This assessment delves into the multifaceted implications of adopting the ICD-10 coding system in the healthcare landscape of Saudi Arabia. Drawing from a range of perspectives, including insights from healthcare professionals, policymakers, and experts in health informatics, the study investigates the potential benefits, challenges, and transformative aspects associated with the shift to ICD-10. Key findings highlight the system’s capacity to assimilate diverse clinical data, enhance specificity in coding, and improve overall healthcare quality. The study also addresses critical challenges such as workforce training, technological readiness, and the impact on health data standards. Moreover, it sheds light on the unique challenges faced by Saudi Arabia in this transition and proposes strategies for effective implementation.
Hazelwood (2003, p. 3) stated the following benefits of transforming to ICD-10:
“In general, ICD-10-CM assimilates considerable amount of clinical data, information, and
specificity related to ambulatory as well as managed care supervision and encounters.
Furthermore, the structure or framework of ICD-10-CM helps in greater expansion and
proliferation of code numbers. The Version 10 of the International Statistical Classification of
Diseases i.e. ICD-10 will also go beyond just classifying injuries and diseases to encompass the
various risk factors or elements that are oftentimes experienced in a basic health care setting.
This new classification or system also involves illnesses, infections or ailments that have been
found out since ICD-9-CM got last revised. The classification of diseases has been improved and
upgraded so that it is consistent with the latest clinical practice. The increased level of accuracy
and specificity should offer more elaborate information, which will help payers, providers, as
well as policy makers in setting right reimbursement rates, enhancing healthcare delivery,
enhancing as well as appraising the quality of health care, and keeping both resource and service
utilisation under supervision”
Guffey and Duchek (2013) noted that:
“Even though the transition or transformation to ICD-10 would need serious, thorough
preparation from manufacturers, suppliers and the remaining people in the industry, we will be
able to notice as well as experience the actual advantages of ICD-10 only after its
implementation gets completed, including more systematic and organised clinical data
documentation, more uniformity and stability in detailing changing trends in public health, as
well as decreased amount of rejected claims resulting from inefficiencies in coding.”
Aboul‐Enein (2002) noted:
“In the end of 1995, a mandatory health insurance policy for the employees who are expats was
introduced by the government, 80 percent of the insurance costs being supported by the
employer of company and 20 percent by the workers.”
Alnaif (2006, p. 694) said:
“The health insurance schemes would offer fixed, standard benefits consultation charges,
treatment as well as medication; preventive care like childbirth, vaccination parental care;
radiology and lab tests; maternity care, inpatient services as well as operations; and treatment of
diseases related to gums and teeth. The person seeking medical coverage or the employer can
also negotiate their medical premiums with the insurance company.”
Khouja (2013) stated:
“CCHI is motivating healthcare providers or health insurers for applying coding system - ICD-
10-AM by 2014. At present, the Council of Cooperative Health Insurance is providing training
sessions to become proficient in using ICD-10-AM and Australian Refined Diagnosis Related
Groups and has made it compulsory for validation.”
Dyers, Evans, Ward, du Plooy, and Mahomed (2016) describe DRGs as:
“Purchasing by using or through DRGs i.e. diagnosis-related groups has been clearly mentioned
in the NHI (National Health Insurance) policy, for which ICD coding system will be vital and
necessary.
Khouja (2013, p. 31) stated:
“An additional issue is that of the poor infrastructure for health insurance in the Kingdom. The
Council of Cooperative Health Insurance is working to address this issue. At present, the council
is developing initiatives to enhance electronic communication, and improve communication
channels as well as information exchange between different parties. One of the recent initiatives
of the council is Saudi Health Insurance Bus project. It is a national project aimed at
standardising health insurance schemes as well as enabling stakeholders to safely exchange
various health insurance transactions through electronic means. This will impact the health
insurance business in a positive way. CCHI is motivating healthcare providers and insurers to
employ ICD-10-AM by 2014. At present, the Council of Cooperative Health Insurance is
providing training sessions to become proficient in using ICD-10-AM and Australian Refined
Diagnosis Related Groups and has made it compulsory for validation.”
