clinical coding education and training for excellence in healthcare - imedx.com.au

Understanding the Distinction: Education vs. Training in Clinical Coding for Excellence in Healthcare

Education and training are frequently interchanged, yet they represent distinct concepts with varied objectives and results. At iMedX, we recognise the importance of distinguishing between education and training, particularly for individuals and organisations aiming to cultivate essential skills and knowledge in today’s dynamic and competitive landscape.

In the realm of clinical coding, understanding the nuances between education and training is crucial for ensuring accurate coding, compliance, and streamlined healthcare operations.

How well does your team know the difference?

Education encompasses the acquisition of knowledge, the cultivation of critical thinking abilities, and the promotion of intellectual development. It represents a comprehensive approach to learning that extends beyond gaining specific job-related skills.

The primary goal of ICD-10AM education is to provide Coders with a well-rounded understanding of various topics, theories, and concepts that can help them think critically, solve complex coding problems, and navigate to new situations.

In contrast, training focuses on the practical implementation of ICD-10 coding principles in real-world settings. ICD-10AM training includes hands-on practice, coding scenarios, case studies, and simulations designed to replicate authentic coding scenarios. Training assists coders in developing the necessary skills to effectively navigate the ICD-10AM code set, accurately apply coding guidelines, and ensure correct code assignment for reimbursement and data reporting purposes.

Education and training differ significantly in their approaches to learning. Education emphasises theoretical knowledge, conceptual understanding, and critical thinking skills, whereas training prioritises practical application, hands-on experience, and skill development.

Both education and training are essential for personal and professional development, and coders and organisations can benefit from combining the strengths of both approaches to achieve their learning goals and objectives.

At iMedX, we offer both education and training, recognising their crucial roles in developing proficient Clinical Coders. Our aim is to empower coders to accurately assign diagnosis and procedure codes, ensure coding compliance, and support efficient healthcare operations. By combining education and training, coders can refine their skills, enhance coding accuracy, and contribute effectively to high-quality healthcare data management.


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Discover how iMedX can support your team with smarter tools that empower coders to assign accurate diagnosis and procedure codes, stay compliant, and keep healthcare operations running smoothly.


InstaNote AI-Powered Clinical Documentation - imedx.com.au

Introducing eSOne™ InstaNote AI-Powered Clinical Documentation

AI-powered precision transforms clinical documentation, saving you both time and money.

See how iMedX is revolutionising the way clinical documentation is produced and delivered, giving time back to patient care.

InstaNote AI-Powered Clinical Documentation from @iMedxANZ

AI-powered clinical documentation technology release from iMedX Australia & New Zealand that will help in medical professionals’ workflow and save time in transcribing patient letters, giving them time back for quality patient care.

Any surgeon, radiologist, clinician or medico-legal team can use this technology to save valuable time in patient care. This technology is available for all Australian and New Zealand medical professionals.

As well as viewing the @imedxanz YouTube video, you can also visit the iMedX website after to learn more about InstaNote here: InstaNote, and then contact the iMedX Sales Team to get started.

Revolutionise Your Clinical Documentation with InstaNote!

  • Instant Transcriptions
  • Time-Saving
  • Secure & Compliant

Experience the future of clinical documentation today. Try InstaNote available exclusively from iMedX ANZ and transform the way you work.

SAVE TIME FOR PATIENT CARE

Case Study: Specialist letter integration with My Health Record

Context & background

The Australian Digital Health Agency (ADHA), responsible for the roll out of My Health Record – a secure, online summary of an individuals key healthcare information, accessible by the individual and healthcare providers whenever they need it – have partnered with the Victorian Department of Health (DoH) to work with hospitals in Victoria to integrate specialist letters with My Health Record, expanding the key healthcare information available in My Health Record.

As this joint initiative was mobilised, partner hospitals of iMedX enquired whether the iMedX solution provided the possibility of integration of their specialist letters with My Health Record.

iMedX is the leading clinical documentation provider in Victoria, through our clinical documentation platform, eScription One (eSOne), we provide solutions that support the documentation and delivery of outpatient specialist letters. iMedX was best placed to support this work with the Victorian hospitals.

