A qualitative evaluation of clinically coded data quality from health information manager perspectives

Area of Science:

• Health Information Management
• Clinical Coding Quality
• Healthcare Data Analytics

Background:

• High-quality clinical documentation and coding are essential for accurate healthcare data production.
• Clinical coding quality directly impacts the reliability and utility of health information.

Purpose of the Study:

• To qualitatively assess the strengths and barriers affecting clinical coding quality.
• To gather insights from health information managers on improving clinical coding processes.

Main Methods:

• Semi-structured interviews were conducted with 10 health information managers and clinical coding quality coordinators across nine Canadian provinces.
• Data analysis involved directed content analysis informed by institutional ethnography to identify key themes.

Main Results:

• Key barriers identified include incomplete/unorganized documentation and insufficient physician communication.
• Limited departmental resources (staffing, budget) also hinder clinical coding quality.
• Managers suggested interactive training for clinical coders and streamlined chart information as improvement strategies.

Conclusions:

• Despite general perceptions of high quality, managers report challenges with documentation consistency and resource allocation.
• Inconsistent documentation and increasing data demands without commensurate resources limit perceived clinical coding quality.
• The study offers new evidence and actionable strategies for enhancing clinical coding quality in Canada.