Concern about the shortfall in the coding workforce in Australia has been raised in a number of national fora. This report seeks to quantify the scope of the existing shortfall, to project future numbers required to cover increasing demands, and to provide a consolidated set of recommendations to address the issues identified. For the purposes of this report, the coding workforce has been described as comprising Health Information Managers (HIMs), Clinical Coders (CCs) and Costing Specialists (CSs).
Coding has been undertaken in Australian hospitals for over 60 years for the purposes of public health measurement, health services management, planning, performance and activity monitoring and epidemiological studies. However, with the introduction of casemix management in Australia in the early 1990s, different drivers for the quality and completeness of coding emerged. The first state to implement a case based funding mechanism was Victoria in 1993–94, followed by several other states and territories whose implementation of casemix was variously for management or funding purposes.
In 2010, in light of increasing pressures to deliver quality services to an ageing population which is experiencing increasing rates of chronic diseases, greater reliance on technology, increased consumer expectations and growing workforce shortages, the National Performance Agreement on Hospital and Healthcare Reform has proposed the introduction of an Activity Based Funding (ABF) model. This will be for an increased range of services, particularly in the case of outpatient services, and is based on the need for more and better health information to support public accountability and efficiency of hospital based services. The implementation of ABF and other aspects of the National Partnership Agreement (NPA) will require a larger and more productive coding workforce as coded data provides the source of many of the performance reporting and measurement targets.
The current coding workforce
There is a recognised shortfall in the coding workforce in Australia, as has been articulated in two previous national surveys (HIMAA 1995; McKenzie & Walker 2003). This report identifies changes in the workforce across the period since 1994, including an ageing workforce, general dissatisfaction with employment conditions and salaries, a greater number of part-time workers, an increasingly flexible and mobile CC population often working across multiple facilities, increased reliance on contract coding companies and the use of shared and ‘roving’ HIMs and CCs. These latter workers often have to travel great distances in order to manage the coding in rural and remote hospitals. Despite the greater reliance on complete and accurate coded data, there is evidence that the coding workforce continues to be required to undertake many other tasks as well as their coding roles.
In addition the inclusion, for the purposes of this report, of CSs within the definition of the coder workforce has created some issues, as this group is currently not a recognised specialist workforce. Thus further work is required to define these workers if their numbers are to be measured, and therefore no comparison over time is made.
The current coding workforce, as reported by respondents to the 2010 AIHW Coding Workforce Survey compared with the previous surveys, has the following broad characteristics:
- increasingly educated through the VET sector and not universities
- 65.3% CCs and not HIMs (except in Victoria, where the majority of the workforce is represented by HIMs who have graduated from an undergraduate program)
- increasing duration of coding experience
- predominantly female (92.8%)
- more than 50% aged 45 years or over
- around 50% working part-time
- two-thirds employed in public sector facilities
- 177.4 FTE vacant positions reported in respondent facilities, with the highest percentages reported in New South Wales, Queensland and Western Australia
- nearly 1 in 5 facilities employed contract coding companies to manage their coding workloads.
Other responses to the survey indicated issues relating to education, including the cost and duration of training, accessibility and the need to provide individualised support for new coders at facilities, regardless of how they have obtained their initial coding education. This issue was noted as difficult to manage because it also reduces the productivity of the supervisor.
The identified workforce deficit is anticipated to become more acute as the proposed government initiatives are implemented. A similar workforce shortage has been identified in a number of other countries that have also implemented case-based funding mechanisms. Australian state and territory health departments have also recognised the shortfall, and most have conducted their own studies to identify and count the workforce and to develop strategies and opportunities to improve its productivity. Common strategies identified across the states and territories include:
- use of a state-wide licence for the use of the 3M™ Codefinder™
- use of the Performance Indicators for Coding Quality (PICQ) tool
- creation of Coding Auditor and Educator positions
- state coding committees and coder websites for improved communication with coders.