Mercy Hospital for Women and Peninsula Health joined the project as pilot sites to co-design, test and refine the solution in a live environment. This piece of work required excellent collaboration between all stakeholders, working with the requirements of the hospitals and My Health Record and, the availability of existing technology and workflow structures.

Objectives

Delivery of this initiative brought together key stakeholders – iMedX and the two pilot sites. The objectives of the project group were identified as:

  • Successful integration of approved specialists’ letters with My Health Record.
  • Implementing My Health Record integration into the current iMedX-enabled clinical documentation workflow within the hospitals, ensuring no disruptions to the workflow.
  • Alignment to the interoperability roadmap as defined in the document published by ADHA, Connecting Australian Healthcare: National Healthcare Interoperability Plan – improving interoperability between clinical documentation capture and availability of the document within the My Health Record.
  • ADHA define a requirement that all documentation in My Health Record must be uploaded from a healthcare provider. Therefore, iMedX set out to ensure that documents are integrated directly from the hospital without extra burden on hospital resources.

Approach

The project ran over a 9-month period, with official go-live achieved at both pilot sites by 22 November 2023.

The approach taken aligned closely with the implementation approach iMedX follows in technical integrations of this nature. This included:

  1. Project team mobilisation including onboarding of the two pilot sites, Mercy Hospital for Women and Peninsula Health.
  2. A technical discovery period was undertaken including a review of the technical specifications. As iMedX has a long-standing partnership with both pilot sites, our understanding of the technical landscape at both sites was drawn upon at this stage.
  3. From the findings of technical discovery, a prototype was built that had the capability to deliver approved specialist letters to My Health Record from the hospital environment.
  4. Rigorous testing, redefining, and recreating the solution was conducted over a 3-month period.
  5. Sign off from both hospitals on User Acceptance Testing was achieved to enable go-live planning.
  6. iMedX worked with each site to determine their preferred approach to go-live.

Outcomes

The overarching outcome achieved through this project is the implementation of a solution that is improving patient care through greater interoperability.

The project achieved successful go live at two pilot sites:

  • The Mercy Hospital for Women went live with full deployment, meaning all approved specialist letters are made available in My Health Record.
  • Peninsula health went live with a phased deployment, meaning the integration will be activated one department at a time, over time.

Successful go-live in this project means, at point of completion, the specialist letter can be provided to the hospital’s medical record, as well as the approved document can be sent to My Health Record, without disrupting current clinical documentation processes.

The outcomes of the project have provided validation of the limited disruption to current clinical documentation processes whilst improving interoperability of clinical documentation capture to My Health Record. This will support the continuous roll out across hospitals in Victoria and Australia.

Here’s what Mercy Hospital for Women have to say about their experience:

“iMedx were a receptive and competent partner to work with on this important project.  Their solution allows the automated upload of Specialist Clinic letters using the IMedX transcription service to the patient’s My Health Record without disruption to our current workflows.  Importantly it provides medical staff with an option to remove any documents deemed of a sensitive nature from upload by simply starting during a dictation ‘Do not upload to My Health Record’   

 Access to health information contained in the My Health Record can help reduce the instance of adverse medication events (including hospital re-admissions), decrease duplicate diagnostic testing and improve continuity of care for patients across the primary and secondary care sectors.

Mercy Health already uploads CPF Discharge Summaries, pathology and imaging results to My Health Record. The addition of Specialist Clinic letters will help My Health Record become an even more valuable tool for patients’ health care providers.” – Julie Brophy, Director Health Information Services, Mercy Health Services

instanote transforming clinical documentation with ai powered efficiency - imedx.com.au

InstaNote – Transforming clinical documentation with AI-powered efficiency

iMedX, under our exclusive partnership with DeliverHealth is pleased to present eSOneTM InstaNote, an AI-powered documentation tool designed to transform the way clinicians document patient outcomes.

InstaNote seamlessly integrates into the familiar workflows that clinicians trust and rely on. With InstaNote, healthcare professionals can expect more choice, efficiency, and flexibility in document creation, all powered by generative AI technology.

What is InstaNote?

