Davies Aled, Ahmed Haroon, Thomas-Wood Tracey, Wood Fiona
PRIME Centre Wales, Cardiff University, Cardiff.
Division of Population Medicine, Cardiff University, Cardiff.
Br J Gen Pract. 2024 Dec 26;75(750):e43-e49. doi: 10.3399/BJGP.2024.0036. Print 2025 Jan.
Clinical coding allows for structured and standardised recording of patients' electronic healthcare records. How clinical and non-clinical staff in general practice approach clinical coding is poorly understood.
To explore primary care staff's experiences and views on clinical coding.
Qualitative, semi-structured interview study among primary care staff across Wales.
All general practices within Wales were invited to participate via NHS health boards. Semi-structured questions guided interviews, conducted between February 2023 and June 2023. Audio-recorded data were transcribed and analysed using reflexive thematic analysis.
A total of 19 participants were interviewed and six themes were identified: coding challenges, motivation to code, making coding easier, daily task of coding, what and when to code, and coding through COVID.
This study demonstrates the complexity of clinical coding in primary care. Clinical and non-clinical staff spoke of systems that lacked intuitiveness, and the challenges of multimorbidity and time pressures when coding in clinical situations. These challenges are likely to be exacerbated in socioeconomically deprived areas, leading to underreporting of disease in these areas. Challenges of clinical coding may lead to implications for data quality, particularly the validity of research findings generated from studies reliant on clinical coding from primary care. There are also consequences for patient care. Participants cared about coding quality and wanted a better way of using coding. There is a need to explore technological and non-technological solutions, such as artificial intelligence, training, and education to unburden people using clinical coding in primary care.
临床编码有助于对患者的电子健康记录进行结构化和标准化记录。目前人们对全科医疗中的临床和非临床工作人员如何进行临床编码了解甚少。
探讨基层医疗人员对临床编码的经验和看法。
对威尔士基层医疗人员进行定性、半结构化访谈研究。
通过英国国家医疗服务体系（NHS）健康委员会邀请威尔士所有的全科诊所参与。2023年2月至2023年6月期间，以半结构化问题为指导进行访谈。对录音数据进行转录，并采用反思性主题分析法进行分析。
共访谈了19名参与者，确定了六个主题：编码挑战、编码动机、简化编码、编码日常任务、编码内容及时间，以及新冠疫情期间的编码。
本研究表明了基层医疗中临床编码的复杂性。临床和非临床工作人员提到系统缺乏直观性，以及在临床环境中编码时存在的多种疾病并存和时间压力等挑战。在社会经济贫困地区，这些挑战可能会加剧，导致这些地区疾病报告不足。临床编码的挑战可能会对数据质量产生影响，特别是对依赖基层医疗临床编码的研究所得出的研究结果的有效性。对患者护理也会产生影响。参与者关心编码质量，并希望有一种更好的编码使用方式。有必要探索技术和非技术解决方案，如人工智能、培训和教育，以减轻基层医疗中使用临床编码的人员的负担。
