Structuring and coding in health care records: a qualitative analysis using diabetes as a case study.

Robertson, Ann R.R.; Fernando, Bernard; Morrison, Zoe; Kalra, Dipak; Sheikh, Aziz

Abstract

Background: Globally, diabetes mellitus presents a substantial burden to individuals and healthcare systems. Structuring and/or coding of medical records underpin attempts to improve information sharing and searching, potentially bringing clinical and secondary uses benefits. Aims and objectives: We investigated if, how and why records for adults with diabetes were structured and/or coded, and explored stakeholders’ perceptions of current practice. Methods: We carried out a qualitative, theoretically-informed case study of documenting healthcare information for diabetes patients in family practice and hospital settings, using semi-structured interviews, observations, systems demonstrations and documentary data. Results: We conducted 22 interviews and four on-site observations, and reviewed 25 documents. For secondary uses – research, audit, public health and service planning – the benefits of highly structured and coded diabetes data were clearly articulated. Reported clinical benefits in terms of managing and monitoring diabetes, and perhaps encouraging patient self-management, were modest. We observed marked differences in levels of record structuring and/or coding between settings, and found little evidence that these data were being exploited to improve information sharing between them. Conclusions: Using high levels of data structuring and coding in medical records for diabetes patients has potential to be exploited more fully, and lessons might be learned from successful developments elsewhere in the UK.

Citation

ROBERTSON, A.R.R., FERNANDO, B., MORRISON, Z., KALRA, D. and SHEIKH, A. 2015. Structuring and coding in health care records: a qualitative analysis using diabetes as a case study. Journal of innovation in health informatics [online], 22(2), pages 275-283. Available from: https://doi.org/10.14236/jhi.v22i2.90

• Journal Article Type: Article
• Acceptance Date: Oct 31, 2014
• Online Publication Date: Apr 1, 2015
• Publication Date: Apr 1, 2015
• Deposit Date: Aug 25, 2020
• Publicly Available Date: Aug 25, 2020
• Journal: Journal of innovation in health informatics
• Print ISSN: 2058-4555
• Electronic ISSN: 2058-4563
• Publisher: BCS, The Chartered Institute for IT
• Peer Reviewed: Peer Reviewed
• Volume: 22
• Issue: 2
• Pages: 275-283
• DOI: https://doi.org/10.14236/jhi.v22i2.90
• Keywords: Diabetes mellitus; Medical records; Clinical coding; Qualitative research
• Public URL: https://rgu-repository.worktribe.com/output/963203