Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study

Area of Science:

• Health Informatics
• Medical Documentation
• Health Services Research

Background:

• Professional coders translate patient charts into codes for research and policy.
• Accurate administrative data relies heavily on healthcare provider documentation.
• Physician-related barriers impact the quality of coded health information.

Purpose of the Study:

• To explore physician-related barriers affecting the quality of administrative data coding.
• To identify challenges faced by coders due to physician documentation practices.

Main Methods:

• Qualitative study involving 28 coders in Alberta (December 2015–March 2016).
• Purposive and snowball sampling for participant recruitment.
• Semistructured interviews analyzed using thematic content analysis.

Main Results:

• Coders face limitations interpreting physician documentation, which is often incomplete, nonspecific, and contains errors.
• Discrepancies in terminology and a communication divide between physicians and coders impede data quality.
• Physician documentation is the primary barrier to accurate administrative data coding.

Conclusions:

• Physicians significantly influence administrative data quality through their documentation.
• Advocating for a culture change in physician attitudes towards documentation and coders is essential.
• Accurate chart information is vital for reliable health research and policy decisions.