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Which barriers affect morbidity registration performance of GP trainees and trainers?
Jip de Jong1, Mechteld R M Visser, Margreet Wieringa-de Waard
1Division of Clinical Methods and Public Health, Department of General Practice, Academic Medical Center-University of Amsterdam, The Netherlands. jipdejong@amc.uva.nl
International Journal of Medical Informatics
|March 5, 2013
Summary
General practitioners achieve high diagnosis coding rates, but improving motivation and user-friendliness of the International Classification of Primary Care (ICPC) system can enhance performance and data accuracy.
Area of Science:
- Medical Informatics
- Primary Care Research
- Health Data Management
Background:
- Diagnosis coding in general practitioner (GP) training is crucial for electronic patient record (EPR) data validity.
- Existing barriers to coding impact the completeness and accuracy of diagnostic data.
- High coding percentages are observed, yet imperfections suggest room for improvement.
Purpose of the Study:
- To investigate the link between barriers encountered by GP trainees and trainers in coding diagnoses using the International Classification of Primary Care (ICPC).
- To assess the relationship between these barriers and both self-reported and actual coding performance.
- To compare coding performance against electronic patient record (EPR) data.
Main Methods:
- A questionnaire was distributed to GP trainees and trainers at the Academic Medical Center, University of Amsterdam.
- Response rates were high: 97% for trainees (71/73) and 95% for trainers (103/108).
- Barriers and self-reported coding performance were compared with one year of EPR-derived data extractions.
Main Results:
- Mean coding percentages were 88.3% (trainees) and 82.3% (trainers).
- Telephone consultations, repeat prescriptions, and administrative actions were coded less frequently than consultations and home visits.
- 'Insufficient refinement of the ICPC system' was a notable barrier.
- Barriers related to motivation and ICPC usability correlated with coding performance; 'ICPC coding is unpleasant to use' predicted performance for both groups.
Conclusions:
- While mean coding percentages are high, enhancing GP motivation and ICPC user-friendliness can further improve performance.
- EPR-derived data may be biased, particularly due to unrecorded telephone consultations.
- Addressing usability issues and motivational factors is key to optimizing diagnostic coding in primary care.
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