Skip to main content

Coding & Informatics Services

Coding takes your health information and structures it into viable data for health care decision makers.

Coding & Informatics Services is a Lower Mainland Consolidated Service serving 30 hospitals at Providence Health Care (PHC), Fraser Health Authority (FHA), Provincial Health Services Authority (PHSA) and Vancouver Coastal Health (VCH). 

Coding and Informatics services analyzes patient health information and assigns standardized codes to create structured data, which is used internally for decision making, performance measurement, quality improvement and externally for hospital funding, clinical research, and national benchmarking. 

In Fiscal Year 2014/15  PHC, FH, PHSA and VCH submitted data for:

  • 255,000  Acute Care visits
  • 242,000 Surgical Day Care visits
  • 1,029,000 Emergency visits

‎ A Lower Mainland Consolidated Service serving 30 hospitals across all 4 Health Authorities (FHA, PHC, PHSA and VCH).  Our team is comprised of:

 

1. MANAGEMENT TEAM

Management team consists of  Regional Director, Regional Manager-Coding Information Systems, Data Quality and Projects,  Manager-Coding Informatics and Strategic Improvement and five Coding Coordinators across all four Health Authorities.

   

2. CODING BUSINESS SERVICES SUPPORT TEAM  

Clinical Documentation Improvement Specialists

Working with clinical teams and physicians to improve clinical documentation for discharge summary content, patient safety outcome measures such as Care Sensitive Adverse Events (CSAE), Hospital standardized mortality ratio (HSMR) and Hospital Harm Indicators captured using Discharge Abstract Database (DAD). 

 

Coding Standards and Data Quality Specialist 

Provides leadership to support standardization of the DAD data coded from patient records. Leads development of the DAD Data Quality strategy to ensure data integrity across all 4 Health Authorities (FHA, PHC, PHSA and VCH). 

 

NACRS Coding Application Specialists

Leads a robust Data Quality program and monitors NACRS data on a monthly basis for Fraser Health and PHSA. 


System Applications Coordinators and Coding Application Specialist

Leads Informatics initiatives such as interfaces and mapping working towards Electronic clinical documentation supporting structured data and interoperability between systems.    

 

Data Analysts

Dedicated resource to each Health Authority to monitor and sustain data quality initiatives, HIM indicators, Report writing and assists with testing of Coding systems.


3. CODING SPECIALISTS

Captures patient’s entire visit in the hospital by assigning standardized codes while adhering to the Canadian National Standards for Discharge Abstract Database (DAD). 

 
  • Coding and Informatics HIM professionals complete a 2 year CHIMA recognized full time diploma program including courses such as Health Data collection and classification with ICD-10-CA and CCI, Human biology and anatomy, Health Information Reporting, System analysis and design, Medical terminology and Database management
  • Many have post diploma degrees
  • Only graduates of CHIMA recognized health information management education programs (including the External Graduate program) may challenge the national certification examination to become certified professionals. Their professional designation is CHIM, Certified in Health Information Management. National certification provides the graduate with recognition and portability of credentials across Canada. Upon certification, individuals become bound by the profession's Code of Ethics. Certification is required for active membership with CHIMA.
  • Continuing profession education (CPE) credits are required to maintain CHIMA Certification.

 

Coding and Informatics Services collects clinical data from the patient's legal record to tell the full story of a patient's hospital stay into standardized alpha numerical coded values. 

Coding and Informatics Services submits data to:

  • Canadian Institute of Health Information (CIHI)
    • CIHI is an independent, not-for-profit organization that provides essential information on Canada's health system and the health of Canadians. 
      Stakeholders use a broad range of health databases, measurements and standards, together with CIHI’s evidence-based reports and analyses, in day-to-day decision-making. 
  • Minimal data set to the BC Ministry of Health.
  • Perinatal Services BC
  • Canadian Neonatal Network
Development of Electronic Health Record for Clinical & Systems Transformation; and Fraser Health Meditech Intergrated Plan of Care Projects.
Learn more about CST
 
  • Nationally by CIHI
  • Provincially by BC Health Authorities
  • Hospital sites key indicator report cards and score cards
  • Physicians determining the complexity of patient populations
  • Hospital Programs and clinicians for outcomes.
  • Administration
  • Senior leadership
  • Committees
  • Researchers

 
  • NACRS/DAD BC Ministry of Health Data Quality Working Groups meet monthly with the BC Health Authorities representatives to address Data Quality concerns provincially
  • Coding's Clinical Data Management Group monitors the data across the 4 Health Organizations  including standing members from Coding and Decision Support Reporting Groups
  • CIHI conducts Re-abstraction Studies to ensure national compliance to standards
  • Coding and Informatics Services staff  attend  annual mandatory educational sessions to  ensure compliance with annual new standards
  • Strive to obtain data from source
  • Discharge Summary contents – working with the physicians and clinicians for communication and  transition of care
  • Built in system checks occur during electronic data collection
  • Coders follow CIHI Canadian National standards comprised of the DAD and Canadian Coding Standards to assign International Classification of Diseases ICD10-CA diagnoses and CCI interventions.

Did you know?

 

The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situation of population groups. It is used to monitor the incidence and prevalence of diseases and other health problems, proving a picture of the general health situation of countries and populations.

 

It provide the basis for the compilation of national mortality and morbidity statistics by the World Health Organization (WHO) Member States. All Member States use the ICD which has been translated into 43 languages. Most countries (117) use the system to report mortality data, a primary indicator of health status. 

  • Provides insight for better decisions clinically, administratively and financially 
  • Supports better care and outcomes 
  • Better knowledge to track clinical trends 
  • Better data to transform into actionable Information to optimize processes 
  • Codified data is required for optimal use of e-health systems 
  • Standardized data allows comparison at all care levels inform health policies
SOURCE: Coding & Informatics Services ( )
Page printed: . Unofficial document if printed. Please refer to SOURCE for latest information.

Copyright © Provincial Health Services Authority. All Rights Reserved.