ArticleCMAJ open2017
Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study.
Article in CMAJ open, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 42 papers, 1 of them a synthesis that pooled it.
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Who cites it
42 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review.Journal of the American Medical Informatics Association : JAMIA · 2019Pooled it
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- (Alzheimer's) dementia in adults with Down syndrome in Germany: Administrative prevalence based on a claims data analysis.Journal of Alzheimer's disease : JAD · 2026Article
- How does the mapped ICD data in an EHR system compare to the hospital DAD data in Alberta, Canada?BMC health services research · 2025Article
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- Assessing the validity of ICD-10 administrative data in coding comorbidities.BMJ health & care informatics · 2025Article
- A Linked Population-Based Analysis of Severe Lower Extremity Traumas in Ontario.Plastic surgery (Oakville, Ont.) · 2025Article
- Measuring Diagnostic Quality: The Capacity of Routinely Collected Data and Applications to Chronic Respiratory Disease.Pragmatic and observational research · 2025Article
- Developing and testing a framework for coding general practitioners' free-text diagnoses in electronic medical records - a reliability study for generating training data in natural language processing.BMC primary care · 2024Article
- A Data-Driven Approach to Defining Risk-Adjusted Coding Specificity Metrics for a Large U.S. Dementia Patient Cohort.Healthcare (Basel, Switzerland) · 2024Article
- A scoping review of the methodological approaches used in retrospective chart reviews to validate adverse event rates in administrative data.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2024Article
- International Classification of Diseases clinical coding training: An international survey.Health information management : journal of the Health Information Management Association of Australia · 2024Article
- Assessing the diagnostic utility of the Gaucher Earlier Diagnosis Consensus (GED-C) scoring system using real-world data.Orphanet journal of rare diseases · 2024Article
- Evaluating the coding accuracy of type 2 diabetes mellitus among patients with non-alcoholic fatty liver disease.BMC health services research · 2024Article
- Characterizing the limitations of using diagnosis codes in the context of machine learning for healthcare.BMC medical informatics and decision making · 2024Article
- Barriers to healthcare data quality and recommendations in public health facilities in Dire Dawa city administration, eastern Ethiopia: a qualitative study.Frontiers in digital health · 2024Article
- Secondary Use of Clinical Problem List Descriptions for Bi-Encoder Based ICD-10 Classification.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2024Article
- Exploring the reliability of inpatient EMR algorithms for diabetes identification.BMJ health & care informatics · 2023Article
- Patient and Physician Factors Associated with First Diagnosis of Non-affective Psychotic Disorder in Primary Care.Administration and policy in mental health · 2023Article
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Authors and funding
3 authors.
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No grant is acknowledged in the PubMed record.
Abstract
backgroundProfessional 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.
methodsIn 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.
resultsFive 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 nonspecific, 3) chart information tends to be replete with errors and discrepancies, 4) physicians and coders use different terminology to describe clinical diagnoses and 5) there is a communication divide between coders and physicians, such that questions and issues regarding physician documentation cannot be reconciled.
interpretationPhysicians play a major role in influencing the quality of administrative data. There is a need for physicians to advocate for culture change in physicians' attitudes toward coders and chart documentation, in recognition of the importance of accurate chart information.
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