Background: Health information managers (HIMs) routinely support research through their management, clinical coding, and governance of health data and information. Recent research highlights a disconnect between the reliance, for research, on HIM-managed data and the extent to which HIMs and others within the wider health information management workforce engage in research. Objective: To investigate the implicit and explicit uses of research skills by Australia’s HIMs in their professional practice, by: (i) describing the characteristics of abstracts published in the Health Information Management Association of Australia’s (HIMAA’s) Conference Proceedings, 2020–2025; (ii) identifying the application of research-related skills and knowledge, explicitly or implicitly stated, within “professional practice/case-study” (PP/CS) abstracts authored by Australian HIMs. Method: A qualitative documentary analysis of abstracts was undertaken, and descriptive characteristics were extracted. For PP/CS abstracts, a competency-based scoring tool was developed. The five research-based, profession entry-level competencies in the HIMAA 2023 Competency Standards, Domain E, were utilised to categorise explicit and implicit research knowledge/skills using the criteria: Implicit (suggested, but not stated); Explicit (clearly stated and appropriate); None (no evidence of indicator). Scores applied were: 0 (no evidence of indicator ); and 1 ( either implicit or explicit criteria met ). Implicit and explicit totals were calculated for each domain and applied to the abstract review for: Research Implicit Score; Research Explicit Score; No Score. Results: Across the study period, 252 abstracts/papers were identified: PP/CS (55.5%); research (24.2%); workshops (11%). Results: “Classification, clinical documentation and coding excellence” was the most frequent topic addressed (38.9%), followed by “workforce transformation and professional collaboration” (16.7%). Of 106 PP/CS abstracts eligible for analysis, 35% ( n = 37) met the threshold for sound research competency (i.e. ⩾3 research indicators were present), with implicit indicators more commonly observed than explicit indicators; 40% showed no evidence of indicators; four abstracts exhibited all five research indicators. Conclusion: These findings demonstrate that research skills are embedded within routine professional practice and not confined to formal research activities. Implications for health information management practice: Research competencies appear to be used implicitly in everyday decision-making and problem-solving, to interpret clinical documentation, apply coding standards, evaluate information, and support data quality.
Background: Accurate medical record front-page (discharge summary face sheet) documentation supports diagnosis-related group (DRG) classification and payment review. Evidence on disease-specific management for diabetic nephropathy (DN) remains limited. Objective: To evaluate associations of refined front-page management with complication coding patterns, length of stay, total hospitalisation cost and cost structure in adults admitted principally for DN. Method: We retrospectively compared 48 index hospitalisation episodes in 2023 with 85 episodes from January 2025 to February 2026 at Peking University First Hospital Linquan Hospital. Both periods used the International Classification of Diseases, Tenth Revision, National Clinical Edition 2.0 diagnosis dictionary and China Healthcare Security Diagnosis Related Groups 1.1 framework. Results: Drug cost proportion decreased from 26.7% to 16.1% (difference, −10.6 percentage points; 95% confidence interval (CI), −15.0 to −6.2; standardised mean difference (SMD), −0.97; p < 0.001), while medical service fee proportion increased from 17.9% to 21.3% (difference, 3.4 percentage points; 95% CI, 1.5–5.3; SMD, 0.60; p = 0.001). Total costs were unchanged (median (interquartile range), 3508.56 (2940.07–4186.97) vs. 3475.42 (2902.41–4161.56) RMB; p = 0.850). Coding with E11.700 (Type 2 diabetes mellitus with multiple complications) or E11.700x033 (Type 2 diabetes mellitus with multiple complications, diabetic nephropathy) increased from 0.0% to 52.9% (risk difference, 52.9 percentage points; 95% CI, 40.1–63.2; Cramer’s V = 0.54; p < 0.001), compared with E11.201 + N08.3* (Type 2 diabetes mellitus with diabetic nephropathy; N08.3*, glomerular disorders in diabetes mellitus). Conclusion: Refined front-page management was associated with more service-oriented costs and more complete capture of documented complications, without higher total costs. Implications for health information management practice: Disease-specific checklists and coder-physician review may strengthen payment-related data quality under DRG reimbursement.
Background: Health Information Managers (HIMs) routinely work with patient records containing detailed accounts of illness, trauma and death. While the biopsychosocial-spiritual (BPSS) impacts of trauma exposure have been widely documented among clinicians, little is known about the wellbeing of non-patient-facing health professionals who are repeatedly exposed to sensitive patient information. Objective: To explore the BPSS impacts experienced by HIMs following exposure to information contained within patient records. Method: A qualitative study informed by grounded theory methodology was undertaken. Semi-structured interviews were conducted with 30 HIMs employed across a range of Victorian healthcare organisations in Australia. Participants were purposively recruited to represent diverse career stages and workplace settings. Interview data were analysed using reflexive thematic analysis, guided by the BPSS framework. Results: All participants described impacts in at least one BPSS domain, with many reporting experiences across multiple domains. All participants experienced psychological impacts such as empathy, emotional distress, personal resonance, health anxiety, intrusive thoughts, emotional fatigue, desensitisation and positive psychological responses. Three-quarters of respondents experienced spiritual impacts such as existential reflection, moral and ethical appraisal, compassion, helplessness and gratitude. Biological impacts affected over 50% of participants and included somatic (physical) expressions of emotion, sleep disturbances and physical fatigue. Social impacts were least prevalent, affecting only 10% of participants, and included health advocacy within personal networks and social withdrawal. Conclusion: Findings demonstrated that repeated exposure to patient information alone, despite the absence of direct patient contact, was sufficient to influence participants’ wellbeing across multiple domains. These findings challenge assumptions that non-patient-facing health professionals, including HIMs, are unaffected by the emotional consequences of patient care and highlight the importance of recognising occupational wellbeing risks associated with indirect exposure to trauma-related material. Implications for health information management practice: Recognition of BPSS impacts should inform workplace wellbeing initiatives and professional support for the HIM workforce. The findings also highlight the need to consider how education and ongoing professional development can better prepare HIMs to recognise and manage the potential wellbeing impacts associated with working with sensitive patient information.
