Factors affecting the quality of diagnosis coding data with a triangulation view: A qualitative study

Area of Science:

• Health Informatics
• Medical Record Management
• Quality Improvement

Background:

• Accurate medical record coding is crucial for healthcare utilization and data quality.
• Challenges persist in maintaining high-quality diagnosis coding in medical records.
• A comprehensive understanding of influencing factors is needed to improve coding quality.

Purpose of the Study:

• To investigate factors affecting the quality of diagnosis coding.
• To adopt a multi-dimensional approach involving various stakeholders.
• To identify barriers from physician, coder, and administrative perspectives.

Main Methods:

• Conventional Content Analysis of effective factors.
• Semi-structured interviews with 32 medical record coders.
• Web-based survey of 86 hospital staff across 25 provinces.
• Focus group discussions with 18 coders nationwide.

Main Results:

• Barriers to inpatient record coding quality fall into three main categories: physician-related, coder-related, and managerial, financial, and administrative factors.
• Physician-related factors impact coding accuracy through documentation completeness and specificity.
• Coder-related issues include training, workload, and adherence to guidelines.
• Managerial, financial, and administrative factors encompass resource allocation, policies, and system support.

Conclusions:

• A triangulation of perspectives from coders, physicians, and administrative dimensions is essential for identifying diagnosis coding quality barriers.
• The study provides insights for policymakers to develop effective strategies and interventions.
• Improving clinical coding quality necessitates a holistic approach addressing all identified stakeholder-related factors.