(Interview 24, Cognitive Behavioral Therapist, Secondary Care). Lack of Direct Patient Care Benefits and a Number of Risks Surrounding the Coding Clinical Data in Depression The perceived benefits of coding clinical information were mainly noted as the opportunity to readily access information for management and research purposes. Coded clinical information was also suggested as being useful for clinical audits (performed as an internal peer review activity), not only for organizations, but also for individual teams as it allowed an insight into activity levels, helped to monitor patient populations, and to prioritize the allocation of resources. ‘‘It’s about teams understanding their own activities…ad- mission rates, discharge rates, average patient stay, average age of patients…which from a team point of view is very helpful for us to understand what’s going on in any given month really…’’ (Interview 20, Ward Manager with nursing background, Secondary Care). Despite these indirect benefits to patients, most clinically practicing interviewees stated that clinical coding was designed to achieve organizational targets and offered very little value for direct patient care. ‘‘Clinically it feels like you’re doing it really for the organization rather than for any benefits for the patients… it’s just time out that’s not helpful, it feels like you’re feeding information back…for commissioning purposes so that you get paid basically rather than it being a clinically useful tool.’’ (Interview 24, Cognitive Behavioral Therapist, Secondary Care). Many clinical users therefore felt detached from the develop- ment of clinical codes, stating that coded clinical data input was a time-consuming administrative activity, which often detracted from the focus of delivering patient care. This was exacerbated by many clinical users, particularly those in secondary care, being unsure as to why they needed to record coded clinical information and what data were used for. On a practical level, clinical users struggled to juggle the demands of data input with delivering adequate patient care for the complex demands of depressive patients in the limited time available. This was particularly pronounced in primary care, where consultations were shorter than in secondary care. Clinical coding was often viewed as a bureaucratic exercise with no particular purpose in itself and a lack of meaningful representation of clinical activity. ‘‘… you try and talk to your patient and then quickly enter everything on to the template. But you have ten minutes. Before somebody comes in and interrupts you, will you just sign this prescription, then the phone rings and somebody says oh doctor there’s somebody in treatment room, I think they’ve got cellulitis, will you just run across and see if they need antibiotics. So you do that, so you’ve then got six minutes. For a psychiatric patient, to assess them and make all the notes. It’s not actually possible.’’ ‘‘There Are Too Many, but Never Enough’’ (Interview 13, GP). Consequently, notes were often taken on paper and coded after the clinical encounter. This was felt to be necessary in depressed patients as there was often a significant amount of counseling involved in encounters and coding clinical information was viewed as disrupting communication flows. ‘‘We just remember it and then at the end of the day put it in the computer who you saw and what you did, perhaps do a scribbly note to yourself of who you saw.’’ (Interview 26, Occupational Therapist, Secondary Care). ‘‘… when we are seeing patients we have to talk the patient we can’t be actually sitting in front of the computer and typing…, you need to communicate with the patient you can’t just do the typing while you are taking to patients.’’ (Interview 30, Consultant Psychiatrist, Secondary Care). Other underlying reasons for negative attitudes towards clinical coding amongst healthcare professionals were related to the perceived particularities of mental health disorders. For example, many interviewees raised the difficulty of fitting complex mental health conditions into coded clinical categories as they felt that context was often lost. Information reflected in free text was therefore valued, whilst clinical coding was perceived to facilitate labeling and force-fitting patients into boxes. ‘‘Sometimes people just don’t fit the coding…and you’re actually trying to fit them into the ICD-10 rather than the ICD-10 being created to match the general public really… sometimes you are putting a square peg in a round hole.’’ (Interview 29, Nurse Practitioner, Secondary Care). Clinicians found it hard to choose an appropriate clinical coding category, often picking the closest match as opposed to what they felt to be an accurate description. As a result of perceived issues surrounding the rigidity of applying labels to complex mental health conditions, clinicians (particularly in primary care) were often hesitant to apply diagnostic codes due to the uncertainty surrounding the persis- tence of symptoms and the potentially contestable nature of diagnoses. This reluctance was further exacerbated by the potential ramifications of diagnoses beyond the clinical care setting, such as social stigma, inclusion in the mental health register, implications for insurance reports and occupational health screening. Diagnostic coding was further complicated by perceived issues surrounding the definition of depression, due to its multi- dimensional nature and the absence of biomarkers. For example, GPs highlighted the need to be cautious in applying diagnostic labels as some individuals presenting with depressive symptoms may be merely experiencing a normal reaction to adverse life events. ‘‘… you have to be careful with labeling people. And yes it might be you know is it a depressive episode because their serotonin levels are low? …is it because actually their partner’s just lost their job and finances are tight and PLOS ONE | www.plosone.org 6 August 2012 | Volume 7 | Issue 8 | e43831