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Factors Affecting the Quality of Diagnosis Coding Data With a Triangulation View: A Qualitative Study Publisher Pubmed



Hosseini N1, 2 ; Kimiafar K3 ; Mostafavi SM1 ; Kiani B1 ; Zendehdel K4 ; Zareiyan A5 ; Eslami S1, 6, 7
Authors
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Authors Affiliations
  1. 1. Department of Medical Informatics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
  2. 2. Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
  3. 3. Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
  4. 4. Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran
  5. 5. Public Health Dept, Nursing Faculty, Aja University of Medical Science, Tehran, Iran
  6. 6. Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
  7. 7. Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands

Source: International Journal of Health Planning and Management Published:2021


Abstract

Objective: The most important challenge in utilizing medical record codes is the quality of coding data. The present study aims to investigate factors affecting the quality of diagnosis coding from different aspects covering different stakeholders in a multi-dimensional approach. Methods: First, we used Conventional Content Analysis to maximally gather all effective factors. As such, semi-structured interviews were conducted with medical record coders (N = 32) at the referral hospitals in Mashhad, Iran. Second, 86 hospital staff members from 25 provinces were surveyed using a web-based questionnaire. Finally, a focus group discussion was conducted among coders (N = 18) in different hospitals across the country. Results: In general, the barriers to quality of inpatient record coding can be classified into three categories: (I) physician-related, (II) coder-related, and (III) managerial, financial and administrative factors. Conclusion: A triangulation view (related to coders, physicians as well as managerial, financial and administrative dimensions) could be used to identify the barriers affecting the quality of diagnosis coding data. The results of this study may help policymakers in development and implementation of appropriate strategies and effective interventions to improve the quality of clinical coding. © 2021 John Wiley & Sons Ltd.
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