InstaNote is an AI-powered documentation tool, available exclusively in Australia and New Zealand to iMedX customers, that assists clinicians in creating their patient documentation effortlessly. Through cutting-edge and secure speech recognition and generative AI technology, InstaNote translates dictations and ambient conversations into transcribed documentation within seconds. This means that InstaNote can accelerate the pace at which patients receive documentation of their visits, while ensuring secure and high-quality outcomes.

All in the one platform

A key advantage of InstaNote is it is built into the same, secure and trusted eSOne platform that healthcare providers love. This means clinicians will be able to use InstaNote without the need for extensive training or workflow changes.

As with all documentation features within the iMedX clinical documentation solution, clinicians have the option to use InstaNote flexibly, meaning it can be their primary method of document creation, or used case-by-case.

Tried and Tested with Clinicians

InstaNote has been tried and tested in real-world clinical settings, receiving positive feedback from clinicians who have experienced its benefits firsthand. This ensures that InstaNote meets the practical needs of healthcare professionals, providing them with a tool that is both effective and user-friendly. The feedback from clinicians has highlighted InstaNote’s ability to offer choice, efficiency, and flexibility in document creation.

Key Benefits of InstaNote

  • Flexibility and Choice: InstaNote, combined with eSOne, offers clinicians multiple options for document creation, accommodating various use cases and preferences.
  • From patient to provider, delivery times reduced: InstaNote provides near instant transcribed and formatted documentation, cutting down on traditional turnaround times. Clinicians can use InstaNote confidently for any priority cases and be assured their letter will be ready within seconds to deliver.
  • Cost savings: InstaNote can provide healthcare services up to 40% cost savings from traditional transcription services.
  • Efficiency creation: InstaNote cuts down documentation time by up to 1 hour per day. From dictation and ambient recording, InstaNote takes over the transcription and letter creation components of the traditional transcription workflow, meaning less reliance on outsource transcription and improved opportunities to redirect precious resources towards enhancing patient care and operational efficiency.

Explore what AI-powered documentation can do for you As GenAI is forging new paths and redefining clinical documentation, we’re sure you’d like to understand how it will work for you. To ask your questions and to book a demo of InstaNote today, please contact our team at sales@imedx.com.au or through this link: https://imedx.com.au/staging/3510/contact/instanote-book-a-demo/

enabling scalable end-to-end clinical documentation solutions - imedx.com.au

Enabling scalable end-to-end clinical documentation solutions

Automatic and integrated delivery of documents via HealthLink

iMedX has brought DeliverHealth and HealthLink together to drive the connection of more services across the clinical documentation process.

iMedX has partnered with DeliverHealth and HealthLink to set up an enterprise grade delivery solution for completed clinical documentation to be delivered directly from the eScription One (eSOne™) platform.

The integration partnership allows greater visibility for users in managing their message delivery through one single interface, alleviating the need to connect individual systems to ensure the recipient has received the completed document.

The HealthLink messaging system is currently used by more than 20,000 health services, vendors and providers for Outpatient referrals and the delivery of results and letters. HealthLink deliver over 100 million clinical messages annually across Australia and New Zealand.

The partnership will deliver benefits including:

  • Building on technology advancements – AI generated documentation can be sent instantly to recipients
  • Efficiency improvement – healthcare providers can significantly reduce time and costs associated with tasks required for message delivery.
  • Streamlined Workflow – Hands-off instant delivery of letters to recipients.
  • Integrated solutions – All managed from one secure ecosystem, creating improved workflow oversight

We are excited to offer more comprehensive solutions for secure message delivery that will make document creation and delivery secure, simple and faster to all eSOne customers  – Alex Zacher, Managing Director, iMedX Australia & New Zealand

HealthLink are pleased to be part of this collaboration with iMedX and DeliverHealth to enable the increase use of integrated Secure Messaging across a range of clinical settings – Dave Young Managing Director Australia Clanwilliam.