Alkadi (2016, p. 1) defined health informatics as:
“Health informatics is a multidisciplinary area which is used for enhancing the managing as well
as processing of healthcare by way of offering latest technology for providing advanced,
innovative medical services.”
Thompson and Brailer (2004, p. 38) described Health Information Technology as:
“Implementing information processing requires and encompasses both computer software as well
as hardware that takes care of storage, recapture, sharing as well as utilisation of information,
knowledge as well as data related to healthcare for the purpose of decision making and
communication.”
As Hammond (2005, p. 1205) stated:
“In the IT world, this requirement is known as interoperability. When participating groups
support or brace common procedures, systems and functions, it is known as functional
interoperability.
When the communication language is understandable and accessible by a computer which is
there at the communication’s receiving end.
Altuwaijri (2012, p. 339) noted that:
● In Saudi Arabia, a majority of health centres or hospitals still use paper to document the
information of patients.
● There is a rapid increase in the volume health related information. However, various
health sectors and hospitals make use of different types of systems having little or no
interoperability. This results in development of disconnected pools of information.
● A majority of information systems that exist today are of administrative nature rather
than being focused on patients. This is because these healthcare systems organise
healthcare delivery around healthcare institutes and not around the ones seeking health
care (patients).
McConnell (2003, p. 36) stated:
“Presently, this is in planning stages and encompasses the period of 1st five years out of the total
20 years of IT general strategies. The Computing Society of Saudi as well as the King Faisal
Specialist Hospital are together working with the Kingdom for formulating and establishing a
systematic and well-developed infrastructure for health information as part of the Kingdom’s
National Informational Technology Plan. They are doing this as it will not be possible to develop
a realistic, detailed and integrated plan for a 20 year period as it is presently in the planning
stage. The plan entails eHealth, eLearning, as well as Telemedicine from all angles.”
In the regard of health care systems, ‘health data standards’ can be defined as:
The main informatics elements or components which are important for smooth flow of
information via infrastructure of national health information are known as Data Standards.”
Aspden, Corrigan, Wolcott, and Erickson (2004, p. 128) stated:
“The absence, unavailability or shortage of mainstream data standards has hampered sharing of
information between healthcare facilities and commercial clinical labs, between chemists and
hospitals regarding prescriptions, as well as between healthcare institutes and insurance
companies or payers regarding reimbursements.”
Katherine Kim (2005, p. 5) stated:
“Particular codes for various diseases are provided by these vocabularies. They also provide
distinct codes for clinical concepts like allergies, problem lists, diagnoses and medications that
may have fluctuating or differing textual illustration in a transcription, chart or paper. For
example, LOINC is the terminology used for lab results universally, ICD is used for medical
diagnoses, and SNOMED is used for clinical terms.”
Kijsanayotin et al. (2016) said:
“Different systems of health information is a major challenge for nations to establish integrated,
functional and effective procedures and systems of health information. It is very much obvious
and discernible that lack of stable data standards will result in information fragmentation.”
Alkraiji, Jackson, and Murray (2013) pointed out in regard to the implementation and
utilisation of Health Data Standards in the hospitals of Saudi that:
“The major barriers include lack of a data exchange plan and an effective national regulator.
Other barriers include lack of adequate, reasonable policies related to medical IT plans or
systems, national healthcare system and information management. Also, the switching costs and
and technical barriers to the data standards are major ones.”
Health Information Exchange has been described by Vest and Gamm (2010, p. 288) as:
“HIE can be defined as process of effectively sharing electronic health information on patient
level between various institutions; the prospective impact of providing the healthcare
professionals with the patient level information which was previously unavailable are
widespread.
Kaelber and Bates (2007) said:
“Enhanced patient safety is one of the most promising benefits of HIE. If the appropriate
information about a patient is available and accessible at the right time, then nearly 70 percent of
unfortunate drug events and 18 percent of patient safety inaccuracies can be eliminated. This is
very much possible through the use of Health Information Exchange (HIE).”
