By Mary Butler
Long before the Zika virus or Ebola outbreaks became a threat in the United States, public health has been an international endeavor. According to some estimates, the Spanish flu—which peaked between 1918 and 1920—killed more than half a million Americans and 50 million people worldwide in one year.1 The outbreak’s indiscriminate reach impacted populations as diverse as soldiers in the trenches of France, to the president of Brazil,2 to the Dutch East Indies and Ghana. Today, while Zika and Ebola can have devastating local impacts, advances in disease surveillance—which is helped along by international coding systems, disease registries and databases, and consistent clinical documentation—prevent these illnesses from wiping out entire populations.
Part of the credit for advances goes to organizations such as the World Health Organization, which combats disease with research, surveillance, preparedness efforts, and disease response. But a critical part to supporting those efforts also comes from health information management (HIM) professionals, who play as critical a role abroad as they do in the US—though many don’t have professional organizations like AHIMA to provide education, training, and visibility in the healthcare organizations where they work.
“A challenge that we have seen and heard voiced by HIM professionals in some regions outside the US is that HIM is not recognized as a distinct profession,” says Deborah Green, MBA, RHIA, AHIMA’s executive vice president and chief innovation and global services officer. “While health IT (HIT) and health informatics are typically recognized, HIM is not necessarily acknowledged and in some cases just seen as an extension of HIT.”
One of the reasons, Green says, is that certifications for HIM professionals are unavailable in many regions outside of the US, so individuals have been unable to obtain validation of knowledge or competence.
Over the last year, Green and AHIMA’s Alexandre Bouché, MBA, MA, have been working to change this by building the groundwork in various countries to offer certification and exam preparations in several HIM domains.
In October 2016, AHIMA announced the launch of the AHIMA World Congress (AWC), of which Bouché serves as global managing director, at the International Federation of Health Information Management Associations (IFHIMA) World Congress in Tokyo, Japan, and issued a formal announcement in Baltimore, MD, at AHIMA’s Annual Convention and Exhibit.
|HIM Concerns Overseas Similar to US
Yes, healthcare is global, and it turns out that many of the pillars of what’s considered HIM practice are just as relevant abroad as they are domestically—ensuring privacy and security, quality documentation, and properly maintained health information.
Michelea Peech, RHIT, CCS, CCS-P, runs her own coding and documentation consulting company in Abu Dhabi, United Arab Emirates. She moved to Abu Dhabi in 2006 when her husband took a job there with an airline. She has also served as a coding and documentation consultant for the Health Authority of Abu Dhabi (HAAD). When she moved to the United Arab Emirates the term “HIM” was unknown there. However, the country’s healthcare best practices, code sets, coding guidelines, documentation regulations, and certifications are either the same as the US or are based on US practices, Peech says, with the only exception being dental coding.
According to Peech, “the AHIMA ethic and gold standard is well known here” in the United Arab Emirates. Peech says the country’s government has held AHIMA in high esteem since she introduced the HAAD to AHIMA’s coding training materials in 2006. This echoes what Alexandre Bouché, MBA, MA, global managing director of the AHIMA World Congress, and Deborah Green, MBA, RHIA, AHIMA’s executive vice president and chief innovation and global services officer, have consistently heard from partners abroad—that AHIMA is a standard bearer when it comes to coding expertise and resources.
While HIPAA is a main privacy law maintained by HIM in the US, privacy and security laws abroad vary. Rachel Rose, JD, MBA, whose legal practice focuses on a variety of healthcare and securities law issues related to industry compliance, advises providers to do their due diligence when vetting business associates in foreign countries. Rose says that a majority of countries have privacy and security laws comparable to HIPAA on their books. But differences do exist.
This fact is especially important for US companies that outsource coding to companies in other countries. This partnership would render those non-US companies business associates of the US healthcare organization, and subject to the regulations of HIPAA—but actual HIPAA enforcement outside of the US is difficult. Therefore it is important for US healthcare organizations to spell out HIPAA compliance expectations in their contracts with non-US based companies, and not only depend on foreign law.
Objectives of the AHIMA World Congress
The AWC is structured as an international organization founded by AHIMA, Bouché says. The AWC will leverage AHIMA’s name and infrastructure abroad without distracting from the association’s domestic activities, which remain AHIMA’s focus.
The AWC will concentrate on:
- Developing and supporting membership in AHIMA for individuals
- Creating outside-US chapters of AWC around the world, focusing on concentrating AHIMA members based outside the US
- Creating organizational memberships for business entities, governmental authorities, and other types of institutions who wish to offer and facilitate training for their healthcare professionals
- Working with other associations and organizations, such as IFHIMA, HIMSS International, and others on international health information-related projects
- Promoting AHIMA certifications and providing exam preparation (including the CCS, CCS-P, CCA, CDIP, and CHDA)
- Providing professional development in areas such as: coding, clinical documentation improvement (CDI), health data analytics, informatics, HIM best practices, and information governance
AHIMA has been involved in work outside of the US for a number of years, and currently has more than 2,000 members and certified professionals outside the US in 66 countries. That number grows to more than 5,000 individuals when including customers outside the US that purchase products from AHIMA. In 2013, AHIMA’s House of Delegates approved a “Global/Outside US” membership category. Subsequently, AHIMA—with financial assistance from the US Department of Commerce and in collaboration with IFHIMA—created the Global Health Workforce Council (GHWC) in 2014. The GHWC’s purpose was to oversee the development of an internationally applicable health information curricula and competency standard. The curricular competencies established for HIM, health informatics, and health information and communications technologies provide standards for educational program development, and support the recruitment and development of HIM workforces around the world, Green says.
