Health information management : journal of the Health Information Management Association of Australia最新文献

{"title":"Representation and differentiation of audiology interventions within the international classification of health interventions.","authors":"Alida Naudé, Amisha Kanji, Faheema Mahomed-Asmail, Kutloano Mtimkulu, Sakhile Nkosi","doi":"10.1177/18333583261489749","DOIUrl":"https://doi.org/10.1177/18333583261489749","url":null,"abstract":"<p><strong>Background: </strong>Standardised intervention coding supports service visibility, reimbursement, resource planning and health-system analytics. The International Classification of Health Interventions (ICHIs) provides a standardised framework for representing health interventions, but its ability to capture the breadth and clinical specificity of contemporary audiology practice requires evaluation.</p><p><strong>Objective: </strong>To evaluate the extent to which contemporary audiology interventions can be represented and differentiated within ICHI and identify limitations in coding granularity that may affect health information management, service reporting and reimbursement.</p><p><strong>Method: </strong>An inventory of audiology interventions was derived from historical and current South African tariff schedules, scope-of-practice documents, university curricula and contemporary clinical practice. A total of 105 interventions spanning hearing and vestibular assessment, electrophysiology, device-related procedures, and counselling and rehabilitation were independently mapped to ICHI using a structured coding rubric aligned with the Target-Action-Means framework. Interrater agreement was calculated for a predefined subset.</p><p><strong>Results: </strong>All included interventions could be represented within ICHI. Most (92.3%) demonstrated direct one-to-one alignment with an ICHI stem code. The remainder required approximate ('best-fit'), postcoordination, or composite coding using multiple descriptors and/or extension codes. Clinically distinct interventions frequently converged under identical stems, particularly within rehabilitation, counselling, device management and tele-audiology. This convergence reduced coding granularity and differentiation of clinical intent, service complexity and resource utilisation.</p><p><strong>Conclusion: </strong>ICHI provides broad structural coverage of contemporary audiology interventions; however, limited granularity constrains its utility for detailed health-system reporting, reimbursement modelling and service evaluation. Greater differentiation within rehabilitation- and technology-related categories is warranted to better represent contemporary audiology practice and support person-centred ear and hearing care within universal health coverage frameworks.Implications for health information management practice:High-level ICHI stems may obscure clinically meaningful variation in audiology services, reducing data precision for funding, workload measurement, service evaluation and national reporting. Implementation guidance and standardised composite coding protocols may improve specificity where existing stems are insufficient. Identified classification gaps may inform formal submissions to the World Health Organisation Family of International Classifications Network. Improved specificity could strengthen interoperability, secondary data analytics, reimbursement modelling, and evidence-based h","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261489749"},"PeriodicalIF":1.8,"publicationDate":"2026-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149278045","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Understanding the consumer experience using the MyDHR portal: Do consumers perceive direct delivery of real-time pathology tests as helpful or harmful?","authors":"Fiona Webb, Erin I Walsh, Leah Mathews, Melinda Bower, Tsheten Tsheten, Ziqi Liu, Twinkle Mali, Bernie Bissett","doi":"10.1177/18333583261490215","DOIUrl":"https://doi.org/10.1177/18333583261490215","url":null,"abstract":"<p><strong>Background: </strong>Real-time release of pathology results through patient portals is growing globally, yet little is known about how Australian consumers experience this shift in result delivery. While immediate access may enhance consumer autonomy, it is not known whether consumers perceive this shift away from clinician-mediated result delivery as helpful or harmful.</p><p><strong>Objective: </strong>To explore consumer experiences, satisfaction and usage of a patient portal (MyDHR) that allows consumers to access clinical results in real time, bypassing traditional clinician-mediated delivery.</p><p><strong>Method: </strong>Prospective mixed-methods study using de-identified usage data and a cross-sectional online survey. <i>Setting</i>: Australian Capital Territory, April 2024-December 2024. <i>Participants</i>: Consumers using the MyDHR portal (April-June 2024, <i>n</i> = 33,886) and respondents to a pop-up invitation in the MyDHR portal (December 2024, <i>n</i> = 657).</p><p><strong>Main outcome measures: </strong>Usage demographics (age, gender, timing and frequency of access) were analysed using ordinal logistic regression, while qualitative responses were analysed using thematic analysis.