We are proud to expand our partnership with iMedX and bring innovative documentation technology to HealthLink customers. As we continue to innovate our solutions and leverage AI to continue on our mission to improve patient care, we are helping providers reduce costs, streamline workflows and  reimagine clinical documentation so they can provide optimal patient care. – Sasanka (Sy) Yella Manchali, CEO, DeliverHealth

HealthLink integrated letter delivery is on track for the launch in 2024. We value diversity, integrity, and a passion for making a positive impact on our customers. Joining the iMedX community means being part of an organisation that embraces innovation, fosters professional growth, and creates a supportive and inclusive work environment.

iMedX and DeliverHealth: Enabling Comprehensive Clinical Documentation Solutions.

iMedX, Australia’s largest transcription solution provider has partnered with DeliverHealth to transform the way ANZ providers manage clinical documentation. 

It’s no secret that documenting healthcare service outcomes and the creation of timely, accurate clinical documentation are putting increased pressure on clinicians. As an outcome of these pressures, increasingly healthcare providers are looking for ways to reduce their documentation workloads to free clinicians up to focus on patient care while reducing costs. 

Powered by the eScription One (eSOne™) platform, iMedX and DeliverHealth are using advanced AI technology to generate efficiencies centred around faster documentation creation and faster turnaround times on letter delivery.  

Under an exclusive innovation roadmap our partnership aims to transform the way traditional transcription services are delivered for all eSOne customers.  

The roadmap will leverage the experience and expertise iMedX has in Australian and New Zealand hospitals and health services with new technologies, aiming to elevate the value we deliver across the entire workflow process through workflow management, integration, quality documentation, after sale support, turnaround times and operational efficiencies that reduce costs.  

The roadmap will deliver additional benefits in: 

  • Meeting the needs of your health service and meeting clinicians where they are at  
  • Enhanced speech recognition options for clinicians in the clinical documentation workflow 
  • Real time turnaround for clinical documentation using AI technology  
  • Utilisation of the very latest integration technology to do the heavy lifting workflow automation   
  • Efficiency creation – increasing productivity and improving cost savings 

“We are thrilled this exclusive partnership will allow IMEDX to be able to offer all eScription One customers the ability to natively improve clinician productivity and reduce documentation costs through these new features” Alex Zacher, Managing Director, iMedX Australia and New Zealand 

”We are proud of this partnership with IMEDX as we continue to innovate products and services leveraging AI with a clear mission to reduce the documentation burdens placed on providers while improving patient care. Sasanka (Sy) Yellamanchali, CEO, DeliverHealth 

Our clinical documentation roadmap is on track for the launch in 2024. 

We value diversity, integrity, and a passion for making a positive impact on our customers. Joining the iMedX community means being part of an organisation that embraces innovation, fosters professional growth, and creates a supportive and inclusive work environment. 

Clinical Documentation Solutions, iMedX Australia & New Zealand (Health Information Management) imedx.com.au

Creating patient-centred clinical documentation through facilitated, digitised and connected solutions

The main objective of a clinical documentation solution is to deliver timely, accurate, concise documentation about the patient, to the patient and caregivers.

Operating an effective clinical documentation solution requires engaging a combination of components including, dictating and referring clinicians, administration staff, external recipients, the PAS and EMR, in-house typists, an outsource transcription company and speech recognition.

A digitised solution that is efficient and cost-effective relies on all these components being integrated and accessed easily, simple to deploy and manage, and is housed in a secure and scalable platform in the cloud.

At iMedX we know that hospitals and providers need all these components to operate effectively, whilst being responsive to their needs and strategic objectives.

Striking the right balance

If one of these key components is not considered, the effectiveness of the solution and its ability to meet all stakeholder needs is hampered. It is easier to balance the utilisation of these, while creating a flexible and appropriate solution, if the platform is electronic and secure.

There are hospitals that need to access outsource resources easily, and others that require clinician accessibility and flexible working, ultimately the platform needs to be able to accommodate for all the needs of the users and provide the appropriate integration.

iMedX provides the platform to access these components and integrate with them but gives the provider the power and the control to manage the utilisation of them.

Leveraging the components

The key to providing timely, accurate, concise documentation about the patient, to the patient and caregivers is effectively leveraging the usage of each of the components.

What we commonly see in hospitals is that clinicians need to access speech recognition, as well as outsource transcription; inhouse typists need to access speech recognition; managers need access to an overview of the process and reports to ensure efficiency; everyone needs to access the PAS; and everything needs to end up in the EMR.

