The way a patient’s spell in hospital is coded is based on an important narrative. Not only does this narrative impact the financial returns of an organisation, but collectively the data produced from codes also provides a view of the care a setting delivers, the state of the public health, and much more. The need to get these codes correct has been emphasised in recent weeks as we all keenly watch the rise and fall of Covid-19 diagnoses around the world. Over the coming months, it is the coded data that will give us a better insight into how the disease spread and what were the most effective treatments.
Even though clinical coders play an integral role in this process, they are often undervalued. At each hospital, coders work with different systems, have different levels of visibility, and there are different pay scales. These variations can present a barrier to coders’ efficacy and efficiency, as well as their job satisfaction.
Earlier this year, Nuance held a roundtable event to discuss the challenges coders face, bringing together senior figures from across the NHS and beyond to highlight possible solutions, and what the future of the role may look like. We have today published a report detailing this expansive conversation alongside a series of recommendations.
The most significant and potentially most impactful recommendations are around the quality of clinical records and notes. Often, where information is unclear or missing, coders must spend time consulting clinicians or wading through documents to find relevant information. This may happen more frequently if coders are working from handwritten notes, but it can also be the case even when using electronic patient records (EPRs), as these can lack structure and are accumulative, which is useful for clinicians documenting a chronic condition or comorbidities, but presents difficulties when it comes to defining an episode of care. Engaging clinicians in the coding process is therefore vital.
Educating clinicians on the consequences of inaccurate information or minor inconsistencies further down the line could also be beneficial. Equally, improving coders’ knowledge and understanding of diagnoses and treatments would perhaps mitigate the need for coders to raise questions.
Although guidance from the PRSB exists, mandating structure and quality for record keeping and updating standards to align with EPRs would lead to greater clarity and consistency and therefore require less interpretation or searching from the coder when it comes to translating information into codes.
As well as extensive recommendations, the report contains many examples of where trusts are recognising the value of clinical coders and helping them to better fulfil their responsibilities, and where this benefits the trust as a whole. What our roundtable and report make clear is that elevating the role of the clinical coder will have a positive ripple effect for many other aspects of the healthcare system, enabling coders to produce information that tells a more detailed, accurate, and valuable narrative.
To read our report ‘Clinical coders – the challenges, opportunities and the role technology can play in their future’, please click here.