Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study.

Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study. CMAJ Open. 2017 Aug 15;5(3):E617-E622 Authors: Tang KL, Lucyk K, Quan H Abstract BACKGROUND: Professional coding specialists ("coders") are experts at translating patient chart information into alphanumerical codes, which are then widely used in research and health policy decision-making. Coders rely solely on documentation by health care providers to complete this task. We aimed to explore physician-related barriers to coding that results in high-quality administrative data. METHODS: In a qualitative study conducted from December 2015 to March 2016, we recruited 28 coders who worked in health care facilities in Alberta using purposive and snowball sampling. Semistructured interviews were conducted, audio-recorded and transcribed. The interviews delved into coder training, work environment, documentation and coding standards. Thematic content analysis of transcripts was performed by 2 study investigators through line-by-line coding and constant comparison, after which the codes were collated into themes. RESULTS: Five themes emerged regarding physician-related barriers in coding of high-quality administrative data: 1) coders are limited in their ability to add to, modify or interpret physician documentation, which supersedes all other chart documentation, 2) physician documentation is incomplete and non...
Source: cmaj - Category: General Medicine Authors: Tags: CMAJ Open Source Type: research