Department of Medical Informatics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran.
Int J Health Plann Manage. 2021 Sep;36(5):1666-1684. doi: 10.1002/hpm.3254. Epub 2021 May 25.
The most important challenge in utilizing medical record codes is the quality of coding data. The present study aims to investigate factors affecting the quality of diagnosis coding from different aspects covering different stakeholders in a multi-dimensional approach.
First, we used Conventional Content Analysis to maximally gather all effective factors. As such, semi-structured interviews were conducted with medical record coders (N = 32) at the referral hospitals in Mashhad, Iran. Second, 86 hospital staff members from 25 provinces were surveyed using a web-based questionnaire. Finally, a focus group discussion was conducted among coders (N = 18) in different hospitals across the country.
In general, the barriers to quality of inpatient record coding can be classified into three categories: (I) physician-related, (II) coder-related, and (III) managerial, financial and administrative factors.
A triangulation view (related to coders, physicians as well as managerial, financial and administrative dimensions) could be used to identify the barriers affecting the quality of diagnosis coding data. The results of this study may help policymakers in development and implementation of appropriate strategies and effective interventions to improve the quality of clinical coding.
利用病历代码的最大挑战是编码数据的质量。本研究旨在从多维度角度，涵盖不同利益相关者，调查影响诊断编码质量的因素。
首先，我们使用常规内容分析来最大程度地收集所有有效因素。因此，在伊朗马什哈德的转诊医院对病历编码员（N=32）进行了半结构化访谈。其次，对来自 25 个省份的 86 名医院工作人员进行了基于网络的问卷调查。最后，在全国不同医院的编码员（N=18）中进行了焦点小组讨论。
总的来说，住院病历编码质量的障碍可分为三类：（I）与医生相关的，（II）与编码员相关的，和（III）与管理、财务和行政因素相关的。
可以采用三角视图（与编码员、医生以及管理、财务和行政方面相关）来确定影响诊断编码数据质量的障碍。本研究的结果可能有助于政策制定者制定和实施适当的策略和有效的干预措施，以提高临床编码的质量。
