Vera Alonso1,2, João Vasco Santos1,2,3, Marta Pinto2,4,5, Joana Ferreira1,2, Isabel Lema1,2, Fernando Lopes1,2, Alberto Freitas1,2. 1. Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal. 2. CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal. 3. Public Health Unit, ACES Grande Porto VIII - Espinho/Gaia, Vila Nova de Gaia, Portugal. 4. Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal. 5. Subgroup of Terrorism and Security of the Crime and Justice Group of Campbell Collaboration, University of Queensland, Australia.
Abstract
BACKGROUND: Health records are the basis of clinical coding. In Portugal, relevant diagnoses and procedures are abstracted and categorised using an internationally accepted classification system and the resulting codes, together with the administrative data, are then grouped into diagnosis-related groups (DRGs). Hospital reimbursement is partially calculated from the DRGs. Moreover, the administrative database generated with these data is widely used in research and epidemiology, among other purposes. OBJECTIVE: To explore the perceptions of medical coders (medical doctors) regarding possible problems with health records that may affect the quality of coded data. METHOD: A qualitative design using four focus groups sessions with 10 medical coders was undertaken between October and November 2017. The convenience sample was obtained from four public hospitals in Portugal. Questions related to problems with the coding process were developed from the literature and authors' expertise. The focus groups sessions were taped, transcribed and analysed to elicit themes. RESULTS: There are several problems, identified by the focus groups, in health records that influence the coded data: the lack of or unclear documented information; the variability in diagnosis description; "copy & paste"; and the lack of solutions to solve these problems. CONCLUSION AND IMPLICATIONS: The use of standards in health records, audits and physician awareness could increase the quality of health records, contributing to improvements in the quality of coded data, and in the fulfilment of its purposes (e.g. more accurate payments and more reliable research).
BACKGROUND: Health records are the basis of clinical coding. In Portugal, relevant diagnoses and procedures are abstracted and categorised using an internationally accepted classification system and the resulting codes, together with the administrative data, are then grouped into diagnosis-related groups (DRGs). Hospital reimbursement is partially calculated from the DRGs. Moreover, the administrative database generated with these data is widely used in research and epidemiology, among other purposes. OBJECTIVE: To explore the perceptions of medical coders (medical doctors) regarding possible problems with health records that may affect the quality of coded data. METHOD: A qualitative design using four focus groups sessions with 10 medical coders was undertaken between October and November 2017. The convenience sample was obtained from four public hospitals in Portugal. Questions related to problems with the coding process were developed from the literature and authors' expertise. The focus groups sessions were taped, transcribed and analysed to elicit themes. RESULTS: There are several problems, identified by the focus groups, in health records that influence the coded data: the lack of or unclear documented information; the variability in diagnosis description; "copy & paste"; and the lack of solutions to solve these problems. CONCLUSION AND IMPLICATIONS: The use of standards in health records, audits and physician awareness could increase the quality of health records, contributing to improvements in the quality of coded data, and in the fulfilment of its purposes (e.g. more accurate payments and more reliable research).
Entities:
Keywords:
International Classification of Diseases; clinical coding; data accuracy; data quality; diagnosis-related groups; focus groups; health information management; medical records; qualitative research
Authors: Vera Alonso; João Vasco Santos; Marta Pinto; Joana Ferreira; Isabel Lema; Fernando Lopes; Alberto Freitas Journal: J Med Syst Date: 2020-02-08 Impact factor: 4.460
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