Abstract
Dear Editor,
The COVID-19 pandemic has provided a good example of the importance of good quality health information that is timely, accurate and reliable and can be used to make evidence-based decisions. During the pandemic, important decisions are being made throughout the world based on these data. Hospital discharge data have been collected for many years. 1 In the early days, these data collections were used for administrative and academic purposes. More recently, the data collections have also been used for payment systems such as activity-based funding in Australia, Ireland and many other countries. The use of these data for hospital payments has had a dramatic impact on the timeliness, completeness and consistency of these data. The COVID-19 pandemic is likely to have a similar impact on the quality of the data as they are used to better understand the clinical nature of this disease.
The data challenges posed by the COVID-19 pandemic
New codes for a new disease
COVID-19 is a new disease with pandemic status. These attributes meant that it was important that the disease be coded consistently around the world as soon as cases were treated in hospitals. The World Health Organization (WHO) provided space in the International Classification of Diseases 10th Revision (ICD-10) for codes to be used in an emergency. The WHO responded quickly to the new disease by issuing advice on how to capture COVID-19 using the emergency codes in ICD-10 (WHO, 2020). In Australia, the Independent Hospital Pricing Authority (IHPA) quickly followed, issuing advice on which codes to use for the Australian Modification of ICD-10 (ICD-10-AM) (IHPA, 2020a). The Irish Healthcare Pricing Office followed with specific advice for coding in Ireland (Healthcare Pricing Office, 2020).
Hospital activity data in the spotlight
The experience of countries with early and widespread exposure to COVID-19 showed that hospitals were overwhelmed with admissions and the use of intensive care units. There was growing alarm about whether there would be sufficient beds and ventilators to cope with the demand. This meant that urgent planning was needed to anticipate and provide the capacity that may be needed. Coding of COVID-19 cases was prioritised to provide the necessary planning information.
Coding the full clinical picture of every hospitalised COVID-19 case
The deadly nature of this disease makes it imperative to understand the full clinical picture of every hospitalised case. COVID-19 will be coded as a diagnosis in accordance with the standards described above, and all of the diagnoses should be coded to reveal any underlying conditions. However, the definition of additional diagnoses in ICD-10-AM includes only conditions treated during the hospital episode (Australian Coding Standard 0002, IHPA, 2020b). Given the deadly nature of COVID-19 for those with underlying conditions, it may be useful to analyse the supplementary codes for chronic conditions provided in ICD-10-AM (U78 to U88) to give a better understanding of the clinical status of each person hospitalised. Examples of supplementary codes that may be useful include U78.1 obesity, U834 bronchiectasis without cystic fibrosis and U821 ischaemic heart disease. However, while these supplementary codes have long been part of ICD-10-AM, it is doubtful whether they are assigned with consistency, and auditing of these codes has not been a priority because they have no impact on the payment system. Not all ICD-10-AM users use the supplementary codes; for example, these codes are not used in Ireland.
Variation in data collection
As described above, consistency in hospital discharge data has improved because of the use of these data in payment systems. The usefulness of these data for clinical purposes is likely to improve through increased use. The hospital discharge data depends on good consistent clinical documentation followed by consistent application of the coding standards.
Hours of mechanical ventilation have been coded in the past mainly to identify the high cost cases for payment systems. For COVID-19 cases, these data items are important to our understanding of the variation in patient outcomes including death and recovery pathways. This information is usually downloaded from hospital information systems and used by coders to code ventilation interventions. Coders cannot assign the correct intervention codes if the information has not been collected properly in the hospital information system in the first place. The Condition Onset Flags (COF) have been used in the past to assist in understanding hospital-acquired complications but use of this flag varies. COVID-19 could be acquired within the hospital giving added importance to using the COF accurately and consistently to identify such cases.
Future challenges
In future, it will be important to identify those people who return to hospital with a history of COVID-19. A history of COVID-19 code(s) is needed to understand the long-term impact of the disease on health and the use of hospital resources.
Conclusion
Opportunities to use data to inform decision-making
Hospital discharge data are collected routinely. The COVID-19 pandemic highlights the usefulness of these rich data sources for health service planning, shining the spotlight on the value of coded hospital data and creating an opportunity to promote the value of health information management for additional uses. It is timely to work on improving the quality of data for uses other than funding purposes alone. If we get the data right the first time, we can re-use them time and time again, even in unexpected situations such as unforeseen global pandemics.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
