Primary healthcare professionals' approach to clinical coding: a qualitative interview study in Wales.

Abstract

Background: 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.

Aim: To explore primary care staff's experiences and views on clinical coding.

Design and setting: Qualitative, semi-structured interview study among primary care staff across Wales.

Method: 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.

Results: 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.

Conclusion: 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.