ArticleJournal of medical systems2020
Problems and Barriers during the Process of Clinical Coding: a Focus Group Study of Coders' Perceptions.
Article in Journal of medical systems, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 21 papers.
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Who cites it
21 citing papers in PubMed.
- Why is the data quality of hospital morbidity so heterogeneous? A nationwide survey of Portuguese clinical coders.Archives of public health = Archives belges de sante publique · 2026Article
- (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
- Challenges and Solutions in Applying Large Language Models to Guideline-Based Management Planning and Automated Medical Coding in Health Care: Algorithm Development and Validation.JMIR biomedical engineering · 2025Article
- Validating adverse events in administrative healthcare data in ireland: a retrospective chart review study.BMC health services research · 2025Article
- Machine-Learned Codes from EHR Data Predict Hard Outcomes Better than Human-Assigned ICD Codes.Machine learning and knowledge extraction · 2025Article
- Article
- Primary healthcare professionals' approach to clinical coding: a qualitative interview study in Wales.The British journal of general practice : the journal of the Royal College of General Practitioners · 2025Article
- Optimising the paradigms of human AI collaborative clinical coding.NPJ digital medicine · 2024Article
- Large language models could make natural language again the universal interface of healthcare.Nature medicine · 2024Article
- Achieving Robust Medical Coding in DRGs Systems: Innovative Actions Adopted in Greece.Healthcare (Basel, Switzerland) · 2024Article
- Unsupervised algorithms to identify potential under-coding of secondary diagnoses in hospitalisations databases in Portugal.Health information management : journal of the Health Information Management Association of Australia · 2024Article
- Development and validation of the intention to use the ICD-11 questionnaire in the Malaysian medical records context.PloS one · 2024Article
- AI integration in nephrology: evaluating ChatGPT for accurate ICD-10 documentation and coding.Frontiers in artificial intelligence · 2024Article
- Natural language processing for the automated detection of intra-operative elements in lumbar spine surgery.Frontiers in surgery · 2023Article
- Automated clinical coding: what, why, and where we are?NPJ digital medicine · 2022Review
- Deep Learning Analysis of Polish Electronic Health Records for Diagnosis Prediction in Patients with Cardiovascular Diseases.Journal of personalized medicine · 2022Article
- Estimating and examining the costs of inpatient diabetes care in an Irish Public Hospital.Diabetic medicine : a journal of the British Diabetic Association · 2022Article
- Spatial Patterns in Hospital-Acquired Infections in Portugal (2014-2017).International journal of environmental research and public health · 2021Article
- Review
Corrections and comments
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Authors and funding
7 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Coded data are the basis of information systems in all countries that rely on Diagnosis Related Groups in order to reimburse/finance hospitals, including both administrative and clinical data. To identify the problems and barriers that affect the quality of the coded data is paramount to improve data quality as well as to enhance its usability and outcomes. This study aims to explore problems and possible solutions associated with the clinical coding process. Problems were identified according to the perspective of ten medical coders, as the result of four focus groups sessions. This convenience sample was sourced from four public hospitals in Portugal. Questions relating to problems with the coding process were developed from the literature and authors' expertise. Focus groups sessions were taped, transcribed and analyzed to elicit themes. Variability in the documents used for coding, illegibility of hand writing when coding on paper, increase of errors due to an extra actor in the coding process when transcribed from paper, difficulties in the diagnoses' coding, coding delay and unavailability of resources and tools designed to help coders, were some of the problems identified. Some problems were identified and solutions such as the standardization of the documents used for coding an episode, the adoption of the electronic coding, the development of tools to help coding and audits, and the recognition of the importance of coding by the management were described as relevant factors for the improvement of the quality of data.
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