</p><p><strong>Results: </strong>Of 494,866 pathology results, 60% were viewed within 1 day and 80% by day 5. Females were 1.8 times more likely than males to view results. Highest engagement was among females aged 25-34 (23%), 35-44 (21%) and ⩾65 years (21%). Survey respondents (<i>n</i> = 657) were predominantly female (64%) aged ⩾65 years (25%) or 25-34 years (22%). Most consumers (88%) reported satisfaction with MyDHR. Privacy concerns were noted by 29%, but these did not detrimentally affect satisfaction. Qualitative feedback highlighted benefits such as autonomy, the ability to prepare questions for their healthcare provider, and tracking trends over time. Drawbacks included difficulty interpreting medical terms and frustration over delayed or missing results, particularly from private providers or during hospital admissions.</p><p><strong>Conclusion: </strong>In this first Australian study exploring consumer experiences with accessing real-time pathology results via a portal, consumers demonstrated strong engagement, high satisfaction and desire for broader access, including private pathology data.Implications for health information management practice:These findings highlight the value of patient-centred and timely access to integrated health information through portal systems. Enhanced portal supports could include robust cross-sectoral health information governance processes, and digital health literacy support that enables consumers to safely interpret and use real-time access to their own health information.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261490215"},"PeriodicalIF":1.8,"publicationDate":"2026-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149278135","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Exploring the research competencies and skills utilised by health information managers in their professional practice: A documentary analysis.","authors":"Merilyn Riley, Grant Smith, Melanie Tassos, Stephanie Gjorgioski, Joan Henderson, Jenny Davis, Kerin Robinson","doi":"10.1177/18333583261492008","DOIUrl":"https://doi.org/10.1177/18333583261492008","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Objective: </strong>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.</p><p><strong>Method: </strong>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 <i>(no evidence of indicator</i>); and 1 (<i>either implicit or explicit criteria met</i>). Implicit and explicit totals were calculated for each domain and applied to the abstract review for: Research Implicit Score; Research Explicit Score; No Score.</p><p><strong>Results: </strong>Across the study period, 252 abstracts/papers were identified: PP/CS (55.5%); research (24.2%); workshops (11%).</p><p><strong>Results: </strong>\"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% (<i>n</i> = 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.</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261492008"},"PeriodicalIF":1.8,"publicationDate":"2026-10-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149231257","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Building patient safety: A normative framework for health information management professionals.","authors":"Trixie Kemp, Kerryn Butler-Henderson, Jennifer Ayton, Salma Arabi","doi":"10.1177/18333583261490959","DOIUrl":"https://doi.org/10.1177/18333583261490959","url":null,"abstract":"<p><strong>Background: </strong>The study focused on how health information management (HIM) professionals in Australia contribute to patient safety.</p><p><strong>Objective: </strong>The aim was to develop a normative framework that illustrates how the values, beliefs, attitudes and behaviours of HIM professionals influence patient safety across various governance domains.</p><p><strong>Method: </strong>Utilising findings from mixed-method data collection, the research drew on insights from HIM professionals and patient safety experts, using grounded theory strategies for data analysis.</p><p><strong>Results: </strong>The results are organised within a house-themed normative framework, which positions core professional values as the foundation of HIM practice. These values inform shared beliefs regarding patient safety, supporting clinicians, data accuracy and continuous learning. The attitudes of person-centredness, governance and speaking up mediate the enactment of these beliefs. The corresponding behaviours visibly demonstrate HIM contributions across four governance domains: clinical, corporate, data and information.</p><p><strong>Discussion: </strong>Patient safety literature centres on clinical roles. As healthcare becomes increasingly data-driven, the risk of patient harm arising from information, data quality and governance failures grows. There is a notable gap in the conceptual frameworks that articulate how HIM professionals contribute to patient safety beyond their functional tasks, especially from a normative professional identity perspective.</p><p><strong>Conclusion: </strong>This framework highlights HIM professionals as integral contributors to patient safety rather than supportive background figures. It provides clarity for education, workforce development and health policy, thereby enhancing recognition of the governance and system impact of HIM practice on patient safety.Implications for health information management practice:(a) This framework provides a mechanism to visualise the values, beliefs, attitudes and behaviours of HIM professionals towards patient safety and the domains in which their outputs are seen; and (b) demonstrate how involvement of HIM professionals in patient safety will enable the profession to be better utilised, understood and valued in the health system and inform education, workforce development and health policy.