At iMedX we believe that the most effective clinical documentation solutions are not achieved through solely utilising just one component, for example speech recognition, but rather connecting them to one another and facilitating the relationships in the most productive, cost-effective way.

Visit imedx.com/au and contact Kath Rawson on 0800 753 250 or nz-sales@imedx.com for more info.

Enabling innovation in the end-to-end revenue journey

Healthcare is seeing a new age of innovation. One that brings prospects of a more connected and technologically enabled system with real-time accessibility of care and data. Whilst innovation is heavily focused on delivery of care, the backend operators of our hospitals, including health information and hospital revenue processes are also ready for innovation. The opportunity we see lies in maximising hospital revenue through the end-to-end journey.

The end-to-end funding journey

While health information, finance, and clinical services of the hospital often operate separately, when we piece the revenue journey together, they are all reliant and critical to one another. At iMedX we’re focused on understanding the entirety of the journey from pre-admission to revenue or budget utilisation, finding that at each step best practice is not always obtained due to its reliance on other steps. For example, quality coding relies on accurate and timely discharge summaries which in turn rely on comprehensive and complete records of the patient stay. This means that innovation must take into account every step and its people in order to truly make a difference.

What innovation looks like

Innovation in the end-to-end revenue journey is more subtle than what we see in other scenarios. In this context innovation looks like an interconnected, consistent, and reliable journey that enables each function in the journey to operate at its best. The way we do that varies with each hospital.

Innovating across such a complex journey can be a complicated task. From our experience, there are some core factors that are fundamental for innovation.

  1. Aligned processes and procedures
    To achieve consistency and reliability across the journey, processes and procedures are a great place to start. Most importantly, their alignment in relation to the Health Information Services (HIS), Clinical and Finance departments. There are three (3) things to consider; standardisation which involves clear steps and requirements for staff to follow; adoption, including how staff will implement these processes in an effective way that is inclusive, strategic and does not place any further workload burdens; and governance, starting with suitable training and performance management strategies.
  2. Technology
    In our experience, a challenge the HIS department faces often is operating on an IT system that is outdated. Although IT can be a complex problem to resolve, it is integral to the funding journey operating at its best. Technology in healthcare is improving, however IT systems of the backend operations are being left behind. Investment in the uplift of these systems seeks to improve workflows, productivity and reporting requirements which creates better revenue results and improved clinical care.
  3. The profile of HIS department
    The clinical documentation process is core to the function of coding and ultimately revenue or activity reporting and budget utilisation. The greatest governors over accurate documentation is the HIS department who, too often are overshadowed by clinical and finance departments.The best and easiest way to raise the profile of HIS is to deliver the facts. Analysing hospital data means audit samples can be selected that will provide the key to facilitating and lifting the profile of HIS. This knowledge enables coders and HIMs to approach clinical staff confidently to educate and refine documentation processes that record the care of every patient that is treated.

The iMedX perspective

Each journey offers different opportunities for innovation, iMedX is focused on finding them and helping hospitals to set up their end-to-end journey to maximise revenue opportunity and improve clinical care. Our work aims to uplift and strengthen steps in the process from maintaining clinical coding throughput, auditing for accuracy and helping to promote the highest quality documentation for patient safety, whilst keeping the bigger picture in mind.

Medical Transcription and Clinical Documentation Solutions, iMedX Australia & New Zealand (Health Information Management) imedx.com.au

Co-source Transcription in New Zealand

iMedX works in partnership with New Zealand’s DHB’s and we have gained firsthand insight into the cost pressures impacting clinical operations today. We know many DHB’s are operating in a financially challenging environment and are looking for ways to reduce costs and deliver efficiencies.

This whitepaper explores the challenges DHB’s are facing surrounding increasing transcription demand, battling workforce shortages and increasing service costs; provides insight into how Australian hospitals have transformed these same processes using a technology and service enabled co-source delivery model; and presents the ways in which this can impact positively in New Zealand.

Access the whitepaper here.

Medical Transcription and Clinical Documentation Solutions, iMedX Australia & New Zealand (Health Information Management) imedx.com.au

CodeR at Maryvale Private Hospital

iMedX delivers a remote coding solution providing a continuous service to Maryvale Private Hospital through CodeR.

