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The quality of diagnostic coding in cerebrovascular disease
M Hasan1, R J Meara, B K Bhowmick
1University Department of Geriatric Medicine, Glan Clwyd Hospital, Bodelwyddan, Rhyl, Wales, UK.
Insights
Diagnostic coding for cerebrovascular disease (CVD) in electronic health records is often inaccurate. Improvements in doctor and coder training are needed to enhance data quality for healthcare planning.
Area of Science:
- Health Informatics
- Clinical Data Management
- Cerebrovascular Disease Research
Background:
- Accurate diagnostic coding is crucial for effective healthcare management, including audit, costing, and planning.
- Computerized clinical information systems are widely used but their data quality can be variable.
- Cerebrovascular disease (CVD) coding accuracy is essential for understanding disease burden and resource allocation.
Purpose of the Study:
- To evaluate the accuracy of diagnostic coding for cerebrovascular disease (CVD) within a computerized clinical information system.
- To identify the primary reasons for coding discrepancies in CVD patient records.
- To recommend strategies for improving diagnostic coding quality in hospital information systems.
Main Methods:
- Retrospective review of 166 patient case notes diagnosed with cerebrovascular disease (CVD).
- Comparison of diagnostic codes from the casemix database with codes assigned by investigators after case note examination.
- Analysis of discrepancies to determine the nature and cause of coding errors.
Main Results:
- Overall diagnostic coding inaccuracy was found in 26% (44/166) of cases.
- Specific errors included 5% (9/166) of patients incorrectly coded as having CVD and 21% (35/166) coded as 'acute but ill-defined stroke'.
- Inadequate information in discharge letters was the most frequent cause of discrepancies, cited in 21 cases.
Conclusions:
- Significant deficiencies exist in the diagnostic coding quality for cerebrovascular disease (CVD) in the studied system.
- Improving coding accuracy requires enhanced education and training for both physicians and coding clerks.
- Establishing continuous dialogue between clinicians and coding staff is vital for rectifying coding deficiencies and improving the utility of hospital information systems.
Abstract:
We investigated the quality of diagnostic coding in relation to cerebrovascular disease (CVD) in a computerized clinical information system by comparing the codes on the computer printout, obtained from casemix database on 166 patients with a diagnosis of cerebrovascular disease, with the codes allocated by the investigators after examining the case notes. Overall, the diagnostic coding was incorrect in 44 (26%) cases. These inaccuracies included 9 (5%) patients who did not have CVD and 35 (21%) patients who were incorrectly coded as "acute but ill-defined stroke". The inadequacy of information in discharge letters was the main reason for such discrepancies (21 cases). There is a need for adequate education and training of doctors and coding clerks and for a constant dialogue between them if the deficiencies in coding are to be rectified and the value of hospital information system in the audit, costing and health care planning is to be improved.