Background: The quality of Australia’s coded clinical data is essential for its reliability in myriad applications throughout the healthcare system, signalling the need for clinical coding auditing. Internal clinical coding auditors audit hospitals’ coded data, ‘in-house’. Independent, external auditors undertake audits on behalf of purchasers and providers: state/territory governments; health insurance funds; private hospital proprietors. Objective: To identify the professional knowledge, skills and specialist functions of certified clinical coding auditors in Australia. Method: A cross-sectional study design was utilised. A purposively designed, self-administered online survey was distributed to the study population ( N = 241), who achieved a ‘Certificate of External and Internal Clinical Coding Auditing’ or ‘Certificate of Internal Clinical Coding Auditing’ from La Trobe University, Australia, from 2005 to 2021. Results: Of the 93/241 (38.6%) respondents, these results concern those who had engaged, predominantly, in either external or internal auditing within their previous 5 years of employment. The responses of 42 practising auditors were analysed: 83.3% ( n = 35) had predominantly undertaken internal auditing within the past 5 years; 59.5% ( n = 25/42) had a Certificate of External and Internal Clinical Coding Auditing, 28% ( n = 7/25) of whom had predominately undertaken external auditing. The respondent-auditors reported on 52 core knowledges/skills/functions, which we aggregated into 4 discrete clusters: (a) health classification; (b) health informatics and technology; (c) health data analysis; (d) health information and business management. Of these knowledges/skills/functions, six applied to 100% of internal and external auditors; most applied fairly equally to external and internal auditors; four were utilised by <25% of external auditors; eight were used by <25% of internal auditors; 57.1% of external, and 68.6% of internal, auditors reported statistically analysing audit results. Conclusion: The findings provide the first evidence-base for clinical coding auditors’ knowledges/skills/functions, and prompt recommendations for their more extensive engagement in: (a) data analysis (including underpinning research methodology); and (b) preparation for artificial intelligence–related developments. Implications for health information management practice: This pioneering research on the work of clinical coding auditors provides a platform to inform (a) educational curricula updates, (b) development of professional competency standards for clinical coding auditors, (c) enhanced governance in audit practice and (d) development of national standards for clinical coding auditing.
Background: Clinical documentation facilitates the delivery of safe, effective, and timely patient care. Failures in communication or inadequate documentation can contribute to poor patient outcomes. Multiple barriers exist to producing clinically meaningful and coding-compatible documentation. To address this, a collaborative approach was undertaken between clinicians, coders and clinical documentation specialists (CDS) at our institution. Objective: To evaluate whether condition-specific auto-text improves documentation clarity and increases the capture of ICD-10-AM coded postoperative conditions. Method: A retrospective cross-sectional comparative audit was conducted at a tertiary Australian hospital. The analysis compared all patients discharged from a cardiothoracic unit in May 2023 (post-implementation) to those discharged in May 2022 (pre-implementation). We designed and implemented 12 condition-specific auto-texts, and a targeted clinician education programme. Documentation clarity was assessed using an ambiguity scoring framework. Results: A total of 80 patients were analysed (45 pre-implementation; 35 post-implementation). Documentation ambiguity improved significantly following the introduction of auto-text, with a mean reduction of 0.8 points on a 5-point scale ( p < 0.01). Lower ambiguity scores were associated with increased likelihood of coding, with each one-point increase in ambiguity reducing coding odds by 66% ( p < 0.01). The odds of clinical coding increased by 110% with the introduction of auto-text (odds ratio 2.1, 95% Confidence interval 1.3 to 3.3; p < 0.01); the mean number of diagnoses coded per patient increased from 9.36 to 13.3 ( p < 0.01). While the mean Queensland Weighted Activity Units increased from 7.32 to 9.58, this was not statistically significant ( p = 0.5). Conclusion: This preliminary evaluation suggests that clinician-led auto-text tools may reduce documentation ambiguity and improve the capture of coded patient complexity. As a low-cost and scalable intervention, this approach has the potential to support more accurate clinical documentation and hospital reporting. Future research should explore the sustainability of these strategies and their interaction with emerging artificial intelligence tools in clinical documentation. Implications for health information management practice: Clinician-led auto-text tools, supported by CDSs, may provide a sustainable, low-cost practical strategy to reduce ambiguity, improve the capture of patient complexity and optimise hospital data integrity within existing clinical workflows.