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261490959"},"PeriodicalIF":1.8,"publicationDate":"2026-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149208258","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Diagnosis-related group front-page management, coding patterns and cost structure in diabetic nephropathy.","authors":"Hongfei Li","doi":"10.1177/18333583261490625","DOIUrl":"https://doi.org/10.1177/18333583261490625","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Objective: </strong>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.</p><p><strong>Method: </strong>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.</p><p><strong>Results: </strong>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; <i>p</i> < 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; <i>p</i> = 0.001). Total costs were unchanged (median (interquartile range), 3508.56 (2940.07-4186.97) vs. 3475.42 (2902.41-4161.56) RMB; <i>p</i> = 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 <i>V</i> = 0.54; <i>p</i> < 0.001), compared with E11.201 + N08.3* (Type 2 diabetes mellitus with diabetic nephropathy; N08.3*, glomerular disorders in diabetes mellitus).</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261490625"},"PeriodicalIF":1.8,"publicationDate":"2026-10-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149168952","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The biopsychosocial-spiritual impact upon health information managers from exposure to sensitive information within patient records: A qualitative study.","authors":"Melanie Tassos, Lindsay B Carey, Stephanie Gjorgioski, Brad Hodge, Merilyn Riley","doi":"10.1177/18333583261489939","DOIUrl":"https://doi.org/10.1177/18333583261489939","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Objective: </strong>To explore the BPSS impacts experienced by HIMs following exposure to information contained within patient records.</p><p><strong>Method: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261489939"},"PeriodicalIF":1.8,"publicationDate":"2026-10-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149171624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of auto-text documentation on ICD-10-AM code assignment in cardiothoracic surgery: An Australian cross-sectional comparative study.","authors":"Charlotte C Frost, Joevin Vincent, Mark Jones, Andrie Stroebel","doi":"10.1177/18333583261483476","DOIUrl":"https://doi.org/10.1177/18333583261483476","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Objective: </strong>To evaluate whether condition-specific auto-text improves documentation clarity and increases the capture of ICD-10-AM coded postoperative conditions.</p><p><strong>Method: </strong>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.</p><p><strong>Results: </strong>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 (<i>p</i> < 0.01). Lower ambiguity scores were associated with increased likelihood of coding, with each one-point increase in ambiguity reducing coding odds by 66% (<i>p</i> < 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; <i>p</i> < 0.01); the mean number of diagnoses coded per patient increased from 9.36 to 13.3 (<i>p</i> < 0.01). While the mean Queensland Weighted Activity Units increased from 7.32 to 9.58, this was not statistically significant (<i>p</i> = 0.5).</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261483476"},"PeriodicalIF":1.8,"publicationDate":"2026-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149139617","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The professional knowledge, skills and specialist functions of certified clinical coding auditors.","authors":"Kerin Robinson, Stephanie Gjorgioski, Melanie Tassos, Sally Richardson, Merilyn Riley","doi":"10.1177/18333583261487269","DOIUrl":"https://doi.org/10.1177/18333583261487269","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Objective: </strong>To identify the professional knowledge, skills and specialist functions of certified clinical coding auditors in Australia.</p><p><strong>Method: </strong>A cross-sectional study design was utilised. A purposively designed, self-administered online survey was distributed to the study population (<i>N</i> = 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.</p><p><strong>Results: </strong>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% (<i>n</i> = 35) had predominantly undertaken internal auditing within the past 5 years; 59.5% (<i>n</i> = 25/42) had a Certificate of External and Internal Clinical Coding Auditing, 28% (<i>n</i> = 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.</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261487269"},"PeriodicalIF":1.8,"publicationDate":"2026-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149139607","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"From data entry to digital transformation: Allied health perspectives on standardised electronic medical records data.","authors":"Maria Schwarz, Elizabeth C Ward, Sarah Jeffery, Joshua Simmons, Kristy Perkins, Philip Juffs, Sara Burrett","doi":"10.1177/18333583261481088","DOIUrl":"https://doi.org/10.1177/18333583261481088","url":null,"abstract":"<p><strong>Background: </strong>Electronic medical records (EMRs) currently rely on standardised data fields to support secondary data use for clinical care, performance monitoring, and system-level reporting. However, utilisation of standardised data capture and reporting within allied health remains underdeveloped in practice. Greater understanding of how allied health clinicians and managers perceive the purpose, value, and impact of standardised data collection is needed to support advancement in data maturity and transformation of utilisation.