actually it’s stress and worry about that which isn’t depression.’’ (Interview 11, GP). Participants across care settings further expressed a tension relating to the number of clinical codes IT systems offered. On one hand, existing clinical code lists were felt to be too detailed resulting in a large number of irrelevant items, whilst, on the other hand, available clinical codes often did not accurately reflect diagnoses or interventions. ‘‘…there’s anxiety with depression, there’s recurrent de- pression, there’s depressed mood, there’s loads of them, ok? So you have to select a suitable code and…they’re never exactly right …there’s either too many of them so you don’t know which one to choose or there’s not enough because the one circumstance that you’ve got sitting in front of you isn’t the one that’s got a code.’’ (Interview 5, Academic GP). Strategies Employed to Align Clinical Value with Managerial Demands Despite these difficulties and the overall perceived lack of direct patient care benefits resulting from clinical coding, when prompted, some participants valued the ability to obtain an overview of clinical information on the summary screen, the ability for different healthcare professionals to share patient information, the ability to use of coded clinical information for clinical decision support systems, and the potential of facilitating medication reviews (e.g. allowing to link problems to medications). Despite these perceived benefits, across care settings, the main incentives for clinical coding information were financial. ‘‘I don’t see any value in encoding any specific bits of that other than a particular depression score which I get paid for recording and why else would I do it?’’ (Interview 1, Academic GP). ‘‘I think people will probably be more likely to code better. If people realize that they’re not going to get paid unless they’ve actually done things for the patient they’re more likely to put correct stuff in…’’ (Interview 25, Physiotherapist, Secondary Care). In addition, across care settings the potential of clinical coding to facilitate adherence to quality indicators was valued in the context of using templates, which were perceived to be able to guide clinical decision making by ensuring that appropriate aspects were considered. Templates, devised by individual organizations relating to various conditions and/or for different practitioners, were also perceived to address the tension between tailoring of systems to suit individual practices and the need for some degree of standardization to ensure the usefulness of coded clinical data for management and research. ‘‘I would say that [GPs] are not interested in inputting codes…I think I’ve got more chance of them using the templates, clicking the hot spots and it automatically coding it than actually inputting the coding themselves.’’ ‘‘There Are Too Many, but Never Enough’’ (Interview 16, Quality and Outcome Framework Manager). Moreover, and mainly in secondary care settings, clinical coders were employed to take over the responsibility for the coding of clinical information. Most clinicians stated that they would prefer clinical coders to input information for them as they were busy with providing patient care. This was seen as an acceptable compromise on quality (as their clinical coding may not be as precise as that of clinicians) and utility (as the benefit from real- time clinical coding may be lost). Others stated that clinical coding by clinicians at the point of care provided a more timely and up- to-date patient record than retrospective clinical coding by clinical coders. Increasing clinical coding by clinicians at the point of care was felt to have the potential of addressing inaccurate retrospective clinical coding by non-clinical staff. Some participants, notably those that worked with coded clinical data outputs, also argued that clinical coders were particularly valuable in ensuring consistency. Clinical coders were viewed as experts in the field of allocating clinical codes, which was not the expertise of healthcare professionals. ‘‘I’m sure there’s a whole host of problems, you know, without us directly inputting the information but I do know when we were inputting things into the system we were getting it wrong which meant that it was causing more problems hence it being taken back off us for the clinical information team to do.’’ (Interview 20, Ward Manager with nursing background, Secondary Care). Similarly, clinical coders were often highly valued by clinicians as an expert resource and safety-net: ‘‘…generally it [referring to clinical coders checking diagnoses with clinicians] also acts for the clinicians to avoid that mistake happening again so it becomes educational and then reduces further errors.’’ (Interview 30, Consultant Psychiatrist, Secondary Care). Discussion Summary of Main Findings This work has revealed the range of approaches to coding clinical data on patients with depression and how these are shaped by varying contexts, information systems and practices. We have outlined how, despite the value of coding clinical information relating to depression for management and research purposes, there is a perceived lack of direct patient care benefits and a number of risks associated with clinical coding practices in this area. In exploring strategies employed to align clinical value with managerial demands, we have discussed the underlying clinical motivations to code clinical information relating to depression, as well as the potential value of employing templates and clinical coders. Strengths and Limitations As far as we are aware, this work is the first in-depth empirical study of the approaches to coding clinical information in depression and our findings are we believe likely to be transferable to other mental health conditions and international settings. The likely transferability of this work is further reinforced by the existing empirical literature surrounding clinical coding in other conditions, which has pointed to related concerns and issues [34– PLOS ONE | www.plosone.org 7 August 2012 | Volume 7 | Issue 8 | e43831