Adler-Milstein, Bates, and Jha (2011) noted:
“Effective utilisation involves all providers meeting the core criteria and selecting a subset from
the menu criteria. The core criteria encompass recording of the patient data and information,
decision support, electronic prescribing, and the facility of performing HIE. The menu criteria
involve elements aimed at bettering coordination between health care setting and equipping
patients with accurate clinical and educational information.”
Schloeffel (2002) defines EHRs as:
“A proper record of data and information of a patient’s health in a form that is computer
processable, stored as well as disseminated in a secure manner, and accessible by all the
authorised users. The Electronic Health Records (EHRs) system is primarily aimed at supporting
effective as well as quality integrated health care. EHRs contain past, present and prospective
information.”
Bieber, Richards, and Walker (2005) stated:
“It is important to implement EHRs at a high level. Some of the most compelling reasons why
EHRs should be implemented at a high level include increasing the safety of patients, enhancing
the quality as well as accuracy of health care, and making the administrative and clinical
processes more efficient.”
as cited by Hillestad et al. (2005, p. 1103), is:
“It evaluates that there are a large number of health and safety benefits related to widespread
implementation of EMRs i.e. electronic medical records systems, and concludes that effective
adoption as well as networking of EMRs can eventually save over $80 billion per year simply by
enhancing efficiency and safety of health care. It also concludes that Health Information
Technology-enabled management as well as prevention of chronic diseases can nearly double
those savings.”
However, the real core advantage of employing EHRs is highlighted by Farhan, Al-
Jummaa, Alrajhi, Al-Rayes, and Al-Nasser (2005):
“The most important part of the health information system in the medical or healthcare
institutions is the the medical records. A systematically and appropriately documented health or
medical record is critical to sound health care as it acts as a primary communication channel
between various health care workers. Coding can be defined as properly classifying as well as
representing data. Clinical coding can be defined as the process of assigning unique numbers to
procedures and diagnoses for purpose of research, retrieval and reimbursements.
Alsahafi (2012) noted that:
“MOH need to overcome different types of challenges in order to improve the health care
services. These challenges include shortage of workforce, lack of a consistent, unified system,
and negative attitudes of doctors towards implementation of EHR. In order to eliminate these
hurdles, a national strategy has been introduced which is to be established by MOH under the
governance of the Saudi Council of Health Services. In addition to this, another strategy that has
been implemented by MOH to improve the quality of health care services is the eHealth
Strategy.”
Wing (2016) noted that:
“Some significant difficulties for the health information management coders may arise due to the
intricacies of ICD-10. This can adversely affect revenue collection at hospitals.”
Sanders et al. (2012) noted that:
“Certain types of challenges are prominent in planning as well as implementation areas. Also,
challenges exist due to shortage proficient coders, transition’s high financial cost, and unskilled
health care workforce.”
Guffey and Duchek (2013) argue that the most important step to implement ICD-10 is
training employees to using the ICD-10 system:
“Educating as well as training your workforce will prove to be the most important and effective
step in getting ready for ICD-10 transition. Different organisations will have different training
needs. For instance, the physician coders will be required to get trained only in ICD-10 diagnosis
coding, hospital coders, on the other hand, will be required to learn both ICD-10 patient
procedure training and ICD-10 diagnosis coding.”
The study indicated that extensive training as well as development were needed to shift to
ICD-10. DeAlmeida et al. (2014) noted:
“Some of the main difficulties in the transition to the Canadian version of ICD-10 was that the
entire system of coding had to be transformed from that of paper to electronic. Due to this, there
was an urgent need for coder training and education. Similarly, implementation of ICD-10 in
Australia also required coder education, training, and beforehand preparation, as well as planning
on part of workgroups, doctors and clinicians. The two of these research studies indicated that it
took nearly 4-6 months for coders to regain or recover the coding productivity they possessed
before implementation of ICD-10.”