</p><p><strong>Objective: </strong>To explore the perceived benefits, challenges and future opportunities of standardised data collection within an EMR, from the allied health perspective.</p><p><strong>Method: </strong>A qualitative descriptive study using semi-structured interviews was conducted with 28 allied health clinicians and managers from 5 allied health disciplines: Dietetics, Occupational Therapy, Physiotherapy, Speech Pathology, and Social Work.</p><p><strong>Results: </strong>Five overarching themes reflected a gap between the acknowledged value of standardised data collection and its current utilisation in allied health practice: (i) <i>Recognised value but unrealised potential</i> of EMR data, including its role in clinical insights, service planning, financial justification, and professional advocacy; (ii) <i>System and workflow misalignment limits meaningful data use</i>, including disconnect between data collection and use, workflow burden, inefficient data capture, system constraints; (iii) <i>Standardisation as both enabler and constraint</i>, supporting benchmarking and system alignment while limiting clinical flexibility and contextual relevance; (iv) <i>Pathways to advancing data maturity</i>, including training, improved data and digital literacy, and integration with emerging technologies; and the broader impact of (v) <i>Digital workflows reshaping workforce and care delivery</i>, with implications for team-based and person-centred care.</p><p><strong>Conclusion: </strong>While standardised EMR data were recognised as valuable, their potential remains limited when data collection is poorly aligned with allied health workflows. Advancing allied health data maturity requires clinically meaningful, workflow-integrated and feedback-driven approaches that improve usability while supporting high-quality data for secondary use.Implication for health information management practice:Standardisation efforts must balance data quality with clinical relevance, ensuring data collection aligns with real-world workflows and supports meaningful use.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261481088"},"PeriodicalIF":1.8,"publicationDate":"2026-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149129450","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Staff utilisation of an electronic medical record during nursing handover.","authors":"Lisa Browning, Urooj Raza Khan, Sandra Leggat, Nicholas Monypenny, James H Boyd","doi":"10.1177/18333583261486244","DOIUrl":"https://doi.org/10.1177/18333583261486244","url":null,"abstract":"<p><strong>Background: </strong>Electronic medical records (EMRs) are widely implemented to improve information access, patient safety and care coordination. However, less is known about how EMRs are used in routine clinical processes such as nursing handover. Understanding how EMRs influence handover practices is important, given the central role of handover in continuity of care and patient safety.</p><p><strong>Method: </strong>An exploratory mixed-methods comparative case study using a cross-sectional survey design was conducted within a large multi-site public healthcare organisation in Victoria, Australia. An organisation-wide survey captured quantitative data on EMR use during preparation for and delivery of nursing handover, alongside qualitative free-text responses exploring perceived impacts, barriers and facilitators. Responses were compared between EMR-enabled clinical areas and predominantly paper-based or hybrid environments.</p><p><strong>Results: </strong>A total of 385 nurses completed the survey. EMR use during handover was substantially higher in EMR-enabled environments than in paper-based or hybrid settings. Qualitative analysis identified six key areas influencing handover: access to and visibility of clinical information; handover quality, safety and cognitive focus; usability and fit with nursing practice; system implementation and enabling conditions; impact on nursing workflows and time and bedside handover and patient engagement. EMR not only supported information access and verification during handover but also introduced cognitive and workflow challenges, particularly where usability, infrastructure or implementation maturity were limited.</p><p><strong>Conclusion: </strong>EMR use can support safer and more informed nursing handover by improving access to legible, real-time clinical information. However, its effectiveness is contingent on usability, infrastructure and alignment with nursing workflows, consistent with the principles of task-technology fit. Hybrid documentation environments and system access constraints limit the consistent realisation of benefits. Continued reliance on printed summaries, handwritten notes and personalised tools suggests that digital systems may complement, rather than completely replace, existing cognitive supports. Optimising EMR-supported handover requires organisational attention to implementation conditions, workflow integration and the practical realities of clinical work.Implications for health information management practice:Health information management professionals can contribute to EMR optimisation by supporting the accessibility, organisation and effective use of clinical information. Evaluation of information usability, documentation practices and ongoing reliance on paper-based workarounds can help identify opportunities to better support clinical information needs.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":" ","pages":"18333583261486244"},"PeriodicalIF":1.8,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149139599","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}