Health info management in BC: a journey to computer-assisted coding

British Columbia’s Health Information Management (HIM) program is a lower mainland consolidated (LMC) service, supporting Providence Health Care, Provincial Health Services Authority, Fraser Health, and Vancouver Coastal Health.

With nearly 1,400 full-time employees across 42 locations, HIM delivers a comprehensive suite of services, including registration, records management, transcription, coding and informatics, and corporate services.

The HIM Coding team, comprising over 140 coders, data quality specialists, coding application specialist and clinical documentation specialists manages the coding of a vast array of patient visits – spanning inpatient, emergency, surgical day care, rehabilitation, and tertiary mental health. Each year, this team processes more than 250,000 acute care, 300,000 surgical day care, and 1.1 million emergency visits, underscoring the scale and complexity of their responsibilities.

Challenges in health information management: Despite a robust infrastructure, the HIM team faced challenges that were very similar to other coding teams across the country. Coder shortages and tight submission deadlines placed pressure on the team, while the lack of standardized documentation, error-prone manual entry of patient information and the need to navigate multiple systems caused delays and frustration.

The data quality process can be labor-intensive, and retroactive error resolution meant time-consuming rework. As a result, coded data was often submitted with a delay of 60 days or more, reflecting the challenges of managing increasing patient volumes and expanding submission requirements.

Recognizing these obstacles, the HIM team saw an opportunity in computer-assisted coding (CAC) technology, which can analyze healthcare documents, suggest codes, and identify errors, thereby improving data quality and supporting a more efficient coder workflow.

Solution selection and implementation: The journey toward a CAC solution began in the fall of 2019. The team, led by Monique Rasmussen, Regional Director of Coding & Informatics, initiated an Environmental Request for Information, carefully defining their approach and scope, and began engaging with Solventum, formerly 3M Health Care, to understand the capabilities of available products.

A comprehensive governance structure and RFP committee were established, a business case was developed, and funding opportunities were identified. After a thorough evaluation, Solventum was selected as the successful contract recipient, offering the Solventum™ 360 Encompass™ Computer-Assisted Coding System.

This system brought together features such as consolidated document views, annotated terms, advanced search capabilities, and real-time error management. The implementation and rollout followed, with the first site going live in January 2022.

Change management and user engagement: Central to the project’s success was a robust change management strategy, anchored in a vision to improve coding efficiency and accuracy while creating an engaging work environment where coders feel empowered by the technology. The rollout process emphasized training and onboarding, ensuring that coders were well-prepared to adopt the new technology. The organization’s approach was not only about introducing a new tool but also about empowering coders to feel confident and supported as they navigated changes to their workflow.

Evaluation framework and methodology: To assess the effectiveness of the new system, the LMC HIM team developed a rigorous evaluation framework based on Canada Health Infoway’s Benefits Evaluation model. The evaluation focused on three key metrics:

1. Coding speed and volume: Measured using the Coding and Informatics Workload Indicator and Coding Coordinator Dashboard.
2. User satisfaction: Assessed through surveys distributed to sites operational with 360 Encompass for at least two months. The survey captured feedback on ease of use, productivity, workflow adjustments, and feature utility, stratified by coding experience and duration of system use.
3. Coding specificity, accuracy, completeness, and productivity: Evaluated through a controlled clinical coding exercise, comparing performance with and without CAC.

Key Findings: Several key findings from this evaluation were discovered. User surveys indicated an overall satisfaction rate of 84 percent. CAC was reported as most useful for acute and inpatient cases, particularly in internal medicine and long inpatient stays involving multiple procedures, where it quickly surfaced key information and reduced the need for manual searching.

In surgical day care cases, the system’s ability to highlight key details in operative reports made it easier to extract procedures and diagnoses, while organizing operating room reports ensured accurate capture of both primary and secondary procedures.

However, some challenges were noted, including navigation and formatting issues, which highlighted areas for further improvement. Interestingly, two-thirds of coders with less than one year of experience provided a positive recommendation for using the tool, while mid-career coders appeared more hesitant, possibly due to established workflows or differing expectations regarding the tool’s effectiveness.

To further assess data quality and productivity, a single set of cases was recoded twice in controlled environments – once with CAC in a production environment and once without CAC in a staging environment.

A data quality specialist then reviewed the charts to determine the type of discrepancy. The results were compelling: average coding time per chart without CAC was 16.86 minutes, compared to 11.48 minutes with CAC, representing a 47 percent increase in coding efficiency in the controlled test environment.

Gains in data completeness, specificity, and accuracy are anticipated from the latest version of 360 Encompass, which includes auto-suggested coding and data quality worklist functionalities and eventually autonomous coding capabilities. The rollout of this latest version is expected to further streamline coder workflows and enhance data quality.

Recommendations: Based on these findings, several recommendations emerged from the team to maximize the benefits of CAC implementation. A coordinated, organization wide change management approach is essential to support maximum user adoption. Ensuring that all required documentation is available in 360 Encompass will help maximize the utility of the tool. Advancing the rollout of 360 Encompass R2 is recommended to support further improvements in data quality.

Developing longitudinal studies to assess the impact of CAC on clinical outcomes will provide valuable insights for ongoing improvement. Finally, implementing standardized documentation practices will enhance data reliability across the system.

National context – CIHI’s AI strategy: The transformation underway in British Columbia aligns with pan-Canadian efforts led by the Canadian Institute for Health Information (CIHI), which is driving the modernization of health information management by investing in artificial intelligence (AI) solutions to power Canada’s health data systems.

CIHI’s mission is to ensure that health data is trusted, connected, accessible, timely, and comprehensive, supporting better decisions and healthier Canadians. The organization’s AI strategy is focused on driving innovation and efficiency, with a particular emphasis on AI-assisted coding to enhance data accuracy and timeliness.

This enables faster, richer data availability to support rapid policy decisions and responses to health system challenges.

CIHI’s Hospital Data Transformation Initiative aims to accelerate the implementation of AI-assisted coding technologies in hospitals. This approach is key to reducing the manual burden and processes of coding, expanding capacity, and augmenting the value-add of Health Information Management professionals. In addition, coding validation, edits, and auditing – both assisted and AI-driven – can improve specificity and compliance with Canadian Coding Standards.

CIHI is collaborating with hospitals and health authorities to trial AI assisted coding solutions, including Solventum 360 Encompass Computer-Assisted Coding System, and to share learnings from AI-assisted coding implementations via partnerships with innovation centres and vendors.

Ongoing evaluation of coding automation tools for usability, integration across multiple acute care EHR’s, and impact is a priority, with findings shared across stakeholders. CIHI also works with vendor partners to optimize system design, support change management, and ensure ongoing engagement as digital health evolves.

Conclusion: The implementation of computer-assisted coding in the LMC Information Management organization marks a significant step forward in the modernization of health data processes. By embracing innovative technology, fostering a culture of continuous improvement, and aligning with national strategies, the LMC HIM team has demonstrated how digital transformation can drive efficiency, data quality, and user satisfaction.

Ongoing evaluation, collaboration, and adaptation will be essential as the province – and Canada as a whole – continues to advance toward a more connected, responsive, and data-driven healthcare system.