CodeR is a streamlined solution enabling end-to-end remote clinical coding & auditing of paper records. The solution utilises proprietary technology CodeR, a secure info input platform that connects to any scanner and a workflow management platform that stores electronic records for Clinical Coders/Auditors to access.

Maryvale Private Hospital is situated in Morwell in Victoria’s Latrobe Valley and services the Gippsland municipalities of East Gippsland, Wellington, Latrobe, Baw Baw, South Gippsland and Bass Coast. With 46 beds, Maryvale is an acute medical and surgical hospital providing a comprehensive range of medical, surgical and consulting services. The hospital has cared for over 55,000 patients since 1991.

Being a regional hospital with paper records, Maryvale Private Hospital historically needed coding staff onsite to complete the clinical coding. In 2020, the hospital had both coders apply for long service leave for extended periods of time. With this challenge and the need for onsite coding due to paper records there was a risk that the coding turnaround time would increase thus interrupting the timeliness of the revenue stream.

Through the iMedX capability to provide CodeR, our HIS expertise, plus continuous clinical coding service, iMedX was able to effectively fulfil the hospital’s requirements.

“On behalf of the team at Maryvale Private Hospital, we’ve really valued the contribution the iMedX team have made through our partnership. The CodeR platform was simple to learn and implement, providing our staff reliable and experienced clinical coding support for the remote coding of our paper records. The iMedX team are able to view the records easily and quickly through CodeR and then enter the accurate codes directly into our PAS. We have also found it especially valuable being able to leverage the experience of the iMedX team to support us with our Coding Auditing and with their knowledge of the Private Health sector funding model. Thank you iMedX team.”  Susan Chan, Finance Manager

See how the CodeR solution works at Maryvale and the outcomes it has delivered here.

Medical Transcription and Clinical Documentation Solutions, iMedX Australia & New Zealand (Health Information Management) imedx.com.au

iMedX Analytics: Transparency in Clinical Documentation

Get greater visibility of your transcription volume, turnaround times and productivity with the iMedX  Analytics dashboard – updated automatically!

FIND OUT HOW YOUR TRANSCRIPTION WORKFLOW IS TRACKING

Using our data analytics suite for transcription activity, iMedX Analytics transforms data into actionable business insights delivered through an easy to use dashboard interface. Say goodbye to manual tracking and excel spreadsheets!

You can easily see and understand vital parameters such as volume trends, turnaround times, work types, productivity, and much more all without the need for spreadsheets and manual data analysis. When you are able to understand your clinical documentation operations clearly, the opportunities for efficiency, quality, and revenue improvements are endless.

The dashboard allows you to customise your analytics:

  • Include activity from your in-house typists and iMedX typists and compare volumes,
  • Choose the graph formats you’d prefer to view your data in, and
  • Request reports on whichever measurement option you like.

The dashboard has three sections:

  1. The Volume Dashboard presents many data elements which are essential for making informed staffing, turnaround time, and cost projection decisions. Gain a new understanding of your documentation process with trends by work type, dictator, and jobs marked for review. Dictation issues type can be rapidly identified and resolved. Additionally, the volume dashboard allows you to see your complete transcription situation, including total minutes, total jobs, and averages by time.

  2. The TAT Dashboard tracks turnaround time and delivery of transcription. Quick turnaround times are essential for quality patient care and communication. With the TAT dashboard, you can easily identify current TAT loss related to a number of factors including provider, work type, facility, and more. Filters are available to select the desired date range, dictator, work type, or location for viewing trends in various graph formats. Trends, heat maps, and raw numbers are visible at a glance and immediately provide an understanding of where, when, and why TAT may be suffering.

  3. The Productivity Dashboard provides a complete view of the throughput for both your in-house typists as well as iMedX typists. This dashboard enables you to see broad trends in addition to individualised trends for specific typists. The productivity report is helpful for understanding the productivity of your MT base, which enables you to implement management processes as required.

iMedX Analytics for transcription enables you to understand your dictation to transcription workflow with ease. To set up iMedX Analytics with your iMedX transcription solution email us at sales@imedx.com.au

To find out more information on our dictation and transcription solutions, please send us an email or call us on 1300 727 423.