Coding Clinical Data Managers See Technical Obstacles Clinicians See Both Cultural and Technical Obs

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Coding Clinical Data Managers See Technical
Obstacles Clinicians See Both Cultural and
Technical Obstacles.
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Sally Wells Nurse/Honorary Research Assistant
Simon de Lusignan GP/ Senior lecturer
Woodbridge Hill Surgery
Primary Care Informatics St Georges Hospital
Medical School
http//www.gpinformatics.org
N J Hague K Thiru
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Overview

• Introduction
• Aim
• Method
• Results
• Conclusion
• Further research

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Introduction
1999
Questionnaire survey of a Primary Care Research
network STaRNet
Read Coding, Importance? Obstacles? Overcome?
Clinicians Socio - Cultural
Managers Technical
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Aim
What extent do primary care managers and
clinicians think differently about the obstacles
to coding
Do managers see technical issues Do clinicians
take a different view
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Method 1.
Study responses from Questionnaire Group into
common themes
Primary care computer research meeting Group
into common themes
Themes formed basis of Semi- structured
interviews
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Method 2.
Who did we interview ?
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Method 3.
Analysis

• Paper thematic
• NUDIST QSR N5
• Expert Review

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Results
Responses from Questionnaire 81 practices

• Managers
• 95 Technical
• Training
• Equipment
• Standard Read Codes
• GPs enter more data

• Clinicians
• 31 Socio - Cultural
• Time / Training
• Consistency/Attitude
• Stigma label
• Nature diagnosis

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Results
First analysis paper
Common themes

• Lack of training general specific
• Structure Read coding time taken to select
  codes
• Templates

• Lack of motivation

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Results
First analysis paper
Managers
Clinicians

• Training support staff could meet many of
  the gaps in practice data
• Anxiety-getting it wrong
• Clinicians frustrating, would respond to money
  and submitting reports

• Read coding time taken to select codes negative
  influence on relationship
• Anxiety getting it wrong stigma, impact on
  patients
• Free Text enormous value, record interaction

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Results
Second analysis NUDIST software

• Three shared themes
• Importance of coding for numbers
• Interface poor use of templates and memory
  joggers
• Need for training

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Results
Second analysis NUDIST software
Managers themes
Highlighted a much greater homogeneity of view
3 areas only one manager with a view

• Value of free text
• Nature of diagnosis in primary care
• Influence of coding on clinician/patient
  relationship

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Results
Second analysis NUDIST software
Clinicians themes
Paper analysis showed no difference between D
N Sub nodes to concerns about diagnosis

• Nurses focus meaning and interpretation by
  patients anxiety caused
• Doctors focus diagnosis emerges slowly in
  general practice,

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Results
Summary second analysis

• New insights
• More focused view of the managers
• Different aspects of same problems - Drs. Nurses
• Similar ratio technical to Socio-cultural M N
• Twice as many Socio cultural - Doctors

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Results
Expert Referees
Issues reported from clinicians reasonable
representations of attitudes encountered elsewhere
Soft issues present the most important perceived
and actual problems for clinicians
The option to use loose codes as headings and the
ability to add free text are essential
Managers may focus on structure and process while
clinicians focus on the outcomes
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Results
Expert Referees
New issues from referees

• Prevalent among clinicians
• Cumulative effect of multiple additional tasks
  that were hard to prioritise
  
  
• yet another thing to do

• Resentment about the loss of autonomy and over
  regulation of professional life
  
• why should I ?

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Summary
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Do managers see technical issues
?
Do clinicians take a different view

• Managers see technical solutions - training
• Clinicians will code with good reason

• Clinicians concerned about labelling pts. or
  damaging relationship
• Clinicians feel that a definite diagnosis is
  often an anathema in primary care
• Value of free text

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Conclusions
The general practice consultation is complex and
not easily reduced to a single label derived from
the medical model
Not all technical training - clinicians
socio-cultural reservations and motivational
problems need to be overcome
Free Text is a vital constituent of the
computerised medical record and should not be
excluded
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Further Research
Need for training Does technical skill truly
overcome the coding barrier ?
Doctors and Nurses need to be analysed separately
Read code system right level of granularity ?
does it create its own barriers ?
What do the patients think ?
Thank-you