Abstract
BackgroundClinical coding is an integral part of primary care. Disease incidence studies based on primary care electronic health records (EHRs) rely on the accuracy of these codes. Current code validation methods are not appropriate for non-specific conditions and provide limited information about GPs' decision-making behaviour around coding. Qualitative methods could offer insight into decision-making behaviour around coding of patients with non-specific conditions.AimTo investigate the decision-making behaviour of GPs when applying Read codes to non-specific clinical presentations, using Lyme disease as a case example.Design & settingA pilot study was undertaken, involving masked semi-structured interviews of eight GPs in the North West of England.MethodSemi-structured interviews were carried out based on 11 clinical cases representative of Lyme disease presentations. Discrete answers were described descriptively. Interview transcripts were analysed using a thematic approach.ResultsThemes underpinning GPs’ coding behaviour included: GP personal and professional experience; clinical evidence; diagnostic uncertainty; professional integrity and defensive practice; and patient-sourced health information and beliefs. GPs placed Lyme disease on their differential diagnosis list for five cases; in only two cases would GPs select a Lyme disease related Read code.ConclusionGPs were reluctant to code with specific diagnostic Read codes when they were presented with patients with vague or unfamiliar symptomology. This masked questionnaire methodology offers a new approach to validate incidence figures, based on Read codes of non-specific conditions. The reluctance to code poses many problems for primary care EHRs research. Further research is needed to understand what drives GPs’ coding behaviour.
Highlights
IntroductionCurrently being replaced by SNOMED CT codes in the UK, are a hierarchical standard terminology system that encode clinical, diagnostic, and therapeutic patient information.[1] They enable data entry of patient care information during or after a primary care consultation
Read codes, currently being replaced by SNOMED CT codes in the UK, are a hierarchical standard terminology system that encode clinical, diagnostic, and therapeutic patient information.[1]
general practitioners (GPs) were reluctant to code with specific diagnostic Read codes when they were presented with patients with vague or unfamiliar symptomology
Summary
Currently being replaced by SNOMED CT codes in the UK, are a hierarchical standard terminology system that encode clinical, diagnostic, and therapeutic patient information.[1] They enable data entry of patient care information during or after a primary care consultation. This information is stored within a patient’s EHR. Their primary purpose is to digitally record summary clinical and administrative data in primary care, and were never intended for secondary analysis in epidemiological research. Qualitative methods could offer insight into decision-making behaviour around coding of patients with non-specific conditions
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