Bouché stresses that the AWC should not be viewed as an entity of AHIMA akin to the component state associations that exist in the US. Instead, AWC is establishing international chapters that will be offshoots and development arms of AWC, not AHIMA.
“We want to do three things,” Bouché says. “We want to promote AHIMA membership through these chapters, engage and recruit more members outside the US. We want to promote recognition of HIM and its best practices and enable opportunities for professionals to engage and gain access to AHIMA’s products, services, and events, while enabling easy access and collaboration between AWC and local health authorities, ministries of health, healthcare employers and associations. The third is to give AHIMA members opportunities to obtain CEUs outside of the US. Right now it’s very difficult to do that.”
|AHIMA and International Standards
Standards is another international area of interest for AHIMA. “AHIMA has been involved globally for many years in standards for coding classification systems, health informatics and interoperability, and more recently health record content,” Green says. “Through direct involvement in the World Health Organization-Family of International Classifications (WHO-FIC) AHIMA’s involvement is central to coding classification systems development and revision worldwide. Informatics and interoperability activities are through ISO [International Organization for Standardization] and the US Technical Advisory Group, IHE [Integrating the Healthcare Enterprise], and Health Level Seven [HL7]. Our involvement in standards globally and our activities now with AWC will together reinforce the critical role of the HIM professional in standards, practices, and competencies that work directly to enable trust in data and information.”
According to Michael Glickman, MSE, president of Computer Network Architects, and chair of the ISO Technical Committee 215 Health Informatics (ISO/TC215), “standards must be international because disease is not bounded by political borders.” “Certainly, there are regulatory, policy, and reimbursement differences, but the clinical data and outcomes must be shared,” Glickman says. “Having the flu in Illinois is not much different than suffering from it in Hanoi.” Glickman notes that it is more expensive for vendors to develop and maintain systems that are country-specific. “That makes the products cost more to buy and use. It’s more difficult for the users, too,” Glickman says. “Standards reduce complexity and improve safety and outcomes.”
He notes that there are a number of initiatives under way for exchanging summary patient data—the US and the European Union have a memorandum of understanding to work toward achieving this—which will help foster better international health record interoperability. “The patient summary content standardization, on which the AHIMA Standards Team is working, is a good starting point because the effort and data sets involved are focused and bounded,” Glickman says. “It also supports the important clinical handoff at a transition of care.”
International HIM Needs
The US is not unique in experiencing a shift to electronic health records (EHRs) and other health information technologies. And medical coding—whether it’s used for reimbursement, reporting, or research purposes—is performed in countries around the world. The ICD (International Classification of Diseases) coding system is by its nature international and was developed by the World Health Organization. It shouldn’t be surprising then that Bouché and Green have seen the most international demand for training and certifications in CDI, coding, data analytics, and, depending on the country, information governance. Of course, coding demand varies based on the country and the coding modifications in use.
Many US-based healthcare providers and revenue cycle management organizations elect to outsource coding services. This phenomena, economically based, is one the healthcare industry has seen for many years. Organizations providing these services state a clear preference for AHIMA coding credentials to attest to coder competency, Green says. In these countries and in countries that are adopting the US clinical coding modifications, it makes sense for AHIMA to promote coding best practices. For example, the United Arab Emirates is transitioning to an insurance-based reimbursement system in 2017 that will rely on ICD-10-CM coding for billing and reporting purposes, according to Bouché.
He says he’s seen repeatedly that healthcare professionals abroad hold AHIMA’s best practices and certifications as the “gold standard.” He notes that regardless of the coding classification system in use in a country, or whether a given country has a single payer system, clinical documentation skills are valuable to anyone who has them, and is seen as a natural progression for coders, nurses, and many physicians in their career and professional development paths.
AHIMA’s CDI training and services are “being demanded in areas outside the US because quality documentation needs exist in any system. In many countries, coding is performed by doctors and nurses. With that, CDI becomes an even more valuable skill-set for these clinicians,” Bouché says.
During the fourth quarter of 2016 the first public exam preparation workshops for the CCS, CHDA, and CDIP were held in Abu Dhabi and Dubai. Certification preparation training is being planned for late 2016 and through 2017 for these and the additional certifications of CCS-P and CCA in areas outside the US. Beyond certification preparation, AHIMA has provided training on PCS coding, CDI for physicians and healthcare staff, information governance, and emerging workforce roles in health information.
“Why wouldn’t the oldest and largest professional HIM association in the world take a key role in supporting HIM workforce development needs?” Green says. “We believe that by raising the awareness of the HIM profession outside the US we will help to strengthen that recognition inside the US, and solidify the preference for AHIMA’s gold standard certifications, wherever the work is performed.”
“Moreover, AHIMA’s commitment outside the US supports our vision of ‘Improving health through trusted information,’” Green says. “Health is global, health matters, and everyone has a right to safe, quality care. The HIM professional and HIM practices are essential to safe, quality care wherever that care is delivered.”
|Read More: Additional AWC Information Available Online
For a more detailed list of upcoming international training events, presentations, and a comprehensive list of international testing sites, visit AHIMA’s International Resources website.
 Laston, Jennifer. “What Made the Spanish Flu So Deadly?” Time. March 11, 2015. http://time.com/3731745/spanish-flu-history/.
 “Francisco de Paula Rodriques Alves.” Archontology.org. February 25, 2015. www.archontology.org/nations/braz/braz_rep1/rodrigues_alves.php.
Mary Butler (email@example.com) is associate editor at the Journal of AHIMA.
"AHIMA World Congress: Empowering Members Around the Globe"
Journal of AHIMA