Problems and Barriers during the Process of Clinical Coding: a Focus Group Study of Coders' Perceptions
Problems and Barriers during the Process of Clinical Coding: a Focus Group Study of Coders' Perceptions
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DOI：
10.1007/s10916-020-1532-x
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发表时间：
2020-02-08
影响因子：
5.3
通讯作者：
Freitas, Alberto
中科院分区：
文献类型：
--
作者：
Alonso, Vera;Santos, Joao Vasco;Freitas, Alberto
编码数据是所有依赖诊断相关小组为医院提供报销/资助的国家信息系统的基础，包括行政和临床数据。识别影响编码数据质量的问题和障碍对于提高数据质量以及增强其可用性和结果至关重要。本研究旨在探讨与临床编码过程相关的问题和可能的解决方案。作为四次焦点小组会议的结果，根据十名医疗编码员的观点确定了问题。该便利样本来自葡萄牙的四家公立医院。与编码过程相关的问题是根据文献和作者的专业知识提出的。焦点小组会议被录音、转录和分析以引出主题。所发现的一些问题包括用于编码的文档的可变性、纸质编码时手写的难以辨认、从纸质转录时编码过程中由于额外的参与者而导致的错误增加、诊断编码的困难、编码延迟以及缺乏旨在帮助编码人员的资源和工具。确定了一些问题并提出了解决方案，例如用于对事件进行编码的文档的标准化、电子编码的采用、帮助编码和审计的工具的开发以及管理层对编码重要性的认识，这些都是提高数据质量的相关因素。
Coded data are the basis of information systems in all countries that rely on Diagnosis Related Groups in order to reimburse/finance hospitals, including both administrative and clinical data. To identify the problems and barriers that affect the quality of the coded data is paramount to improve data quality as well as to enhance its usability and outcomes. This study aims to explore problems and possible solutions associated with the clinical coding process. Problems were identified according to the perspective of ten medical coders, as the result of four focus groups sessions. This convenience sample was sourced from four public hospitals in Portugal. Questions relating to problems with the coding process were developed from the literature and authors' expertise. Focus groups sessions were taped, transcribed and analyzed to elicit themes. Variability in the documents used for coding, illegibility of hand writing when coding on paper, increase of errors due to an extra actor in the coding process when transcribed from paper, difficulties in the diagnoses' coding, coding delay and unavailability of resources and tools designed to help coders, were some of the problems identified. Some problems were identified and solutions such as the standardization of the documents used for coding an episode, the adoption of the electronic coding, the development of tools to help coding and audits, and the recognition of the importance of coding by the management were described as relevant factors for the improvement of the quality of data.