Improving clinical coding

The Health Informatics Unit (HIU) conducted a programme of work that focussed on improving clinical coding, and clinicians’ understanding of analyses of hospital activity data and Hospital Episode Statistics (HES).

What we are doing

The Health Informatics Unit (HIU) started working with clinical coding in 2005 with the work of the RCP's Information Library (iLab) in Swansea. A research project explored the potential for use of Hospital Episode Statistics (HES) and the Patient Episode Database Wales (PEDW) to support appraisal for consultant physicians. In doing so, the quality of consultant-level data in HES was investigated, along with how it might be improved.

The project led to the production of a physicians' guide to Hospital Episode Statistics (HES).

The iLab project also explored the clinical uses of routine data and highlighted existing issues surrounding the collection and clinical validation of routine activity recorded in HES. This part of the iLab project led to the production of guidance and answers to the questions that clinicians most commonly ask when looking at HES related data for England and Wales.

These were produced in conjunction with ten tips for good note-keeping practice to ensure accurate clinical coding. Our guides are designed to be used in conjunction with analyses of consultant activity, and enable trust information staff to produce and present clinically useful analyses using their own trust's routine data.

The Audit Commission’s payment by results data assurance framework report found significant levels of error. The most common factor found to contribute to errors was the quality of the source documentation from which the coding data was extracted.

Therefore, work in this area continued with the Audit Commission inviting the RCP to collaborate in a joint project to explore the impact on clinical coding of introducing the new record keeping standards. This joint project found that structuring the medical records greatly assisted clinical coders, although the intervention phase of the study was too small and for too short a period to demonstrate change. In addition, the project found that hospital doctors are unaware of those factors in medical notes that support better clinical coding.