedicine and Telecare
• Basic Computer Skills

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Reading and Writing Health Records

• Asked to describe current skills in terms of
  structuring patient records and using them in
  clinical practice and service delivery

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Clinical Language

• The need for a common clinical vocabulary.
  Clinical Terms (eg Version 3) and classification
  codes (HRDGs, ICD-10)

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Summary What Doctors and Nurses Felt about
their HI Skills 1

1 (n161 doctors and 883 nurses)
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The Rhied Study, 2003

• National study of health informatics education
  and training in the UK
• Funded by Department of Health
• Coverage all medical and nursing schools and a
  sample of post registration and post graduate
  programmes
• Also a case study of three acute trusts to
  explore continuing professional development

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Rhied - Methods

• Developed two questionnaires to be completed by
  staff responsible for teaching IT and health
  informatics
• Forms distributed by post, by email and on
  website
• Nearly 50 of nursing and medical schools
  responded
• Lower response rates for post grad and post
  registration programmes

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Rhied the Survey Form

• Questions derived from Learning to Manage Health
  Information (the gold standard)
• Variety of questions on communication and team
  working
• Provided a checklist and asked which topics were
  taught

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Results - Rhied

• Least covered topics Nursing Schools
• National and international classification codes
  only 20 of schools
• Standardised approaches representing clinical
  information 42 of schools
• Pros and cons of structured and unstructured
  records 47 of schools
• At post reg level, none of the schools covered
  national and international codes

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Results - Rhied

• Least covered topics Medical Schools
• National and international classification codes
  only 27 of schools
• Standarised approaches representing clinical
  information 27 of schools

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Reasons for Not teaching HI

• Lack of trained, motivated teaching staff
• Lack of time (nb in nursing programmes)
• Lack of leadership and institutional support
• Lack of co-ordination with clinical staff and
  with hospitals

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Skills Gap

• NHS has conducted two surveys of staff skills in
  HI (in 2001 and 2002)
• Found huge discrepancy between current and
  required skills particularly in relation to
  coding
• 78.4 of nurses say they lack competence
• 66.7 of doctors say they lack competence
• Yet these topics neglected in the curriculum

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To Sum Up

• All the evidence suggests that we have not been
  very successful in getting coding and
  classification integrated into the clinical
  curriculum
• Perceived as boring, irrelevant
• Has not grabbed imagination in same way as
  knowledge management, telemedicine, decision
  support

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What do Clinicians Need to Know?

• Need for greater clarity, guidance
• View of Educationalists and Clinicians
• Do not need to know how to code
• Do need to appreciate the different systems of
  coding and classification
• How differ
• How use codes
• Understand why coding/classification matter
• Consequences of errors, inaccuracies

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Justification for Education and Training Relating
to Coding

• Work going on in relation to SNOMED will only pay
  dividends if doctors, nurses
• Understand basic principles
• Are motivated to learn about coding,
  classification
• Keep knowledge up to date
• Act as role models for juniors, rest of team

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Take Away Questions

• Why teach coding? Justification, rationale
• What to teach? Issues of content, curriculum,
  learning outcomes
• How teach coding? Matters of pedagogy, need for
  good learning resources, activities
• How assess learning outcomes?
• Who to do teaching?
• Who to design learning resources?

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Who is Responsible?

• Medical, nursing schools, schools of health
  sciences
• Professional or regulatory bodies
• The professions themselves
• The learners
• Employers, the health care providers
• System developers, vendors
• Government
• The Health Informatics community

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Initiatives

• Royal College of Nursing, UK
• Has recognised need to focus on language,
  terminology
• Set up new Nursing Advisory Group
• Among the many issues to be tackled from the
  nursing perspective will be the language and
  terminology used in record keeping.

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Nursing Perspective - 2005

• Nurses currently use free text extensively
• Will SNOMED CT, the clinical coding system that
  forms the basis of the NHS Care Records Service,
  meet their needs?
• No, seems to be agreed response
• Dr Malone (General Secretary of RCN) says that
  this is not an issue for nurses alone
• Language has to be understood by other
  professional groups. I believe there is a way to
  package the language so that its available to
  other groups. It has to be something that is
  universally understood.

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Views of the Nursing Clinical Lead at Connecting
for Health (CfH)

• Tierney-Moore agrees terminology is important and
  that nurses need to work with other professions.
• But doubtful as to whether nursing profession
  ready to accept the level of standardisation
  needed in electronic record keeping to get the
  full benefits from a national system

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The Needs of Adult Learners

• Must motivate the learner
• Regular feedback and opportunities for
  self-testing
• Content must be perceived as
• Relevant
• Accessible
• Transferable to real world of clinical practice

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The Way Forward

• Agree core curriculum, learning outcomes
• Train the trainers / teachers
• Devise interesting learning exercises, activities
• Think about assessment methods
• Engage whole faculty
• Promote dialogue SNOMED, experts and
  educationalists

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E-Learning

• E-Learning may be one way of providing
  educational opportunities for clinicians
• Involve HI experts, SNOMED community in design
• Involve educationalists
• Involve educational technologists
• Involve clinicians
• Involve health service managers

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ICD 10
SNOMED???
?? OPCS
HRDGs Whats that
What does all this stuff have to do with me??
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The Incentive for Doctors, Nurses

• To manage patients within an integrated health
  service it is becoming more important to
  communicate information from one setting in a
  digital format while retaining meaning when
  viewed in a different context.

Mitchell Wyatt, 2005