Summary
Objective: In UK general practice, the coding of clinical data (Read Coding) is far from universal.
This study set out to examine the barriers to recording structured information in
computerised medical records; and to explore whether managers and clinicians had different
perspectives in how these barriers should be overcome.
Method: A qualitative study, using semi-structured interviews of general practitioners, primary
care nurses and practice managers. The interviews were recorded verbatim, and then
underwent thematic analysis; additional interviews were conducted until thematic saturation
was achieved.
Results: For clinicians the recording of structured data within a consultation is not a neutral
activity, they are highly aware of diagnostic uncertainty and sensitive to the potential
impact of both a correct and incorrect diagnostic label on their relationship with
their patient. Clinicians accept that data has to be coded if they are to demonstrate
that appropriate evidence based care has been provided to populations; but alongside
this they require free-text as a more powerful reminder of the individual human encounter.
Managers felt that they could encourage clinicians to code data for re-use as part
of population data or as quality target indicators rather than as an enabler of the
next consultation. Conclusions: The primary care consultation is a complex social interaction, and coding of the
medical diagnosis in itself imposes the bio-medical model, carries assumptions about
certainty, and is perceived by clinicians to potentially jeopardise their relationships
with their patient. Further research to elicit patients’ views may help clarify the
magnitude of this barrier.
Keywords
Structured data - classification systems - computerised medical record - primary care
- general practice - medical informatics
