Primary care health professionals' approach to clinical coding: a qualitative interview study

Davies, Aled, Ahmed, Haroon ORCID: https://orcid.org/0000-0002-0634-8548, Thomas-Wood, Tracey and Wood, Fiona ORCID: https://orcid.org/0000-0001-7397-4074 2024. Primary care health professionals' approach to clinical coding: a qualitative interview study. British Journal of General Practice 10.3399/BJGP.2024.0036

Preview

PDF - Published Version Available under License Creative Commons Attribution. Download (112kB) | Preview

Abstract

Background: Clinical coding allows for structured and standardised recording of data in patients electronic healthcare records. How clinical and non-clinical staff in general practice approach clinical coding is poorly understood. Aim: To explore primary care staff’s experiences and views on clinical coding. Design and setting: Qualitative, semi-structured interview study with primary care staff across Wales in 2023. Method: All general practices within Wales were invited to participate via NHS Health Boards. Semi-structured interview questions guided the interview. Audio-recorded data were transcribed and analysed using reflexive thematic analysis. Results: 19 participants from general practices across Wales were interviewed. Six themes were identified: ‘the daily task of coding’, ‘making coding easier’, ’coding challenges’, ‘what and when to code?’, ‘motivation to code’ and ‘coding through COVID’. Conclusion: This study demonstrates the complexity of clinical coding in primary care. Clinical and non-clinical staff spoke of systems that lacked intuitiveness, and the challenges of multi-morbidity and time pressures when coding in clinical situations. These challenges are likely to be exacerbated in socio-economically deprived areas, leading to under-reporting of disease in these areas. Challenges of clinical coding may lead to implications for data quality, particularly the validity of research findings generated from studies reliant on clinical coding from primary care. There are also consequences for patient care. Participants cared about coding quality and wanted a better way of using coding. There is a need to explore technological and non-technological solutions, such as artificial intelligence, training and education, to unburden people using clinical coding in primary care.

Item Type:	Article
Date Type:	Published Online
Status:	Published
Schools:	Medicine Prime Centre Wales (PRIME)
Publisher:	Royal College of General Practitioners
ISSN:	0960-1643
Date of First Compliant Deposit:	10 July 2024
Date of Acceptance:	13 May 2024
Last Modified:	12 Nov 2024 10:30
URI:	https://orca.cardiff.ac.uk/id/eprint/170474

Actions (repository staff only)

Edit Item