This report explores past and current mechanisms for educating the coding workforce and makes recommendations for the future. Coders have been educated through undergraduate and postgraduate HIM programs conducted in four Australian universities, as well as for CCs through the Health Information Management Association of Australia (HIMAA), TAFE sector and through on-the-job training. Little is known about the CS workforce or about how they are educated. However, the universities report lack of enrolments into HIM programs and because of this, half of the previously offered undergraduate programs have been discontinued in recent years. The reported ‘invisibility’ of the coding workforce and the HIM and CC professions have affected enrolment numbers, and targeted marketing strategies are required. The announcement of the creation of Health Workforce Australia (HWA) is anticipated to provide the vehicle for engaging with the universities and other organisations that offer (or previously offered) coder training. This will assist them to identify strategies for recruitment, to better facilitate articulation between tertiary education sectors and to provide a variety of educational pathways for the workforce.
The future workforce needs
There is no way to determine exact figures for the supply and demand of coding workforce, but some attempts have been made in this report to estimate the numbers required. More importantly, this report provides a method for calculating the impact of various policy changes, so that as the details of the health reform become clearer, these calculations could be modified to test these or other hypotheses.
No attempt has been made in this section to estimate the number of CSs required for the future as, until this workforce can be more clearly defined, there are no baseline data on which to base projections. However, it can reasonably assumed that more are needed than are currently employed, and that this need will increase due to the same factors that are affecting the HIM and CC workforce.
One significant difficulty in undertaking these calculations is that the inflows to the workforce are only able to be calculated by the number of people trained, and the workload implications are only able to be calculated by the number of full time equivalents (FTEs) required to perform the function. Given the large proportion of part-time workers in this industry and the geographical challenges of delivering coding services in some areas of the country, the number of people required to meet the FTE calculations below is assumed to be much greater than the number of FTE coders estimated.
Following are the main calculations able to be derived from the data available and assumptions made for the proceeding 5-year period:
- the net gain from HIM and CC training programs, less the anticipated retirements from the workforce, is estimated as 1,476 people
- the results of the survey undertaken demonstrate a current national coder vacancy rate of >175 FTEs
- to code the current volume of annual separations, 1,265 FTE coders are required
- to keep up with the projected growth in separations, Australia will require an additional 193 FTE coders over the next 5 years
- to code all non-admitted hospital services, an additional 1,493 coders will be required, or as few as 149 if only 10% require coder validation following some automated coding process
- e-health and other reform initiatives are expected to require an addition of 150 FTEs, as a low end projection
- the implementation of ABF to all states may not mean additional numbers of staff, but
- may require more qualified staff, as per the Victorian experience.
These calculations indicate that an HIM and CC workforce of between 3,101 and 1,757 FTEs will be required within 5 years (2010 to 2015).
All the recommendations are based on the basic premise that there are three key ways to deal with workforce shortfalls in any area, which are:
- increase workforce numbers and hours worked
- retain the existing workforce
- increase output of the existing workforce.
It is also critical to note that these recommendations are not sequential, and that it is essential that many of these are undertaken concurrently.
It is recommended that the first thing required is the establishment of a Coder Workforce Taskforce under the auspices of HWA to undertake proper workforce planning. This will include assessment of where coding workforce staff are needed, how many and at what level of skill, etc. The outcome of the work of the taskforce will be an integrated plan to address workforce shortages and to determine actions based on the recommendations and action strategies noted below.
- Find non-working HIMs and CCs to fill current vacancies
- Promote immediate improvement in current work arrangements for existing staff.
- Support a more in-depth body of work on the Costing Specialist Workforce, with the aim of developing a set of competencies and training packages
- Finalise the development of an Australian Qualifications Framework (AQF) qualification for Clinical Coding, and assist existing coders to obtain Recognition of Prior Learning (RPL)
- Promote careers in Clinical Coding, HIM and Clinical Costing nationally
- Seek to have these careers listed on skills shortage lists
- Investigate the value of coding software for improving quality and speed
- Enhance continuing professional development opportunities
- Undertake a national review of salary and industrial conditions for CCs, HIMs and CSs.
- Provide scholarships, internships and training incentives
- Establish Coding Workforce Units at the Local Hospital Network (LHN) level
- Use technology to improve access to records to allow remote coding
- Conduct national clinician training on diagnosis assignment and documentation
- Establish a national coding auditing, education and support function
- Define a career path for the coding workforce to integrate the existing workforce and create promotional pathway.