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Managers see the problems associated with coding clinical data as a technical issue whilst clinicians also see
S de Lusignan1, S E Wells, N J Hague
1Primary Care Informatics, Department of Community Health Sciences, Hunter Wing, St George's Hospital, Medical School, London SW17 0RE, UK. slusigna@sghms.ac.uk
Methods of Information in Medicine
|October 10, 2003
Summary
Clinicians find structured data coding in electronic health records challenging due to diagnostic uncertainty and patient relationship concerns. Managers view coding as essential for population health data and quality targets.
Area of Science:
- General Practice
- Health Informatics
- Qualitative Research
Background:
- Structured data recording (Read Coding) in UK general practice is not universally implemented.
- Barriers to recording structured information in computerized medical records require examination.
Purpose of the Study:
- To investigate barriers to structured data recording in primary care.
- To explore differing perspectives between managers and clinicians on overcoming these barriers.
Main Methods:
- Qualitative study utilizing semi-structured interviews with general practitioners, primary care nurses, and practice managers.
- Thematic analysis of verbatim interview transcripts until thematic saturation was achieved.
Main Results:
- Clinicians perceive structured data coding as non-neutral, influenced by diagnostic uncertainty and patient relationship sensitivity.
- Clinicians value free-text for recalling individual patient encounters, alongside coding for evidence-based care.
- Managers see coding primarily for population data reuse and quality targets, not direct consultation support.
Conclusions:
- The primary care consultation is a complex social interaction; diagnosis coding imposes a biomedical model and perceived risks to patient relationships.
- Clinicians' concerns about certainty and patient relationships present a significant barrier to structured data recording.
- Further research into patient perspectives is recommended to understand the magnitude of this barrier.