Uptil now, the research has highlighted the role of technology including EHRs in
implementing and using ICD-10 and Subotin and Davis (2016) cited that:
“Extensive technical training and development, as well as significant labour cost is required for
allotting codes to clinical or health related documentation. This, in addition to making the EHRs
more prominent, has also resulted in development and implementation of natural language
processing algorithms to support the workflow of coding automatically and systematically
deducing right codes from the stored clinical documentation.”
Bah (2009) stated that:
“The subject of transition to ICD-10 has hardly been discussed in the developing or
underdeveloped nations. South Africa is among the few developing nations that have been able
to make successful shift from ICD-9 to ICD-10 so far.”
Farhan et al. (2005) stated that:
“Error-free procedural as well as diagnostic coding cannot be done without clear, complete and
systematically recorded health care data and information. On of the major problems that has
prevailed in the healthcare sector is that of maintaining good quality of clinical records or
documentation. In the medical records maintained by the staff at the King Faisal Specialist
Hospital at Saudi Arabia, only little is known about coding errors and documentation. We
analysed the frequency, as well as the various reasons of errors.”
Alkadi (2016, p. 11) states that lack of proper technology, in terms of compatible and
integrated electronic systems, and shortage of health coders in KSA healthcare facilities,
are some of the bigger challenges to the adoption of ICD-10:
“While some Saudi hospitals have adopted Australian Modification (AM), others are still making
use of ICD-9. The shortage of ICD-10 AM coders, as well as the various technical issues related
to ICD-10-AM have resulted in its incomplete implementation in the hospital information
systems. Due to various compatibility issues, the implementation and applications of ICD-10 is
restricted only to standalone systems.”
Alkraiji et al. (2013) stated that:
“Health data standards are considered as the foundation of interoperability solutions. Despite
this, the present levels of the adoption of health data standards are very low.”
Alkraiji (2012, p. 128) stated that:
“Since the late 1980s, ICD-9 CM (Clinical Modification) was used in the hospitals of Saudi as an
official system to classify diseases and assign unique codes to information related to health
conditions. But, only a few Saudi hospitals implemented ICD-9-CM for reporting the occurrence
or discovery of certain types of ailments to MOH. Moreover, this version was used for inpatients
only. This was mainly because the doctors and the coders were not prepared or trained enough to
deal with the terminology because of lack of proficient coders of terminology standards in the
country. Another reason was that the policies of most hospitals in Saudi were not designed to
compel the doctors for applying the terminology standards regularly. Hence, much of clinical
information was either corrupted or missing because of the limited use of ICD in the country.”
A participant in the study stated that:
“ICD-10-AM implementation does not meet the expectations of the hospital as the main aim is to
have it incorporated or integrated into the HIS system of the hospital with s code finder system
so that the doctors are easily able to assign accurate codes for the treated patients/cases.”
This study further indicated that:
“While some hospitals were not able to implement and use ICD-10-AM as their HIS systems
were outdated and it was impossible to further modify them, the HIS systems at other hospitals
were bought from American vendors and only supported ICD-9-CM as this is the national code
for diagnoses and diseases in America.”
Alkraiji (2012) noted that:
“In the year 2005, it was announced by the MoH that it is mandatory to convert to ICD-10-AM.
Since then, only 3 health care institutes, namely KFMC, KFSH&RC and NGHA have
transformed to this standard. The main reason behind this is that the other health care
organisations in the country are not prepared to apply it due to various technical issues, as well as
the shortage of ICD-10-AM coders.”
Albishi (2014) stated that:
“Some challenges were faced in the implantation of ICD-10. These included coder related
challenges and organisation related challenges. Some of the most serious coder related
challenges included poor English literacy, shortage of training resources needs for adoption of
ICD-10, shortage of health care records workforce and that of coders. No clear and
comprehensible career path for Clinical Coders and Hospital Information Management
Specialists in Saudi is one of the major factors that has limited the coding process in the country.
Organisational challenges include limited awareness of ICD-10, unavailability of a Discharge
Abstract Data System having set minimum data sets, and poor technical infrastructure.”
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Mixed Methods have been defined by Tashakkori and Creswell (2007, p. 4) as:
“Making use of both qualitative as well as quantitative approaches for gathering and analysing
research data, integrating the findings of the research, and drawing inferences.”
Johnson and Onwuegbuzie (2004, p. 17) stated that:
“Mixed methods research is a type of research where the investigator combines qualitative and
quantitative research methods, concepts, techniques, or approaches in carrying out a single
study.”
“Mixed methodology strengthens a research study. It provides certain strengths that can
systematically and simultaneously manage a wide range of confirmatory and exploratory
research questions through the use of both quantitative and qualitative research approaches.
Strong, valid results can be achieved by using mixed methodology.”
Kumar (2011, p.94) stated that:
“A research design is a systematic plan which is used by a researcher to answer research
questions accurately, objectively, validly and economically.”
Minichiello, Sullivan, Greenwood, and Axford (2004, p. 180) stated that:
“In health research studies, different types of techniques are used for the purpose of drawing a
random sample, so that each member of the population gets an equal opportunity of getting
picked up and an independent opportunity of selection.”
Cavana, Delahaye, and Sekeran (2001, p. 263) stated that:
“Here, sampling or sampling technique is limited to certain types of individuals who can provide
desired facts, data or information related to the topic of research, either due to the fact that they
are the only ones who have that information, or because they meet the selection criteria set by the
researcher.”
Minichiello et al. (2004, p. 181) noted that:
“Purposive sampling is suitable as well as valuable in situations where the investigator
understands the population well and hence it is practical to handpick units that can be included in
the research sample.”
Cavana et al. (2001, p. 263) noted that:
Judgement sampling is a sampling method that involves choosing the subjects or people who are
in the best position to provide desired information.”
Babbie (2013, p. 253) stated that:
“Observation method is probably the most suitable and effective method available to the
researcher aiming at gathering original data for describing a population that is too large.”
Steinar (1996, p. 2) noted that:
“An interview can be defined as an exchange of views or opinions between two individuals
having a conversation about a subject of mutual interest.”
An interview has been defined by Green and Thorogood (2004, p. 87) as:
“A communication that is aimed directly or indirectly at the investigator’s need for research data.
It can be seen as type of interaction wherein the investigator (interviewer) and the sample unit
(interviewee) produce research related data.”
Babbie (2013, p. 62) states that:
“Anyone who is involved in research related to social science must have the knowledge of
general agreements shared by various researchers about what is right and wrong while
conducting a scientific research.”
Thomas (2000, p. 70) stated that:
“Every time a partaker is recruited to a research study, it is vital to take a written informed
consent. The research participant is provided with all the information related to the research
stating the purpose of research, and disclosing any type of harm that might be caused to the
participant during the ongoing research.”
Thomas (2000, p.67) stated that:
“It is important for the researcher to ethically evaluate the answers given by the respondents in
the interviews or surveys before making use of them in his/her research study.”
(Thomas, 2000, p. 70) put forward that:
“For the ones who are carrying out low-risk research studies like the completion of a survey
questionnaire, I recommend they include something like, “By returning this survey
questionnaire, I understand that I have given my informed agreement and acceptance to take part
in this research study.”
Liamputtong (2013, p. 206) stated that:
“Once the alteration and evaluation is done, the draft survey is then re-examined and reviewed
by other experts in research topic or in survey development, and feedback is achieved. On the
basis of their feedback, the investigator modifies and perhaps reorders the questions.”
Reliability has been defined by Joppe (2000, p. 1) as:
“The extent to which the survey or research findings and results are consistent and reliable over
time and a precise depiction of the total population that is being studies is said to be reliability. If
the research results are reproducible under a same kind of methodology, then the research tool or
instrument is referred to as reliable.”
Another definition of reliability given by Joppe (2000, p. 1) is:
“Validity decides and concludes whether a research study actually analyses what it was aimed at
analysing or how realistic and valid the results of the research are. Validity is usually determined
by the researchers through the use of surveys and questionnaires and by examining the results of
other similar research studies.”